The downside of requiring young doctors to get more sleep.

Health and medicine explained.
Dec. 10 2008 6:58 AM

Halt the Surgery—It's Time for My Nap

The downside of requiring young doctors to get more sleep.

What happens when residents work fewer hours? Click image to expand.
What happens when residents work fewer hours?

Much to the delight of harried young doctors everywhere, an expert panel recently agreed that medical residents aren't getting enough sleep. Citing evidence that fatigue leads to more medical errors, the Institute of Medicine said last week that doctors in training should not work more than 16 hours without taking a five-hour nap. Though it carries no binding authority, the recommendation of the IOM's report supplements an earlier rule, passed by the Accreditation Council for Graduate Medical Education in 2003, that limited residents to 30-hour shifts and no more than 80 hours of work each week. Surgical residents may someday soon have to prepare themselves to halt an operation and announce that it's nap time.

The American medical establishment has been slow to give up a hazing ritual that assigns grueling schedules to trainees, with supporters of the schedule arguing that the long hours prime young doctors for the rigors of medicine, expose them to many disease scenarios, and promote continuity of care for patients. Other nations have been quicker to jettison that system. New Zealand limits residents to 72 hours of work each week, while France caps the workweek at 52.5 hours. Danish residents work no more than 37 hours a week. (What a breeze!) Elsewhere in Europe, countries are slowly lowering the work hours of "junior doctors" to comply with the European Working Time Directive, which limits hours for all shift workers. By 2009, junior doctors will work no more than 48 hours a week.

Unfortunately, working less comes with a big price tag. Countries that have imposed shorter work hours for residents have faced steep staffing shortages as well as questions about the quality of their medical training.

New Zealand and Australia were two early adopters of shorter hours for residents, and their experiences should have warned other countries against the idea. In 1985, when New Zealand restricted residents to 72 hours of work per week, hospitals faced a sudden shortage and ended up hiring more senior doctors to fill the gap. Australia experienced a similar problem after physicians adopted a 1999 "National Code of Practice" designed to minimize the risks facing all shift workers who work extended hours. By 2004, physician shortages were common in Australia, and the state of New South Wales had 900 vacancies for residents and other doctors in training.

Other countries have seen similar snags. In Europe, where thousands of physicians were needed to fill vacancies created after residents scaled back their hours, hiring additional personnel cost an estimated 1.75 billion Euros. Exceeding the 48-hour-a-week allotment "is the rule rather than the exception" in Portugal, noted researchers in a 2004 British Medical Journal article. The United Kingdom needed an estimated 15,000 additional doctors to staff the National Health Service to comply with the Working Time Directive, which applied to junior doctors for the first time in 2000. In 2004, the BBC reported that the NHS was facing a "staffing crisis" brought on by shorter hours for residents.

But too few doctors isn't the worst of the consequences. Proficiency in the operating room notoriously demands long hours, and one-third of orthopedic surgical residents were deprived of training in the operating theater because of shorter work hours, according to a 2002 survey by the British Orthopedic Association. "To become a competent surgeon in one fifth of the time once needed either requires genius, intensive practice, or lower standards. We are not geniuses," wrote the authors of an article published in the British Medical Journal in 2004. "That many senior house officers arrive at posts halfway through their rotations without any real competence in operative skills as basic as suturing and tying knots is therefore unsurprising," they noted.

As European countries approach a 2009 deadline for fully implementing a 48-hour workweek for doctors, critics have renewed their arguments. In November, a study published jointly by the Royal College of Anaesthetists and the Royal College of Surgeons suggested that medical education in the United Kingdom would need an overhaul in order to maintain certain training standards while complying with reduced-hour rules. Testifying before the U.S. Institute of Medicine's committee on residents' work hours, Dr. Bernard Ribeiro, former president of the Royal College of Surgeons of England and an outspoken critic of shorter work hours, urged members to consider the implications of reducing residents' hours: British residents today perform 25 percent fewer procedures than they did before the regulations began to take effect, he said.

Despite such a warning, lessons gleaned from other countries played a modest role in the committee's deliberations. An appendix, "International Experiences Limiting Resident Duty Hours," took up 19 pages in the IOM's 480-page report, Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. "Each system is different—it's hard to generalize," said one committee member, Dr. Kenneth Ludmerer, a professor of medicine and history at Washington University in St. Louis. "Ultimately, we're concerned about our own country."

But here, too, shorter working hours for residents have a spotty record.

In 2003, when the Accreditation Council for Graduate Medical Education ruled that residents could work no more than 80 hours a week, hospitals were forced to hire additional nurses, technicians, and senior doctors to pick up the residents' slack. Last week, the IOM committee said its recommendations could cost $1.7 billion a year. The committee justified the expense by saying medication errors and the cost of treating drug-related injuries in hospitals add up to more than $3.5 billion a year.

But if the mistakes of drowsy doctors are merely replaced by the mistakes of ill-trained doctors, there won't be as much benefit as the IOM predicts. Dr. Elias Traboulsi, chairman of graduate education at the Cleveland Clinic, points out that a quality medical education often hinges on how much time is spent treating patients and working in the hospital. Time restrictions also limit residents' exposure to the longitudinal nature of illness, said Dr. Joseph Loscalzo, chairman of the Department of Medicine at Brigham and Women's Hospital in Boston. "It really fragments the learning experience we wish our residents could have," said Dr. Loscalzo. The Accreditation Council for Graduate Medical Education allows hospitals to apply for small extensions of up to eight hours a week for some residents on the grounds that certain medical specialties, like surgery, benefit from more training, but those extra few hours might not be enough.

We all want our doctors to be well-rested, but the IOM's effort to ease the burden on overworked residents saddles some doctors with recommendations that could hinder their education. Across-the-board guidelines lump together doctors with vastly different skills, sleep needs, and career goals. More flexibility would keep the United States from facing the doctor shortages and training deficiencies seen by other countries. By allowing individual programs to tailor work hours to meet the needs of their residents, the rules could accommodate aspiring physicians for whom shorter shifts are sufficient as well as those surgery residents who may benefit from logging extra hours in the operating room. Then surgeons won't have to worry about fitting in nap time.

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