I wouldn't trust my Uber driver to drive me after being awake for more than 24 hours. Why would I trust my doctor?
Ever since I started medical school and learned about the terrible 24-hour shifts, I have constantly wondered why they are the standard of practice, much less why they are legally allowed. Why would a hospital want to take responsibility for a sleep-deprived doctor?
I first saw the effects of a 24-hour shift during my general surgery rotation. I have worked with exceptional surgical residents who are thorough, compassionate and caring. One morning, I greeted the senior on my team. He was in front of a computer. As time passes, I wonder: Is this guy really about to ignore me? I sat down at the computer next to him and realized he was sleeping. Sat. Placing an order. I felt a lot of empathy for him, as he was just another intern in a broken medical and hospital education system. At the same time, I was wondering, “How did he get open abdominal surgery an hour ago?”
Controversy surrounding extended shifts has existed since the beginning of medical training. In fact, the term “resident” comes from the fact that new doctors in training lived in the hospital decades ago. Fortunately, we have moved away from those days.
The Libby Zion case illustrates the controversy surrounding long working hours. It was an 18-year-old girl who died in a New York hospital. The death was attributed to an avoidable error made by a sleep-deprived resident who was working a 36-hour shift. This led to a mandate in New York, residents were limited to an 80-hour work week with a maximum of 24 consecutive hours, which was expanded to all residents in 2003.
In 2011, the ACGME mandated that interns be limited to 16-hour shifts, but second- and third-year residents be limited to 24 hours. This measure was repealed in 2017, returning to the previous practice of an 80-hour work week limited by 24-hour shifts.
The ACGME made these decisions based on the study results iCOMPARE Trial, which compared patient mortality and readmission rates between standard programs, which followed 2011 guidelines on 24-hour limits, and flexible programs, which maintained an 80-hour work week with no limit on duration shifts or mandatory time off between shifts. The results revealed no differences between the two groups; however, it is crucial to understand that flexible programs were not required to use extended shifts, even if they were permitted to do so. They found that for most internships, flex programs chose to continue following the 2011 guidelines, limiting shifts to 16 hours, which says a lot. This also means that it does not accurately compare the effects of longer shifts versus shorter shifts.
THE LISTS study directly examined the effects of shortened work hours (less than 16 hours) on attention, alertness, alertness, and serious medical errors compared to extended work hours (more than 28 hours). This study concluded that residents working extended hours had significant attentional lapses, associated with a greater number of serious resident-related medical errors. Reducing work hours has a protective effect on the rate of serious medical errors.
Another study reported worsened symptoms of depression, anxiety, sleep quality, and migraines among residents working extended shifts. And another study concluded that long shifts increased the risk of chronic sleep restriction. As you sit here and read these results, really think about it. Does this really surprise you?
It shouldn't. Even the the public agrees they would not want to be followed by a doctor who has been awake for more than 24 hours. I completely agree as well. Although any changes to this matter are likely to occur before the start of my internship year, it is important to address the negative impacts of this mandate on the quality of life of interns and its effect on patient safety. Fast forward to the days when residents were awake and alert when seeing and treating patients. I mean honestly, my shifts as a waitress were shorter.
Arlene Rivera is a medical student.