A national panel of medical experts proposed significant and costly changes for training new doctors in the nation’s hospitals, recommending mandatory sleep breaks and more structured shift changes to reduce the risk of fatigue-related errors.
The report, issued by the Institute of Medicine, focused on the grueling training of medical residents, the recent medical school graduates who care for patients under the supervision of a fully-licensed physician. The medical residency, which aims to educate doctors by fully immersing them in a particular specialty and all aspects of patient care, is characterized by heavy patient workloads, 80-hour workweeks and sleep deprivation.
But while popular television shows like “Grey’s Anatomy” glamorize residency training as a gratifying rite-of-passage for doctors, the worry is that the massive workload imposed on residents poses a risk to patient safety. The grueling hours of often unsupervised residents were found to have contributed to the 1984 death of 18-year-old Libby Zion in New York, a finding that eventually led to a series of reforms, including limiting residents to an 80-hour workweek and 30-hour shifts.
But the expert panel said those reforms were not enough. Caps on work hours often aren’t enforced, and many residents still don’t get enough sleep, putting doctors and patients at risk for fatigue-related mistakes. While the new recommendations don’t reduce overall working hours for residents, the report says no resident should work longer than a 16-hour shift, which should be followed by a mandatory five-hour nap period.
The committee also called for better supervision of the doctors-in-training; prohibitions against moonlighting, or working extra jobs; mandatory days off each month; and assigning chores like wheeling patients to X-rays and drawing blood to other hospital workers so residents have more time for patient care.
“One of the problems has been that we limited the hours but didn’t change the work to make it better educationally and in terms of safety,” said panel member Dr. Kenneth M. Ludmerer, professor of medicine and history at Washington University in St. Louis. “You have to look at what they do during those hours. Is the total experience a learning experience?”
The panel paid particular attention to the so-called patient handoff, the point at which a resident briefs the next doctor about a patient’s history and needs as he or she is ending a work shift. The handoff is a risky time for patients, because rushed and fatigued doctors often inadequately brief incoming staff members, said Dr. Sandeep Jauhar, director of the heart failure program at Long Island Jewish Medical Center and a reviewer of the report.
Dr. Jauhar, who recently wrote about his medical training in the book “Intern: A Doctor’s Initiation,” recalls a time during his own residency when a fellow doctor-in-training rushed a patient briefing without giving him basic facts about the patient’s serious condition.
“When the nurse asked, ‘What do you want to do, doctor?’ I didn’t have a clue,” Dr. Jauhar said. “I didn’t have his case; I didn’t know what tests had been done. Each time you hand off a patient there is a possibility of error.”
But the big unanswered question from the Institute of Medicine report is whether medical schools and hospitals can afford the proposed changes, which may add as much as $1.7 billion in new costs to cover patient care during mandatory nap times and shift changes. The panel didn’t propose a funding source and said only that medical schools, hospitals, the Veterans Administration and other “stakeholders” in graduate medical training should meet to discuss the issue. Ultimately, whether the guidelines are enforced will be decided by the Accreditation Council for Graduate Medical Education, which is responsible for the accreditation of graduate medical training programs within the United States.
“We know there is a cost to this,” said Brian W. Lindberg, a panel member and executive director of the Consumer Coalition for Quality Health Care in Washington. “If we’re enabling residents to have sufficient sleep, someone has to cover care during those periods. We also believe if you look at the totality of the recommendations, there is the potential for efficiencies in the system and savings from reduction in errors and harms. In the long run, it won’t cost as much as one might estimate.”
While the need for reforms was generally applauded, some health care groups expressed frustration that more isn’t being done to relieve the workload of doctors-in-training.
“How is it reasonable for truckers in our country to be more restricted in their work hours than doctors and resident physicians,” asked Mary Carol Jennings, legislative director for the American Medical Student Association.
Dr. Peter Lurie, deputy director of Public Citizen’s Health Research Group, said that the issue of doctor hours should be regulated by the government, and that the Institute of Medicine report is unlikely to make a difference in patient care.
“It’s unlikely to be enforced,” Dr. Lurie said. “It gives the appearance of taking the problem seriously, but in fact, will likely maintain the status quo.”
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From 1 to 25 of 228 Comments
I’ve always wondered how these human beings could function on so little sleep, while making critical decisions about patients’ lives. It’s the reason I try to avoid the medical or law professions like the plague(s). They’re both like sinking into quicksand.
http://savvyextremeidealist.blogspot.com/
— (S)wineAbsolutely a great idea whose time has come.
The medical establishment should absolutely concentrate on getting hospital outcomes right. This is a great step in that direction.
As TPP has mentioned many times, prevention, though critically important has always been largely outside the scope of the medical community’s responsibility. Prevention and wellness do not happen in the doctor’s office. Part of the problem and discontent surrounding “healthcare” is that responsibility for leading a healthy lifestyle has been foisted upon the medical community, and away from parents, families, schools, and individuals.
If funding is an issue, concentrate it on hospital care.
— jackHallelujah…this was coming for a long time, and I’m glad to see that sleep deprivation among residents is being discussed more openly and seriously. Subjecting anyone to work 30 hours at a time without breaks or sleep is inhumane. To subject doctors who make life-and-death decisions to this is dangerous for society at large.
— GregAs a young adult cancer patient I’m surrounded by interns my own age, both in the hospital and at dinner parties. Crowded around the table they exchange war stories about sleep depravation with the pride of passing an initiation rite. The friend part of me joins in the fascination of their in-the-trenches storytelling. The patient part of me wonders what I can do to help advocate for reforming their work burden. It is purely selfish. It would suck to beat my cancer and die from a medical error.
— Kairol Rosenthalhttp://everythingchangesbook.blogspot.com/
Great. Another unfunded mandate. I was a resident when the 80 hour rule went into effect. It sucked; we were told to do 110 hours worth of work in 80 (as if any of us were spending an extra 30 hours a week in the hospital for the hell of it). The only thing that got cut was education, not workload. I’m all for a reasonable and safe workweek but the only way to do that is to see less patients and in that case, who is going to see them?
— noelle#2 I felt a need to amend my post so as not to be misunderstood.
Funding and responsibility for prevention and lifestyle education and change implementation should come from outside the healthcare pool of funds. It should not be covered by health insurance. Health insurance can’t cover everything; funds and manpower are being spread too thin(ly).
I do NOT mean we should cut funds and manpower for preventive procedures such as colonoscopies and mammograms.
— jackAs the S.O. of one of the undead, I can only feel frustrated at another article expressing the problem. In Nashville, residents work shifts in excess of 30 hours with no time for even a short nap. The 80 hours caps are in name only. Residents who invoke shift guidelines are generally frowned upon and resented, because someone who insists on leaving after 35 hours without sleep creates a larger burden for the next resident in line.
— JoeI know mistakes occur regularly and go unreported, and many of these are caused by sleep deprived doctors. I think it says enough that many of the residents won’t even risk driving themselves home after a 38 hour shift because they consider it a foolish risk askin to drunk driving.
One would think that with all of the medical research on sleep requirements and brain function, the medical community, of all people, would champion the need for sensible work hours.
I think overworked residency training is, indeed, kind of a hazing rite of passage. The old guard docs say they had to go through it, so, by god, the new kids have to, also. No one is going to break the tradition, no matter how ridiculous or life threatening it is.
— Craig at Balanced Immune HealthI think they should make two more ammendments to physician training:
1.) Completely ban all pharmaceutical representatives from all teaching hospitals.
2.) Teach phycisians that a “new” medicine does not always equate to a “better” medicine, and extend their education in pharmaceuticals to more than just ONE semester.
As ALLHAT trial showed–NYTimes 11/28–”A good lie well told and stuck to, is better than the truth…every time.”
— ApothecaryMarkMandatory naptime?
Delegating scut work to someone else? Who?? training hospitals have the laziest most worthless ancillary staff around. When I was an intern I had to do everything myself — blood draws, transport, ekgs, basic stuff. you name it. The nurses would sit around and eat. There would have to be an amazing paradigm shift to change that in NYC hospitals. There would have to be big expenditure. Who would pay for that? The large urban training centers would collapse residents didnt work the hours they do.
Full scale immersion is useful. You learn to deal with anything and everything. There should be changes so patients suffer less from resident fatigue and incompetency but the cahnges should not be blithely handed down in a blanket fashion as they are now.
Naptime? What a joke. You can make changes without turning residency into a clown show. How did all the good attendings who supervise the incompetent, tired residents get good? They weren’t napping.
— CIssue #1: If residents spend less time in the hospital, and their exposure to training opportunities is not carefully protected, they won’t learn enough during their residencies. We already struggle to preserve the decision-making and procedure experiences for trainees (e.g. surgical procedures for trainee surgeons, or endoscopies for future gastroenterologists..).
Issue #2: The doctors who make decisions are not the residents, but the attending physicians. Let’s be clear that protecting patients means having attendings at the bedside, not merely ensuring that residents sleep. Let’s also be clear that at this moment in time, there are NO restrictions on attending hours.
— NYdocDoesn’t anyone else think it’s odd that we take it for granted that residents should be expected to work to just short of the brink of disaster? I have an idea; let’s have doctors work like everyone else, say 40 to 50 hours a week?
Doctors say they need to be around at all hours of the day and night to learn the trade. I think that’s nonsense. When a doctor starts his shift he can just touch base with the person on duty and get up to speed. I think working 30 plus hours non-stop for years on end is just a hazing ritual that washes out anyone with reasonable expectations about work and solidifies a hard core of work-a-holics that can dominate the field.
It’s time to impose restrictions on these doctors so that even normal people can practice medicine. The argument that it’s too expensive to hire enough people to do the work is misleading also. Medicine costs what it costs. Perpetuating a class of medical zombie residents is not justified by cost or some need to experience deprivation in the name of learning. Fixing healthcare isn’t brain surgery, it’s common sense.
— RayA n admirable goal, but one with a number of problems . 1st the issue of funding. 2nd the issue of needing more interns/residents to cover a given hospital if each is to work less hours-where are they coming from? 3rd the issue of “handing off care” gets more complex if there are more physicians involved per patient due to the restricted hours. 4th the issue of whether the same level of training or experience occurs with less hours worked per week/month, etc.
— MCAI’m glad that there’s recognition of the need to change… but honestly, much of what residents do can be taken over by PAs and RNs. With the nursing shortages, however, the residents and med students get overburdened with scut.
I’d say only about 3% of the residents I worked with actually stayed within the 80-hr limit. They officially work 80 hrs, then educate themselves off the clock by scrubbing in on important cases or going to grand rounds…
This is a good step forward, but we have to look at the healthcare system as a whole. I hope other changes will follow soon.
http://renaissancetrophywife.wordpress.com/
— RTW“a gratifying right-of-passage for doctors” — nonsense!
a gratifying RITE-of-passage for doctors.
FROM TPP — You do have an eagle eye…..thanks!
— eagle-eyeHospitals remain financially solvent on the backs of minimum wage (or less) physician laborers, aka interns and residents. Especially the VA system. When resident work hours and responsibilities are cut back even further, how is the hospital going to fix the shortfall? They cannot simply hire more residents; those slots are fixed by the government through medicare. I wonder if one result might be more and more (inexpensive) physician extenders and mid-level providers in emergency rooms and other departments.
— JamieThe reality is that residents are working 80 to 110 hours per week, while getting a paid as if they were working 40. Ideally, residents would have time for an adequate meal, sleep, shower, and surf the internet like the rest of us. However, the harsh reality is that America is getting older, fatter, and sicker. We need more highly trained physicians, residents and medical students. Maybe then will we begin to meet the demands of the changing face of America.
— ShannonAmazing.
I am a junior Doctor in the UK and am just amazed by this - I knew US Drs had it tough (at least until they start earning massive salaries) but this seems crazy.
In the UK junior Drs are limited to 56 hours a week and, whilst the older, hoarier Consultants still tell stories of how hard it was in their day, I cannot imagine it would be possible to find anyone who would seriously advocating going back to the old system with its sleep deprivation and avoidable mistakes.
I suppose it is one of the overlooked advantages of state-funded system that legislation like this can be inflicted top-down and everyone forced to comply (of course the flipside is that lots of uneccessary legislation, bureaucracy and targets can be too!).
— UKDrA long overdue recommendation that the egos at academic centers must genuflect to.
— BGCPatient centered medical education - now that is a new idea.
I totally agree that the changes in residents’ work lives are needed, but I also agree with #5 that we can’t have them as an unfunded mandate. From everything I read, a large problem with our health-care system is that the government and the insurance companies keep reducing the amounts they are willing to pay for services, although the costs of those services keep going up. Just recently the Times discussed doctors who can’t afford to take on any more Medicare patients because of the low reimbursement rates.
— Maria C.I hope the rethinking of health insurance in the new Administration will include improvements in these areas. We pay much more for our medical services than European countries, and we get less for it. What can we learn from them, and then improve upon?
shouldn’t that be “rite of passage” rather than “right of passage”? Great article–I love your work on this blog.
FROM TPP — I’ve always struggled with homonyms! thanks.
— PMMTara-Please note that the term is “rite” of passage. It seems that the word “right” is being substituted erroneously everywhere these days in the papers. Editors, please note.
FROM TPP — A few other readers beat you to it, but thanks! I’ve fixed it.
— RobbieI am a surgery resident, and I agree with Noelle. They can mandate all they want; I will continue to provide what my patient needs, no matter what time it is. I’m not about to scrub out when the clock strikes 16 hours, or 30 hours. The solution is either more residents or fewer patients, both of which are cost-prohibitive. I’m afraid the money must come from somewhere: government/taxes? HMO’s? You tell me.
I’ll just continue with my $40,000 salary, which amounts to $8.00 an hour, and ignore my $150,000 debt. Residents (particularly surgery residents) are cheap high-quality labor and the system totally abuses us; lucky for hospitals (and patients) we generally don’t want to cause anyone harm and we want good careers so we try to do a good job. Despite the work conditions and crap pay.
— TimI personally don’t want a sleep-deprived resident making important medical decisions regarding my care - that is where the medical attending needs to play a key role and I think residents are generally not as well supervised as they should be. There is a down side with residents and attending physicians working shifts however. It is an issue of taking responsibility for your patients. It is all too easy to fall into the trap of deferring difficult medicial decisioins to those coming on in a few hours eg. does this hospitalized patient need surgery now at 3 am or should the decision be deferred to those coming on in the morning. This is a common occurrence, often to the detriment of the patient.
— TomI find it interesting that this blog is run on the same day that another on the NYT was discussing bad MD behavior. In that blog, there was an example a nurse gave of a resident physician that did not take her concern about a child seriously, and subsequently led to the child having a bad outcome. The article assumed that such bad behavior was a result of a few bad personalities, but I would point out that many of these situations result from the bad judgement and irritability that come from severe sleep deprivation.
In my own experience during my residency, I can think of a handful of experiences where, late in the night and having managed to make it to the bunk for a bit of rest, I underestimated the severity of a situation called to my attention by the nurse out of something akin to wishful thinking–if the patient was ok, then I could sleep. I thank God that in each of those occasions, I erred on the side of caution and ultimately did the right thing instead of sleeping. But I count myself as fortunate.
As far as the interpersonal side of this issue, there is no doubt that lack of sleep changes people’s personalities, and makes them more prone to angry outbursts and other types of abrasive behavior. I’m not sure this is cured with anger management classes–often people do well with just a nap!
— philip Ciampa