Long hours, little sleep: bad medicine for physicians-in-training?

ARLINGTON, VA—A nationwide prospective study will test the hypothesis that long hours with little sleep jeopardizes both clinicians’ health and the safety of their patients. It aims to survey all US physicians and dentists in the class of 2002 monthly through their first postgraduate year and perhaps beyond. Most physicians in training in US hospitals are required to work 80 hours or more per week and shifts of more than 30 consecutive hours every third or fourth night. About 80% of physicians and 20% of dentists participate in programs that impose such demands. In some programs, resident physicians allegedly work more than 130 hours per week and are on call every second night. An intervention study, conducted concurrently, will examine the impact of a schedule designed to minimize extended sleep deprivation in interns in their 3-week rotation in a medical intensive care unit (ICU) or a coronary care unit at Brigham and Women’s Hospital (BWH), Boston. The researchers will compare the performance and health of interns working the current national standard ICU resident work schedule—more than 30 continuous hours every third night—with that of those working no more than 12 continuous hours in the ICU, in compliance with a new guidance for residents on ICU duty issued by the Association of American Medical Colleges (AAMC) in October 2001. Charles Czeisler, PhD, MD, who directs BWH’s division of sleep medicine, and a multidisciplinary team of colleagues at Harvard Medical School will lead both studies, with funding from the National Institute for Occupational Safety and Health (NIOSH) and the Agency for Healthcare Research and Quality (AHRQ). Czeisler outlined plans for the studies at a national conference on sleep, fatigue, and medical training here in October. Conference speakers reviewed current knowledge of how sleep deprivation affects performance, discussed ways to curb fatigue, identified information gaps, and proposed research opportunities. The conference was funded in part by an AHRQ grant and sponsored by the American Academy of Sleep Medicine, the American Medical Association Council on Medical Education, the National Center on Sleep Disorders Research at the National Institutes of Health, and the Sleep Research Society. Impetus for the conference and for the BWH studies came from Institute of Medicine (IOM) estimates that medical errors cause more than 1 million injuries to patients in US hospitals each year and may trigger as many as 98000 deaths annually (Kohn LT, et al. To Err Is Human. Washington, DC: National Academy Press; 2000). A petition calling for establishment of national work-hour limits for resident physicians, filed with the US Occupational Health and Safety Administration (OSHA) in April 2001, also heightened interest in the conference. Signers included Public Citizen, a Washington, DC–based consumer advocacy group; the American Medical Students Association (AMSA); the Committee of Interns and Residents; Bertrand Bell, MD, author of New York’s health code restricting resident work hours; and Kingman Strohl, MD, director of the center for sleep disorders research at Case Western Reserve University, Cleveland. While physicians’ working conditions may contribute to the frequency and severity of medical errors, Czeisler said in a postconference interview, systematic data on fatigue in medical settings is lacking. The 287-page IOM report includes only four brief mentions of fatigue. More than 30 published studies compare job performance by sleepdeprived residents with that of those who supposedly are well rested. Results are inconsistent. Most of these studies are flawed, including his own, Czeisler maintained. “Researchers called residents ‘rested’ if they slept 7 hours one night,” he said. “We know now that is incorrect because residents are chronically sleep-deprived. Attempts to detect differences between them may have been lost in the noise. ” The nationwide survey aims to document hours interns actually work, Czeisler said, since some trainees allege discrepancies between their schedules and those their programs report to the Accreditation Council for Graduate Medical Education (ACGME). Work-hour requirements currently vary by specialty. The ACGME, which accredits 7800 post-MD medical training programs in 110 specialties and subspecialties in the United States, does not release information about a specific program’s work schedules to the public. Survey participants will respond to a monthly Web-based questionnaire. About 15000 new physicians and 4000 new dentists will be eligible for the study. They will report hours worked, medical errors, motor vehicle crashes, MEDICAL NEWS & PERSPECTIVES