Medical residents and sleep deprivation
One of the many reasons I didn’t want to go to medical school was because I knew what it would be like during residency: 90-100 weeks with pay that broke down to somewhere around $8 an hour gross. The real deal-breaker for me was the long hours: I get irritable when I’m tired, and my performance goes downhill quickly. I know this, so I avoid it. It came as no surprise, then, when I read this press release regarding the effects of fatigue on doctors. The press release says “young doctors” which is misleading — it should say “new doctors.” Just because your doc looks young doesn’t mean he is, and just because a doc is old, doesn’t mean he didn’t get his degree just three years earlier. In any case, chances are, your “normal” doctor isn’t putting in 100 hours a week doing 24 and 32 hour shifts like he probably did once upon a time.
The effect of sleep deprivation on doctors is similar to giving them three to four drinks. Fatigue has long been blamed as a culprit in auto accidents, cited almost as much as alcohol in fatal accidents. Why then, should it be considered acceptable or even desireable for a young doctor to pull a 32 hour shift? New regulations limit the number of hours that a resident is “allowed” to work, but these are often glossed over or ignored entirely. I don’t think it’s healthy, given the responsibility that rests on their shoulders. While the rest of the country is focused on blaming medication dispensing errors as a significant source of patient mortality — and it is — perhaps the scrutiny should be turned to the residents doing much of the diagnosis and prescribing in emergency situations.
How many patients would like their doctors to have 4 drinks and then make a diagnosis and treatment decision? Probably not many, and now studies are showing that a resident being tired is analogous to being slightly drunk.
For example: The reaction time of residents who had just finished a month of heavy work schedules was 7 percent slower and they committed 40 percent more errors than when they were on a month of light schedules, On a driving simulator, they had more difficulty maintaining a consistent lane position and a constant speed during the heavy work compared to the lighter work schedule. Speed variability on the driving test was also 29 percent higher following the heavy-schedule compared to the light schedule after drinking alcohol, but there were no other performance differences between these two conditions.
In other words, after a month of 90-hour weeks with overnight shifts every fourth or fifth night, residents performed about the same as when they had a BAC of 0.04 percent after a month of 44-hour weeks of daytime shifts.
The idea behind residency is to totally and absolutely immerse the new doctors in medicine, to the point that they eat, sleep, and breath it. This is because the classroom is a poor substitute for the real world when it comes to making diagnoses and treatment decisions. So while I understand and sympathize with the motivation behind the practice of beating residents down with medicine, it clearly doesn’t work after a point. I would think that working 12 hours a day six days a week would have the same effect with fewer detrimental consequences. (And it is likely that I would be on my way to medical school instead of being a pharmacy student.) After all, who can learn or do their job effectively when they’ve been up for 24 hours?
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Um, so, first, residents/interns are now limited to an 80-hour work week. Whether or not that gets carried out in reality is up for debate, but my attending was fairly insistent on getting my intern out by 30 hours (24 hours call + 6 hours post call day). That generally means ~6AM to noon the next day. And they sometimes get to sleep a few hours depending on what is going on. They just need to be available.
I disagree with some of the scheduling and inefficiency in medicine rotations, but I’ll play devil’s advocate. Call is very important in many respects. People are needed in later hours to cover for the rest of their medical team, and it is preferable to have someone who is familiar with those patients, who has heard their main doctor talk about their issues and management, than to have a complete stranger step onto a team and cover their patients. It is also a time when many doctors admit patients and have greater responsibility as far as guiding their own patients’ care. Attendings and consults are always available, but interns and residents refrain from contacting them unless necessary and in the process learn to better take care of patients on their own. There’s a sense of shared responsibility and “covering” one another that comes about through call.
Call isn’t that bad if you only have it every several days. As a med student, I’ve only actually stayed overnight once (they try to get you out by 10-11PM), and while I hit a roadblock around 3AM, it’s not bad when you actually have work to do, and I learned a ton that night. Really, plenty of people have stayed up for 30 hours/pulled “all-nighters” in college and have been fine.
Comment by Yaz — September 9, 2005 @ 5:47 pm
Given all that, do you really think you’re as effective when you’re dead tired, though?
And reading some of hadrian’s posts in the Lounge about how he never has any time doesn’t bode well, I don’t think. Same for Mef. One of them (Mef, I think) is getting a divorce from his wife, and he just got married… and she’s a doc, too. I just think the whole residency thing needs to be re-thought.
Comment by Rian — September 9, 2005 @ 6:00 pm
First, sorry for not noting that you and the article both mentioned the 80-hour week.
Eh…effective? It really depends on what you’re doing. Certainly, stuff like surgery or things requiring great dexterity and concentration are not good to do dead tired. However, in the rotations that I’ve done so far–pediatrics and internal medicine–the main stuff that needs to be done are decisions; decisions about what medications or treatments to give to a patient who’s crashing or who has new lab results. That stuff, the people who I’ve been with are plenty smart enough when tired to handle–entering orders, instructing nurses on what to do, examining patients. Nevertheless, you’re right, it would definitely be preferable to be well-rested, and there can definitely be more mental blunders when sleep-deprived. However, in most cases, in an overly blunt way, when you’re on call, you just need to make sure patients survive through the night.
I forget how far along hadrian is–I think he’s in his third or fourth year of ED residency, but residency isn’t supposed to be easy. Afterwards, in most specialties, you can control what type of schedule you have based on academia vs. private practice, etc., and ED is actually very good for lifestyle; not nearly as good as radiology, pathology, etc., but pretty good. There’s no call for ED…. Experiences really depend on the program and personal disposition too. My brother did internal medicine, which is supposed to be fairly rigorous, but after a busy internship, he gave me the impression that he was fine. He even felt good enough to do some moonlighting (extra work at other hospitals). Similarly, although I’ve been very busy during my rotations, I haven’t been exhausted. I just haven’t had time to do much else besides medicine, which is fine. Some of my classmates, on the other hand, would give you the impression that this experience is unbearable, which is certainly not the case. Heh, in case you haven’t had too much exposure to pre-meds and the like, many of us like to complain about stuff. I’m fortunate in that I can brush stuff off rather easily, but really, I enjoy being in hospitals, and it’s a rather rare opportunity to just be charged with learning as much as you can without too much actual responsibility while you’re still a medical student.
Medicine kills many relationships because of time issues, but it’s not just residency. I’ve seen many relationships fall apart during the first few years of medical school as well. Whether or not one will last is partially dependent on the needs of both people and how willing they are to tough out some years of their life together.
Comment by Yaz — September 9, 2005 @ 6:29 pm