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I myself have experienced the effects of sleep deprivation as a youngster still in training. Days after graduating high school, I went to work for a resident care facility as a full time med-aid and caregiver on the night shift. I attended college full time that year as well. It was not uncommon for me to work from 10:30 at night to 7:30 a.m., sit through lectures and labs in the morning, study and attend to personal things in the afternoon, and not get to bed until the evening. I averaged approximately three to four hours of sleep a day. Meanwhile, the supervising nurse placed me in training to administer insulin injections and blood sugar monitoring. As a med-aid, I also had complications occur in the night or and elderly person pass away in the early morning. Most of time, I felt inadequate to handle such situations; especially with what little rest I received. Once, I worked two 16-hour shifts in a single weekend. As result, I ended up making several errors when administering medications, overlooked details and lacked patience with my elderly residents. In the long run, with strenuous hours, I had lost not only sleep, but also motivation and energy for my studies as well.
No one was able to really help my situation, fortunately, however, something was being done for the people who dealt with life and death situations a thousand times more often than I ever did. A group from the Harvard Work Hours, Health & Safety Group carried out a national survey of first year physician residents or interns across the U.S. (Barger, et al 125). All 2737 residents documented 17,003 “monthly reports” of facts that had to do with any car accidents, sleeping at the wheel, shift hours, and nearly-happened car accidents (Barger, et al 125).
The results of the 2002-2003 study showed that 25% of interns’ longest shifted last about 16 hours on average, however, 75% worked 33 to 36 hours a shift to average 25.3 hours without sleep for the longest duration (Barger, et al 129). This numbers provide evidence that resident programs continued to allow interns 48 to 84 work-hours weekends (129).
Researchers for the survey found that as a result of extended-hour shifts, the rate for monthly car accidents increased by 9.1 percent, and the travel from work rose to 16.1% odds of an accident (129). Out of 320 residents involved in a car accident, 131 occurred on the way from work. In addition 133 of them needed ER treatment, police report, or had to pay a fine of $1000 or more in property damage (129).
The same group that performed a study on resident car accidents also conducted a study, in the same year with the same experience level of participants, on self-inflicted injuries due to sharp objects. Again, they used 17,003 monthly surveys in which residents reported 498 injuries (Ayas 1055). Researchers learned that “lapse in concentration” triggered 64% of the injuries, while 31% sharp pokes resulted from tiredness (1055). Of course, with an average of 29.1 successive, work hours opportunity for injuries is 58% higher than with just an average of 6.1 hours (1055). Incidents happened more between 11:30 p.m. to 7:30 a.m. than 7:30 a.m. to 3:30 p.m. (1055).
A later study also found that interns made 100 serious mistakes out of 1000, as oppose to 136 out of 1000 patient-days. 55.0 of them were caught instead of 70.3 and 28.6 versus 44.8 were not “intercepted” (Bauchner). Serious errors, no matter who was at fault, occurred less frequently when interns worked less hours, 158.4 instead of 193.2 for every 1000 patient-days (Bauchner).
Although much is done to decrease bias in research studies, one cannot expect 100% accuracy. The two surveys conducted in 2002-2003 represented only a portion of one post-graduate level/year out of all the residents in thousands of residency programs in the U.S. In addition researchers face difficulties in taking account every factor and variable that can change the outcome of a study.
In April of 2001, as a result of research that showed the negative effects of extended-work hours to physician residents and their patients, the American Medical Student Association, Public Citizen, and the Committee of Interns & Residents presented a petition to the Occupational Safety & Health Administration, also know as OSHA (“OSHA Denies”). The petition requested that OSHA override the Accreditation Council for Graduate Medical Education (ACGME), which evaluates and accredits U.S. medical residency programs establish current guidelines in which resident programs are permitted to increase hours by 10% for educational purposes only ("OSHA Denies request”). Public Citizen claimed that ACGME’s standards and lack of enforcement neglects to adequately protect residents and patients from physician work hours and sleep deprivation (“OSHA Denies request”). Since the petition to OSHA failed, the next year bills H.R. 3236 and S. 2614 were presented before Congress to set federal guidelines on resident work hours (“OSHA Denies request”).
Finally, on July 1, 2003 the ACGME established a mandate which required all residency programs (with a few exceptions) in the U.S. to restrict resident hours to 80 per week, over an average of four weeks. Residents must also limit shifts to no more than 24 successive hours (including on-call duty) with a rest period of at least 10 hours between shifts. In addition, residents must have one day off a week that excludes all educational and patient related work.
Within the medical academia, few can come up with a general agreement on the effects of limiting resident work hours to 80 hours a week. Some say that the new mandate limits exposure and experience to practice (Croasdale). Residents in surgery have expressed concern over missing out on complicated or non-average patient circumstances when they have to clock out at 30 hours (Croasdale) Other experts feel that quality of time, not quantity of time helps create good doctors (Croasdale).
At the University of Massachusetts Medical School, a study showed that residents had mixed opinions on the subject. Fewer hours working in the hospital provides more time for other activities such as studying, reading or attending academic events. On the other hand, some residents feel that patients suffer due to less consistency in patient care. (Croasdale)
Researchers at the Mayo Clinic carried out a survey across the U.S. which investigated how residents’ opinion of the hour restrictions. They found that out of the programs leaders and participants who responded, 93% believed that hour restrictions negatively impacted “continuity of patient care.” In addition, 41% of directors worry that chief surgical residents experienced fewer complicated situations. This is not the case for every program. Residents at the University of California, Irvine, have lost few hours in other academic activities, but not in operating rooms or office hours (Croasdale).
In an editorial in the Annals of Surgery, Frank R. Lewis, Jr. M.D. from the American Board of Surgery argues against strict restrictions to work hours provided by the ACGME mandate because of the same reasons as mentioned above. According to Lewis, Reports on the number of medical deaths due to sleep deprivation came from outdated studies embellished too far. He claims that long work hours are necessary and beneficial to both patients and residents for two main reasons. First, with reduced hours, residents gain less experience than ever before. Residents have fewer opportunities to truly invest in their patients since many things happened at ungodly hours of the night or in the midst of a holiday rush or weekends. Secondly, “continuity of care” declines dramatically, especially in areas like surgery, critical care, and emergency departments. Patients will have, instead of one doctor who knows them well, but several doctors with bits and pieces of information. He also asserts that Libby’s young doctors received responsibilities that the attending physician should have carried, but failed to do so. Therefore, lack of sleep did not play a factor in her death. Lewis makes a valid point. As patients, we want our doctors and surgeons to feel confident in the most desperate moments. From older professionals I have been told that most of what they know came not from college, but from experiences gained first hand in the workplace. Medicine consists of hands on training, and events that happen in a blink of eye. With further rules to follow, more charting and documenting is required, which can further complicate things. Senior physicians and educators may spend more time monitoring residents’ work hours than in other things.
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