December 2nd, 2008
04:20 PM ET

Are your doctors awake?

By Jennifer Pifer-Bixler
CNN Medical Senior Producer

When I was in college, I had emergency surgery.  The whole incident was a blur. One moment I was being poked, the next, I was being wheeled off to the OR.  When I woke up after surgery, I was groggy and feeling NO pain.  For the next few days, morphine was my best friend.  Granted, my memories from that week are pretty limited, but one thing I do remember is a young doctor stopping by my room to check on me.  I have no idea what he said, but I do remember vividly that he tried to stifle a yawn while he was talking to me.  That made ME yawn and in turn, he yawned AGAIN.  Perhaps it was the pain meds, but boy I thought that was hilarious.

The “dueling yawns incident” pops in my mind whenever I hear about the long hours doctors work while they are in residency.  To succeed, not only do these new doctors have to be smart, they must have endurance.  For a long time, there was no limit to how many hours a resident was expected to be on duty.  But in 2003, the Accreditation Council for Graduate Medical Education, the council that evaluates and accredits medical residency programs in the United States, set up new rules limiting the maximum resident work week to an average of 80 hours and the maximum shift length to 30 hours.  However, according to some researchers, even with the 30-hour limit on shifts, there can be a whole host of serious problems.  I recently spoke with Dr. Charles Czeisler at the Harvard Medical School Department of Sleep Medicine.  He studies lack of sleep and its impact on doctors.  Czeisler's research shows that one in five residents admit making a fatigue-related mistake that hurt a patient.  One in 20 admits making a fatigue-related mistake that resulted in death.  In other words, says Czeisler, working 24 hours straight without sleep is comparable to being legally drunk.

That's sobering news.  And it makes me wonder about the doctor who treated me in college.  I wonder now how many hours he had been working.  Now the Institute of Medicine says it it's time to talk about residents’ hours and workloads.  "Fatigue, spotty supervision, and excessive workloads all create conditions that can put patients' safety at risk and undermine residents' ability to learn," said committee chair Dr. Michael M.E. Johns, chancellor of Emory University in Atlanta, Georgia.

Among the recommendations from the IOM:

           * Limit shifts to 16 consecutive hours

           * Give residents more days off

           * Provide transportation home after a long shift.

The IOM acknowledges that there is no easy solution.  In fact, it says there are very valid reasons for some residents to work long hours.  Keep in mind that this is a training time for doctors.  And getting the most experience possible ultimately benefits patients.  Also, the work flow varies from specialty to specialty and experts say 'one size’ doesn't fit all when it comes to schedules. For example, the time a surgeon needs to spend with a patient is different than a dermatologist.

The committee stresses that limiting resident hours is not a “silver bullet.”  It also recommends greater supervision of residents by experienced physicians and limits on patient caseloads based on residents levels of specialty and experience. 

Reaction to the report has been mixed.  Public Citizen http://www.citizen.org says the IOM has missed “a golden opportunity” and doesn't go far enough to protect patients.   Czeisler, however, says it is an important first step.  But he worries that nothing will change unless the federal government gets involved and enacts new laws.

I want to know what you think.  Do you think these recommendations are needed?  Have you ever been treated by a “drowsy doctor?"  And if you are a doctor, do you think working long hours helped or hurt your residency?

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