Safe Work Hours, Safe Patients

A New White Paper Analyzes How to Implement the 2009 Institute of Medicine Recommendations on Resident Physician Work Hours, Supervision and Safety

Friday, June 24, 2011 at 12:01AM

Twenty-six of the nation’s leaders in medicine, health care, patient safety and research released a white paper today with recommendations for improving patient safety and residency training and well-being. The report, published by the journal Nature and Science of Sleep, called for sweeping changes in the design, supervision and financing of U.S. hospital residency care programs to protect patients from serious, preventable medical errors, and end dangerously long work hours for physicians in training. The authors suggest that all medical residents should work no more than 16 hours without sleep, and that Medicare physician training funds to hospitals should be tied to work-hour compliance.

The report is a product of a conference held last June at Harvard Medical School, sponsored by the CIR Policy and Education Initiative, which was convened to develop a road map for implementation of the Institute of Medicine’s 2009 recommendations for residency reform, documented in the IOM’s pivotal report Resident Duty Hours: Enhancing Sleep Supervision and Safety.

Co-moderated by patient safety leader Lucian Leape, MD and sleep scientist Christopher Landrigan, MD, MPH, the two-day invitation-only roundtable conference and resulting white paper encouraged medical educators and hospitals to embark on fundamental system re-design. “The safety of our patients and our trainees requires nothing less,” write the authors.

» Read and download the report.

» Read the press release.

Researchers Say Doctors Should Disclose Sleep Fatigue to Patients

Prospective patients should think twice on the morning of elective surgery if their surgeon informs them that he has been up all night doing emergency surgery.

But are patients routinely informed? A December 30 New England Journal of Medicine Perspective piece, Sleep Deprivation, Elective Surgical Procedures, and Informed Consent, takes on this ethical issue.

Missing: A Patient Perspective on the Need to Reduce Resident Work Hours

The Problem: You've seen them on Scrubs, ER and Grey's Anatomy -- deeply fatigued interns and residents. But truth is stranger than fiction. More than 100,000 resident physicians in teaching hospitals across the country are routinely scheduled to work shifts of 24-30 consecutive hours, with little or no sleep. They work in operating rooms and ERs, on the wards and in the clinics. And when they are finished working, they get behind the wheel of a car and drive home. After that, they are likely to be back in the hospital for two days of "short" 8 or 12-hour shifts. Then it is another up-to 30-hour "on-call" shift. This brutal schedule can continue for years.

The Evidence: There is substantial scientific evidence that these marathon work hours are linked to a significant increase in attentional failures, performance deficits and medical errors - and to increased car accidents that harm residents and the drivers and passengers they crash into. In fact, resident fatigue was the subject of a gold-standard, randomized controlled trial proving the efficacy of reduced work hours in reducing medical errors. The prestigious Institute of Medicine (IOM) has also concluded that there should be a further reduction in work hours. Other industries responsible for public safety (e.g., the transportation and nuclear power industries) have been subject to federal regulations that limit the number of hours their employees can work for decades. Why not in medicine, where the stakes are at least as high or higher?

Only 1 Percent of General Public Supports Widespread Practice of Resident Physicians Working Shifts Longer Than 24 Hours

WASHINGTON, D.C. (June 1, 2010) - The American public greatly underestimates the extended hours currently worked by resident physicians nationwide and overwhelmingly disapproves of shifts lasting longer than 24 hours, which are currently required by teaching hospitals. New findings, published in today's edition of the online journal BMC Medicine, indicate that Americans strongly favor tighter regulation of the number of consecutive hours that resident physicians are allowed to work. This is the first systematic study of public perceptions of resident work hours.

The authors of the manuscript, which included academic experts as well as consumer and labor advocates, found that 90 percent of Americans believe that the maximum shift duration for resident physicians should be 16 hours or less, as recommended by the Institute of Medicine (IOM). The IOM concluded in 2008 that allowing resident physicians to work more than 16 consecutive hours without sleep is unsafe both for patients and resident physicians themselves. More than four of five respondents in the study believe patients should be informed if the doctor treating them has been working for 24 hours; a similar majority of respondents said that if told that their doctor had been awake for a day, they would request care from a different doctor.

The Accreditation Council on Graduate Medical Education (ACGME), the group that oversees the training of physicians in the U.S., has yet to implement the IOM recommendations. The ACGME currently allows resident physicians to work for 30 consecutive hours and allows such extended shifts to occur up to twice per week. The ACGME has been reviewing the IOM recommendations for limiting resident physician work hours for the past 18 months and is expected to announce its decision later this month.