American Medical Student Association

Additional Statement, Submitted by Josh Rising, Legislative Affairs Director, American Medical Student Association, Reston, VA

Though public attention has been focused on the issue of medical errors, there remains no consensus on the approach to take to address this crisis in the American healthcare system. One of the important issues that is important to examine in this discussion is the impact of health professional overwork. For though it is commonly acknowledged that sleep deprivation is an important issue, no action has been taken on this seemingly simple way to reduce medical errors. Part of the reason is that though there has been extensive work that has demonstrated the effect of fatigue on overall performance, there has been no thorough documentation of the number of medical errors that fatigue causes or the overall cost to society.

Although the problem of overwork is common to healthcare workers in many professions, this paper will focus on resident-physicians, who are perhaps the most blatant example of the problem. After detailing the relevant issues, this paper will then lay out some of the relevant research questions.

The American Medical Student Association has long supported efforts to address resident work-hours in the context of patient safety. The recent attention to medical errors gives us a chance to reexamine some of the underlying structural flaws in the field of healthcare. More research on this subject will enable us to create a safer healthcare system.

Why is Overwork a Problem?

Patient care suffers

Is it acceptable for seriously ill patients to be treated by physically exhausted and inexperienced physicians? One study done at the Medical College of Wisconsin in Milwaukee found that surgical residents were sleep-deprived, sleeping less that four continuous hours, on 89 percent of the on-call nights.

Many studies have been conducted that show that fatigued residents provide lower quality patient care. Well-rested physicians outperformed their sleep-deprived counterparts in tests of memory, mathematical skills, visual attention, concentration, electrocardiogram interpretation and anesthesia monitoring. When surgical residents were monitored while performing operations, those with less than two hours sleep the previous night gave an "inferior" performance when compared to rested surgeons. Inefficiency, indecision and poor planning accounted for more than 30 percent of the operating time. Chronic sleep deprivation may be even more of a problem.

Another study asked residents about the most serious mistake they made within the last year. Forty-one percent attributed the mistake to exhaustion. Similarly, Daugherty et al. reported findings suggesting that the most common cause of physician impairment is lack of sleep. One study found that even one night of sleep loss can affect creative thinking; it is no surprise that sleep deprivation is linked to medical misdiagnosis.

Patient care also suffers when decisions are made based on what is easiest and least time-consuming for the already overworked residents, instead of what is best for the patients. A study of surgical housestaff and medical students found that sleep deprivation, (4 hours or less of uninterrupted sleep per night) resulted in decreased motivation. In the middle of the night, in hopes of getting a little extra sleep, exhausted residents may ignore worried nurses’ calls or order a sedative instead of seeing the patient. An intramuscular drug may be given instead of replacing an intravenous line, ignoring the patients’ increased discomfort and the drug’s more erratic absorption. Residents brag about being able to convince attendings to discharge their patients earlier, since less patients means a lighter workload. If residents don’t factor in their own needs when making medical decisions, a 100-hour workweek may be turned into a 120-hour workweek.

Residents are supposed to be patient advocates. How can they fulfill this role if they work in a system that pits resident interest against patient interest?

Doctor-patient relationship suffers

The effect of sleep deprivation on physician attitudes is well illustrated in this intensive care unit diary entry written by a resident about events occurring in the very early morning. He begins by speaking about an asthmatic patient who may get transferred to the unit:

"I keep thinking he’s blue enough to go to the ICU. I keep hoping he’s too blue to go anywhere. Probably a nice man with a loving wife and concerned children, but I don’t want the SOB to make it because I’ve got one special who is going to keep me up two more hours…I don’t want the asthmatic SOB to live if it means I don’t sleep. I don’t want the special to live if it means I don’t sleep. I just want to sleep."

Many studies have found that fatigue has deleterious effects on moods and attitude. After one night’s sleep loss, mood disturbance increases, anxiety increases and motivation declines. Hostility and anger also rise with sleep loss and are more prevalent in residents at midyear compared to the beginning of residency training.

As fatigue and exhaustion mounts, physicians begin developing resentment toward patients. Patients also begin to resent the arrogant attitudes that develop in physicians. Dr. Timothy McCall wrote, "Too few residents emerge from training thankful for the opportunity to practice in a fascinating and intellectually challenging field. Instead, many believe that the world owes them something for what they have been through."

The physician-patient relationship becomes increasingly negative during the first year of residency training. Residency training often fails to provide young doctors with an environment that promotes professional attitudes and moral growth. How can we expect residents to care about patients when they are working in a system created without regard to their own needs? How can compassion be learned and preserved in a harsh and unforgiving environment? Barriers to the moral development of residents need to be removed.

Effects on residents’ lives

Overworked, exhausted residents oftentimes are unable to meet their own needs. There are 168 hours in a week. If a resident works 100 hours a week, sleeps 40 hours a week on nights off (five nights off With eight hours of sleep per night), plus the time needed to get ready for work, commute and run errands, few hours are left to spend with family and friends. In addition to this hectic schedule, residents are expected to read current literature, attend conferences and study for board examinations while off duty.

Many residents come home to their spouses, who haven’t seen them in days, and are emotionally and physically exhausted. A study found that over 40 percent of residents reported major marital problems, and 72 percent attributed these problems to residency training.³⁰ Residents not in a committed relationship have little time to form one. This also becomes a source of stress as many female residents are nearing the end of their safe reproductive years.

Beginning a residency involves dealing with much insecurity. Residents work in a very competitive environment and must assume a large amount of responsibility for medical decisions for the first time. They are constantly exposed to death and suffering. Studies have shown higher incidence of major depression than expected for that age group in the general population. It has been estimated that 30 percent of residents were depressed an average of five months out of their first year of residency. Especially vulnerable are female and/or unmarried residents. Stress and sleep deprivation may contribute to problems with substance abuse and suicide. Prolonged periods of duty without sleep adversely affect the psychological well-being of residents. "In view of the special vulnerability of medical trainees to occupational stress, all efforts are warranted to reduce sleep deprivation in the medical profession."

Young doctors may also be dealing with issues unrelated to their work, such as separation from their parents, marriage or raising children. Many residents relocate for their residencies as well, moving far from the friends and relatives who provided support. With so many hours spent working, they have little opportunity to develop new support systems.

Yet another concern of residents is getting themselves home safely. In 1999, a third-year resident from the Bronx was needlessly killed in a tragic car accident while driving home post-call. This death is even more troubling because it is not an unusual event. A study found that six out of seven surgical residents had fallen asleep at the wheel after being on call, and three had been involved in car accidents.

Other Countries

Though the United States has the best technology and science available, we trail other nations in protecting our patients and our physicians-in-training. Around the world, other countries have begun to regulate resident work hours:

• New Zealand passed laws years ago limiting their residents’ workweek to 72 hours. Surveys suggest they are being enforced.
• In 1991, the English Minister for Health, Virginia Bottomley, worked out an agreement with the medical profession to reduce the maximum workweek for resident physicians to 72 hours, and preferably, less. She stated, "This agreement will spell the end for the serious and potentially dangerous problem of junior doctors working unreasonably long hours.
• In 1992, Alberta became the first Canadian province to have a mandatory limit of 28 on-call hours for interns and residents. According to Dr. George Goldsand, associate dean of postgraduate medical education at the University of Alberta, the reason for the legislation is a concurrence that today, patients are sicker and on many call nights, residents may be up the entire night. "It is inappropriate for an individual who has not slept to continue to work and continue to provide safe and responsible patient care."
• In November 1999, the European Parliament voted to limit the number of hours logged by junior physicians to a maximum of 48 hours per week by the year 2003.

Potential Strategies to Addressing the Problem

Though the practicality of methods dealing with limiting resident work hours will depend on the specialty and the hospital structure, the variations in the possible strategies to accommodate the limits indicate that there is considerable potential for change. In a 1990 study of the economic impact of legislated limits on resident work hours in California, the Lewin/ICF research consulting group reported the results of a survey of program directors and administrators of 21 programs/hospitals who previously adjusted their programs to limit resident availability. Among the strategies that reportedly involved little additional financial cost are:

• Night float system—Night-time coverage is reorganized through reallocation of existing manpower. Call would be replaced by rotations of night-time duty by one or more residents. Studies of this type of shift system in the UK showed that average working hours could be reduced to below 64 hours per week without detriment to patient care and educational standards. Not only was chronic tiredness reduced, the formal hand-over between shifts resulted in more informed decision-making by the next shift.
• Redefine residents’ scope of work—Eliminate work that can be done by other personnel and which have no educational value. This includes paperwork, specimen delivery and patient transport. This may also mean scrutinizing which are teaching cases and which ones are not.
• Redefine nurses’ scope of work—Routine procedures can be shifted to nurses after proper training.
• Encourage interspecialty substitution—using residents or attendings in one specialty to cover for another stretches available manpower.

Other strategies that were also examined were to:

• Add a transitional year residency program—Add interns who would reduce the workweek and improve the call schedule for residents in all years.
• Add ancillary support positions—Hire additional personnel to perform non-patient care or non-educational tasks.
• Hire additional house physicians—These physicians would help provide coverage and decrease patient loads to a manageable and reasonable number for residents. This strategy is frequently used in the emergency room.
• Reinforce with community and voluntary physicians their responsibilities for direct personal care of their patients. This may include on-call evening, weekend coverage and increased supervision for residents on duty.

Research Questions

There are a number of research questions regarding resident-physician work hours that the American Medical Student Association feels are worthy ones to address:

• How many errors are committed by resident-physicians due to resident-physician overwork?
• How much would reducing resident-physician work hours cost hospital systems? How much money would be saved by reducing the amount of errors that overworked physicians cause?
• Do countries that have addressed this problem have residents that commit fewer mistakes than those in the United States?

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References

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Current as of September 2000

Internet Citation:

American Medical Student Association. Additional Statement. National Summit on Medical Errors and Patient Safety Research. September 2000. http://www.quic.gov/summit/aamsa.htm

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