The Phantom Menace of Sleep Deprived Doctors
as published in the New York Times
By DARSHAK SANGHAVI
Published: August 5, 2011
Last month something extraordinary happened at teaching hospitals around the country: Young interns worked for 16 hours straight — and then they went home to sleep. After decades of debate and over the opposition of nearly every major medical organization and 79 percent of residency-program directors, new rules went into effect that abolished 30-hour overnight shifts for first-year residents. Sanity, it seemed to people who had long been fighting for a change, had finally won out.
A Life-Changing Case for Doctors in Training (March 3, 2009)
Of course, the overworked, sleep-deprived doctor valiantly saving lives is an archetype that is deeply rooted in the culture of physician training, not to mention television hospital dramas. William Halsted, the first chief of surgery at Johns Hopkins in the 1890s and a founder of modern medical training, required his residents to be on call 362 days a year (only later was it revealed that Halsted fueled his manic work ethic with cocaine), and for the next 100 years the attitude of the medical establishment was more or less the same. Doctors, influenced by their own residency experiences, often see hospital hazing as the most effective way to learn the practice of medicine.
But over the last three decades, a counterpoint archetype has emerged: the sleep-deprived, judgment-impaired young doctor in training who commits a serious medical error. “Doctors think they’re a special class and not subject to normal limitations of physiology,” says Dr. Christopher Landrigan, an associate professor at Harvard Medical School and one of the most influential voices calling for work-hour reform. A large body of research on the hazards of fatigue ultimately led to the new rule on overnight shifts by the Accreditation Council for Graduate Medical Education, the independent nonprofit group that regulates medical-residency programs.
More than anything else, it was the death of 18-year-old Libby Zion 27 years ago that served as a catalyst for reform. Zion was jerking uncontrollably and had a fever of 103 degrees when she was admitted to New York Hospital on March 4, 1984. After she was admitted, Zion was given Tylenol and evaluated by a resident and an intern. They prescribed Demerol, a sedative. But her thrashing continued, and the intern on duty, who was just eight months out of medical school, injected another sedative, Haldol, and restrained her to the bed. Shortly after 6 a.m., the teenager’s fever shot up to 108 degrees and, despite efforts to cool her, she went into cardiac arrest. Seven hours after she was admitted, Libby Zion was declared dead.
Libby’s father was Sidney Zion, a columnist for The Daily News. When Zion learned that his daughter’s doctor had by then been on duty for almost 24 hours and that young doctors were routinely awake for more than 36 hours, he sued the hospital and doctors and publicized the conditions he was convinced had led to her death. Stories about overtired interns appeared in major newspapers and on “60 Minutes.”
Reforms followed, albeit slowly. In 1989, New York State cut the number of hours that doctors in training could work, setting a limit of 80 hours per week. And in 2003, the accreditation council imposed the 80-hour limit on all U.S. training programs, prohibited trainees from direct patient care after 24 hours of continuous duty and mandated at least one day off per week.
To Landrigan, this was tremendous, if incomplete, progress. He ran a yearlong study during which a team of interns at Brigham and Women’s Hospital worked alternate rotations, one on the traditional schedule — a 30-hour shift every third night — and the other on a staggered schedule, during which the longest shift was only 16 hours. The results, published in 2004 in The New England Journal of Medicine, shocked the medical world. Interns working the traditional 30-hour shifts made 36 percent more serious medical errors, including ordering drug overdoses, missing a diagnosis of Lyme disease, trying to drain fluid from the wrong lung and administering drugs known to provoke an allergy. Thomas Nasca, the director of the accreditation council, cites this data as the single strongest argument for limiting doctors’ work hours.
But this is where the neat story of the correlation between doctor fatigue and hospital error hits a wall. Landrigan’s research was compelling, but his study was small and controlled. In normal, day-to-day practice in hospitals across the country, medical errors didn’t fall when work hours were reduced. A massive national study of 14 million veterans and Medicare patients, published in 2009, showed no major improvement in safety after the 2003 reforms. The researchers parsed the data to see whether even a subset of hospitals improved, but the disappointing results appeared in hospitals of all sizes and all levels of academic rigor. “The fact that the policy appeared to have no impact on safety is disappointing,” says David Bates, a professor at the Harvard School of Public Health and a national authority on medical errors.
Darshak Sanghavi (firstname.lastname@example.org) is the chief of pediatric cardiology at UMass Medical School and Slate’s health care columnist.