Most Residents Break Work Limits, Many Pay Price in Self-injury

Study Authors Call for Further Cuts in Hospital Hours

A young doctor’s life at the turn of the 19th century was one of monklike austerity. Medical residents lived in the hospital, were not allowed to marry, and socialized almost exclusively with one another. One thing they were not called upon to sacrifice was sleep. This was true through the mid-20th century, when the renowned HMS cardiologist Eugene Braunwald was completing his medical training. “He told me that though they lived in the hospital, the labs were closed at night, there were no intensive care units. Sleep was not really an issue,” said Charles Czeisler, the Frank Baldino Jr., PhD, professor of sleep medicine at Brigham and Women’s Hospital and director of the HMS Division of Sleep Medicine. Patients were admitted and discharged during the day, which is also when procedures were done, making nights in the hospital almost tranquil. “A colleague from that era told me that the only time they were up at night was when they were breaking into the vending machines.”

Photo by Graham Ramsay

“What we are showing in these papers is really common sense,” said Charles Czeisler (right). “It’s not rocket science to figure out that someone who has been working for 29 consecutive hours is going to have a greater risk of injury than if he’s been working six hours.” Czeisler is shown with co-author Christopher Landrigan.

When residents raid candy and coffee machines today, it is rarely on a lark. Though they no longer live in the clinic, they can spend 30 consecutive hours in the hospital, much of that time on their feet working. And they may do so several times a week. “One of the biggest changes in medical training has been the demand for continual wakefulness,” said Czeisler.

Over the past 20 years, he and colleagues have been looking at the effects of extended work shifts on interns and residents. In the past two years, they have published studies showing that sleep-deprived doctors are significantly more likely to make errors while diagnosing and treating patients and that they are twice as likely to have a car accident on their way home from a 30-hour shift. A new study appearing in the Sept. 6 Journal of the American Medical Association suggests that physicians may be endangering themselves even before they set foot outside the hospital.

The Intern’s Catch-22
Najib Ayas, Czeisler, and colleagues surveyed 2,737 first-year residents every month for nearly a year. One third of the interns said they had stabbed themselves with a contaminated needle or scalpel while working an extended shift. In specialties such as surgery and obstetrics and gynecology, the rate of self-reported injuries was so high as to suggest that, on average, nearly every intern had experienced such a mishap. Fatigue was cited by the residents as the major cause of the accidents.

“It is not so much an issue of them hurting themselves; it is more, will they get HIV or hepatitis C or these kinds of things?” said Ayas, assistant professor of respiratory medicine at the University of British Columbia, Vancouver.

An obvious solution to the problem is to limit the number of hours doctors work. And yet in a study appearing in the same issue of JAMA, Christopher Landrigan, Czeisler, and colleagues found that interns routinely violate such standards. Work-hour limits were set by the Accreditation Council for Graduate Medical Education in 2003 in response to growing public concern about the risk to patients of extended physician work hours. The ACGME stipulated that over the course of a month, residents could work no more than an average of 80 hours per week; they must take off an average of one day in seven; and they could work no more than 30 consecutive hours, and not more than twice a week.

Landrigan, HMS assistant professor of pediatrics at BWH and Children’s Hospital Boston, Czeisler, and colleagues surveyed the behavior of 1,278 interns in hospitals across the country during the first year that the limits took effect. They found that 84 percent of interns violated the ACGME standards during at least one month. “The 30-hour rule was the most frequently violated, but violations of the 80-hour rule and the seven-day rule were likewise pretty frequent,” said Landrigan.

The researchers believe that the two JAMA studies paint a troubling picture of current residency programs. “I think that the evidence is crystal clear at this point that work shifts of greater than 24 hours in a row are not safe and yet our standards continue to allow them,” said Landrigan.

Between a Rock and a Hard Place
Debate over medical residency programs—which were originally designed to ensure that doctors had hands-on experience before hanging up a shingle—has a long history. The argument tends to swing between two poles: the need for thorough training and the physical limits of residents. Czeisler entered the fray in 1983, when he was invited by former HMS dean Daniel Tosteson to speak to the HMS faculty about the effects of sleep deprivation on physicians. In his lecture, Czeisler discussed his research on the effects of shift- and night-work on the sleep–wake cycle. “To my surprise, at the end of the presentation, they said the rebuttal is to be given by the chief resident in surgery at the Brigham,” Czeisler recounted. “He said my talk was interesting, but had nothing to do with what they were doing in surgery because they had a very regular schedule of 36 hours on and 12 hours off. So they were not doing shift work.”

Soon after, Czeisler began studying a small cohort of interns who were on extended work schedules at the Brigham and found that nearly three quarters had experienced an actual or near-miss motor vehicle accident. In 2002, he and his colleagues began a larger prospective cohort study to look at the impact of extended-duration work on patient safety, motor vehicle crashes, and occupational safety, in particular, percutaneous injuries such as needle and scalpel lacerations. Participants answered a monthly questionnaire about a wide variety of behaviors. Questions relevant to the current JAMA study on self-inflicted injuries included whether or not the interns had been exposed to contaminated fluids and, if so, whether it involved a needle stick or scalpel laceration. They were also asked where and when—time of day and point during a shift—the injury occurred and also to choose from a list of possible causes, such as lapse of concentration and fatigue.

Interns reported a total of 498 percutaneous injuries, which were sorted into categories according to whether they occurred during the day or night and whether they occurred during an extended work shift or not. The rate of daytime injuries following an extended shift was 61 percent higher. Overall, the rate of nighttime injuries was twice as high as daytime injuries. Fatigue was marked as the cause in 56 percent of nighttime injuries and in 30 percent of all injuries.

Czeisler believes the ACGME standards do not go far enough. “We have a system in which young trainees are being asked to work these extraordinary schedules that are not consistent with any other industry in the United States,” he said. “They are way above the hazard level for all safety-sensitive industries that have been established, whether it be airline pilots or nuclear power plant operators. But it is almost viewed as a badge of honor and something that they have to prove—and they have to prove this in order to get professionally licensed. Unfortunately, they are putting their patients, their families, themselves, and other motorists at risk in the process and, unlike an episode of the TV show Survivor, there is no safety net under the participant.”

—Misia Landau

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