One evening in May, 1999, when I was an intern, I fell asleep at the wheel driving home from a 36-hour shift at the hospital. Drives like that occurred not infrequently in those days, and I had developed techniques to fight off fatigue. Singing at the top of my lungs was one. Opening my car window wide to the brisk Chicago winds was another. Sometimes I had to combine one or both of these with a third, literally prying open an eyelid with one hand while steering with the other. I am embarrassed to reveal today how poor my judgment was then. How could I have taken such risks, endangering not only myself but others as well? I have no excuse, only a feeble explanation: I longed for the semblance of a normal life outside the hospital, and on that particular occasion I was supposed to meet friends for pizza.
My defenses gave way upon arriving first in line at a red light. I drifted off, and, relaxing my foot off the brake pedal, drifted out. I was awakened when my car, a Honda hatchback, seemed to explode. I had been struck by the first two vehicles in cross-traffic, an Audi and a Jaguar. The Honda was totaled, but thankfully I was the only person hurt. For the last 27 years I have suffered from a chronic irritability of the muscles of my neck, for which I am grateful. These spasms are better than being dead, and are a substantial improvement over the flaring agony I used to suffer several times a year for a week at a time.
A Step Backward on Residency Hours
The memory of this accident has returned with the news that the Accreditation Council for Graduate Medical Education (ACGME, the body that regulates medical residencies) will vote in February on a new proposal to loosen restrictions on resident duty hours (see the Health Affairs Blog post by the Chief Executive Officer of ACGME, Thomas Nasca, MD). The restrictions in question, which did not exist when I was in training, limit consecutive work-hours for first-year residents to 16, and more senior residents to 24. The new proposal would allow residents at all levels to work up to 28 consecutive hours and, in a Kafkaesque twist, would require training programs to provide 24-hour access to mental health services in order to deal with the resulting depression and anxiety.
How can it be anything other than reckless for physicians at any level to work more than 24 or even 16 consecutive hours? Is there any other profession, much less one upon which the lives and health of others are so dependent, that has a similar expectation of its workers?
The background of this issue is well known. Throughout most of the history of modern American medical training, residency was brutal, with 36-hour days alternating with one to three 12-hour ones. Indeed, post-graduate trainees are called "residents" because they used to reside in the hospital, there being no reason for them to have a dwelling elsewhere. In the aftermath of the 1984 Libby Zion case, in which the death of an 18-year-old woman in New York City was attributed to the exhaustion of the residents taking care of her, work hour restrictions were adopted by the State of New York. Starting in 2003 the ACGME required similar restrictions as a condition of accreditation nationwide.
Problems with the ACGME Proposal
The proposal now before the ACGME to relax these restrictions is modeled after conditions tested in the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial, published in The New England Journal of Medicine in 2016. The FIRST trial randomized 117 general surgery training programs to either the 2003 or the proposed new guidelines. The main findings were that relaxation of work hour restrictions had no measurable impact either upon the incidence of patient death or serious complications, or upon resident perceptions of well-being. But as large as this study was, it was statistically powered to detect differences greater than only 13 percent between the groups, thus limiting its potential to identify uncommon but potentially significant adverse patient events. An even greater limitation is that there was no attempt to identify adverse outcomes occurring among individual residents, such as automobile accidents, withdrawal from training, and suicide.
Stack these results against research demonstrating significant impairment due to sleeplessness. One such report examined subjects exposed either to alcohol or, at a separate time, to sleep deprivation. It demonstrated that by 17-23 hours after waking, sober subjects experienced deterioration in standardized tests of reaction time, dual-tasking, hand-eye coordination, vigilance, and spatial memory equal to that of the same individuals when intoxicated.
In addition to the FIRST Trial data, other arguments have been advanced to support a relaxation of work-hour limits for medical trainees: 1) Continuity of patient care suffers in the handoffs between one resident shift and another; 2) Residents watching the clock might have to leave in the middle of an episode of care, regardless of how instructive it is; 3) Trainees need to acquire a commitment to altruism, placing the needs of patients above those of the physician; 4) Physicians in practice, unlike trainees, have no work-hour restrictions, and residents need to be conditioned to such circumstances.
Some of these arguments, like the dangers inherent in handoffs, hold water. But the proper solution is to find ways of making handoffs safer, not replacing those perils with others of equal or greater consequence. Similarly, we need to identify better alternatives with which to educate and to inculcate values than sleep deprivation. The claim that trainees should be habituated to sleeplessness because physicians in practice have no work hour restrictions is simply nonsensical. First, conditioning to sleeplessness has never been demonstrated. Second, a true concern for patient and physician safety should impose restrictions upon all physicians, not just trainees, like those that exist for pilots, truck drivers, and soldiers in training.
To this day I think of my automobile accident as a "near miss," despite the fact that it resulted in a collision. My judgment was impaired when I was young and sleepless, but at least I learned my lesson. The ACGME should do the same. Find healthier ways to train our healers.
from Health Affairs BlogHealth Affairs Blog http://ift.tt/2mmw6tu
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