First Year Residents Face Grueling 28-Hour Shifts
Med students, get ready for some grueling shifts. Beginning July 1st, doctors in their first year of practice will be allowed to work shifts up to 24 hours long in direct patient care in hospitals all over the United States. The move lifts the 16-hour limit that has been in place since 2011.
The change was approved by the Accreditation Council for Graduate Medical Education. Supporters of the change argue that the move will reduce the number of shift change handovers from doctor to doctor, and thereby enhance patient safety. They also believe that doctor education will be improved, since doctors will be able to observe critical patients and the effects of treatments longer after admission.
The American College of Surgeons has also argued that shorter shifts degrade patient care because of the higher number of patient handoffs, and also that doctor education suffers because doctors often don’t get a chance to see a case through to the end.
The new set of standards will allow up to four hours of shift overlap to transition patients from one doctor to another, so the total actual shift could last as long as 28 consecutive hours for first-year residents.
The Institute of Medicine, however, had already banned the practice of requiring residents to work as long as 30 consecutive hours.
The public advocacy group Public Citizen has come out opposing the measure, calling the ACGME’s decision “reckless.” “Fourth-year medical students across the country are now bracing themselves for inhuman shifts that will require them, just after graduating from medical school, to make life-or-death medical decisions and to drive home while sleep-deprived for 28 hours or longer,” said Public Citizen’s Health Research Group Director. “The ACGME’s adoption of this dangerous proposal displays a reckless disregard for the lives and health of thousands of medical residents and their patients nationwide.”
The president of the American Medical Student Association, Dr. Kelly Thibert, has also come out strongly opposed to the increased limit: “Extreme sleep deprivation and long hours are a holdover from the early 20th century when residents literally resided in the hospitals in which they trained,” argues Thibert. “There is no reason to continue to subject medical trainees to mental and physical exhaustion for years on end, with the harm that ensues to them, their families and their patients, simply to maintain an archaic tradition.”
For its part, the ACGME argues that studies have not shown that longer shifts and the attendant potential for sleep deprivation and fatigue have not negatively affected patient outcomes. On the other hand, the more doctor handovers at shift change, the more opportunity there is for a communications failure and medical error.
That said, physician burnout and even physician suicide are serious problems in the medical community. But Rowan Zetterman, MD, co-chair of the ACGME task force that gave the ok to the longer shift limits for first year residents, argues that there’s no direct correlation between physician burnout and shift length. For example, Dr. Zetterman notes that residents in emergency services are limited to 12-hour shifts but still experience high levels of burnout, according to reporting by Medscape Medical News.
Ok, we’re not quite sure how he thinks this advances his position. But the argument that shift change causes substantial opportunities for medical error due to doctor handover is well taken. A recent study published in the New England Journal of Medicine found that longer shifts for residents do not pose a net safety risk for patients. Public Citizen’s Medical Research Group, for its part, has attacked the study’s methodology, arguing that patients in the longer-shift group did not give informed consent before participating in the study, nor did the residents.
At the same time, a study published in the Journal of the American College of Surgeons found that burnout among general surgery residents had reached epidemic proportions, with over 2/3rds of the 665 residents surveyed actively engaged in clinical training met the criterion for burnout on at least one subscale. And contrary to Zetterman’s claims, the study showed that burnout levels were, indeed, correlated to higher numbers of work hours, per week, though that is a different measure than shift length.
The ACGME mandates that hospital schedulers must provide not less than 8 hours’ rest between shifts, and at least 14 hours off after they have worked 24 hours in a row.
What To Do Now
- Medical students should work to prepare families for longer shifts, and strive to love as close to training hospitals as possible, in order to limit commute times. Start working on childcare and transportation arrangements ahead of time.
- Residents in good physical condition will have an easier time managing the stress, so hit the gym, and continue to hit the gym regularly in residency to maintain alertness and physical fitness. Good, short, intense workouts, such as tabatas, can do wonders to boost metabolism and promote fitness while being over in a short time, so as to preserve more scarce time between long shifts for recreation, family time and, indeed, sleep!
- Residents facing long shifts must be disciplined with their time between shifts. Learn to say ‘no’ to social commitments when they interfere with critical sleep time.
- Stay in close touch with trainers. The ACGME is not completely blind to the risk of burnout – especially when combined with personal stressors, and is urging trainers to pay more attention to the physical and mental health of young doctors working these grueling shifts.
- Live on less than you make. 24-hour shifts are manageable in most fields. But the combination of 24-to-30 hour long shifts with severe financial stress will drive many people to their emotional breaking points. Arrange your lives so you can spend time stressing about providing better care for your patients, and not how you’re going to make your car payment this month. And skip the high-dollar vacations for a while.
- Read our post on how to prevent or manage physician burnout.
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