Does More Sleep Make for Better Doctors?

By PAULINE W. CHEN, M.D.
05 dec 2008--This week a national panel of health care experts released a report affirming the current mandate that limits the workweek for medical residents to 80 hours and offering additional recommendations to decrease fatigue for doctors-in-training.
The report, “Resident Duty Hours: Enhancing Sleep, Supervision, and Safety,” from the Institute of Medicine, encourages graduate medical education programs to embrace a new culture of training, one that emphasizes patient safety and the importance of sleep. It’s an impressive assessment, at 480 pages, but reading through it I could not help but wonder if in our attempts to solve one set of problems, we will find ourselves facing another.
It reminded me of an aphorism I think of each time I prescribe or operate: every treatment is a double-edged sword. The aspirin that relieves pain can cause intractable bleeding; the chemotherapy that arrests cancer can carry debilitating side effects; and the operation that replaces diseased livers requires toxic immunosuppressive drugs.
Even the best attempts at cure do not come without strings attached.
Residency training, the three to seven or more years following medical school, has historically been the most intense period of a doctor’s professional life. In teaching hospitals and large academic medical centers across the country, freshly minted doctors balance learning myriad clinical skills with serving on the clinical front line. Residents are often the first doctors to see a patient in the admission process and in hospital emergencies. And up until relatively recently, they shouldered these responsibilities while working 110 hours a week or more.
I finished my general surgery training in 1998, five years before the national accrediting organization for residency programs set a limit of 80 hours per workweek for residents across the country. I worked on average 110 to 120 hours per week and had my share of being on call every other night. Like many of my peers, I know about fatigue so overpowering that the odor from your pores smells not like nervousness or exertion but exhaustion. I have experienced the teeth-chattering chill of the early morning, which never leaves despite two layers of clothing, a sweatshirt and a doctor’s coat. I remember that falling asleep at 5 a.m. for an hour before rounds does more harm than good. And I can tell you that a quick but well-timed morning shower after being up all night is the physiological equivalent of a two-hour nap.
This is not the kind of wisdom or experience I think anyone should ever have.
But I can also say that I, like many of my peers, had unparalleled experiences and freedom in residency because our time with patients was not restricted. And a part of me, I have to admit, feels badly for the young doctors and future patients who may not have a chance for the same because of the way we choose to address the problem of resident fatigue.
I was in the hospital a lot, but I was also part of a team of residents, residents who were always available to share in the workload and cover for one another if we had to run a personal errand, make a long overdue phone call or needed a nap because of a tough night on call.
Moreover, I had the privilege of being considered a patient’s dedicated doctor. I had the opportunity to work and care for a wide variety of people who became sick not at predetermined intervals but at unpredictable hours of the day and night. I worked with them as they came into the hospital and had the time to hear the stories of their lives and to learn the nuances of their diseases and personal biology. I was able to forge the kind of strong personal and clinical connections that helped me offer them more relevant, sometimes lifesaving, clinical care. I never had to resort to the simulated patients, computer-generated cases or foam rubber suturing set-ups that educators are now using increasingly in order to round out clinical experiences.
And unlike the young doctors of today, I never had the burden, at the 78th hour of my workweek, of deciding how I would spend my last few hours in the hospital and what might be most important to my education. I had the luxury of never having to choose between spending more time with patients and their families, scrubbing in on a rare operation, or discussing a worrisome patient case with an attending surgeon or senior member of the resident team. I did not feel pressed to maximize my clinical learning within a certain amount of time but could linger, hover even, at my patients’ bedsides to hear all they wanted to tell me about their illness experience and not just what I, with my relative clinical and personal inexperience, might have deemed as the important facts.
And at the end of five years after all those hours, I felt I had acquired the kind of clinical confidence that comes from having done all the required major and minor operations of my field, and from having participated in the pre-operative and post-operative care of those patients. I finished my residency as a fully trained surgeon comfortable not only with taking out a gallbladder and removing a tumor, but also with operating on the wide range of individuals who might walk through my office door and caring for almost any of their complications or complexities. That level of comfort came from the hours I put into my training and the experiences I acquired.
I agree that exhaustion is not good for residents, or for patients, and that an increased emphasis on patient safety and the importance of sleep is clearly needed in the medical profession. But I can’t help but wonder if we may also risk losing something by trying, prematurely perhaps, to fit the unpredictability of the illness experience and the individuality of human relationships into a scheduling grid that has little proven efficacy.
Some of the Institute of Medicine’s recommendations are simply part of good patient care. Supervision by experienced physicians is always critical, and the more supervision, the better. It makes sense, too, that we need to pay close attention to the process of transferring patient responsibility, the “handover,” and that residents should spend less time with non-educational work, such as retrieving X-rays and scheduling tests.
But it’s unclear to me that we are doing the best by our patients, and ourselves, by reaffirming the 80-hour cap, as the Institute of Medicine committee report has done. Yes, fewer hours overall and a mandatory five-hour sleep break during long shifts would likely be helpful, but we are not even completely sure that setting a weekly limit of 80 hours will do what we think or hope it might do. Instead, perhaps we should put the $1.7 billion dollars per year that would be required for the institute’s recommendations into research first on our current situation.
There is, as the expert panel was quick to concede, little conclusive data on the effects of the current residency duty hour limits. In fact, there have been few, if any, large-scale studies on how strictly residency programs have followed the 2003 mandate; which scheduling adjustments have worked, or have not; how the quality of resident education might have been affected; and, most importantly, exactly how patient safety may or may not have been compromised.
As Dr. Michael M. E. Johns, chairman of the expert panel, remarked at a public briefing on the report on Tuesday, “While the science on sleep and human performance provided a rich evidence base for duty hour adjustment, there was limited data on the impact of the 2003 limits on actual hours worked, scheduling practices, education and patient safety.” In other words, in the realm of resident duty hours reform, there isn’t really enough information to make solid evidence-based recommendations.
In fact, the much-touted cap of 80 hours is hardly based on scientific evidence or extensive testing. In a letter last year to The Journal of the American Medical Association, Dr. Bertrand Bell, who was crucial in getting residency reforms passed in the 1980s, wrote, “The specific ’80-hour week’ was actually determined by a colleague on my porch and was based on the following informal reasoning....” That reasoning included, as Dr. Bell continued in the letter, the idea that “it is reasonable for residents to work a 10-hour day for 5 days a week [and] it is humane for people to work every fourth night.” After a series of mathematical calculations, his colleague came up with the now hallowed figure. And “eureka,” Dr. Bell wrote, “that equals an 80-hour week.”
The medical profession needs to address how we can create a safer environment for patients and a more humane workplace for residents. And the recent Institute of Medicine report is an important first step. But the takeaway message is not that we should proceed with costly reforms but that we desperately need more research on what changes have already been made.
Further resident duty hours reform without adequate evidence could lead to an entirely different and equally difficult set of problems for doctors and patients. It could fundamentally affect how we interact with one another. We as patients might have to work a little harder to recall the name of the doctor watching over us on the current shift. We might have to adjust our expectations of those physicians and surgeons caring for us, as the clinical experience of future doctors could be vastly different from that of the doctors we see now. And in a culture of handovers and shifts, where individuals are interchangeable, we might have to accept that each of us, doctor and patient, and our individual contributions to the doctor-patient relationship, would no longer be as unique as we might otherwise have once liked to believe.
Because even the most well intended reform efforts will not come without strings attached.