Medical Trainees Need Their Sleep

Getting five or six hours of sleep — not unusual for many of us — can not only hamper one’s kavanah in davening but can leave a driver impaired to a degree that’s similar to drunkenness. That latter finding comes from a study released this month from the AAA Foundation for Traffic Safety: Drivers who sleep only five or six hours in a 24-hour period are twice as likely to crash as those who get seven or more.

The finding led AAA’s director of Traffic Safety Advocacy and Research Jake Nelson to recommend that, “If you have not slept seven or more hours in a given 24-hour period, you really shouldn’t be behind the wheel of a car.”

Or, one might logically conclude, making medical judgments or performing surgery.

It’s an especially timely conclusion, because the organization that makes the rules for medical trainees — the Accreditation Council for Graduate Medical Education (ACGME) — is proposing that the current number of consecutive hours that young doctors can work be increased, from 16 hours to 28.

Ten years ago, a medical intern could be on duty for 30 hours straight. The Institute of Medicine said that was unsafe. A few years later, at the request of Congress, that physician body asserted that the limit for shifts should be 16 hours. (Or 30 hours with a “5-hour protected sleep period” in the middle.)

In 2010, the ACGME changed its rules accordingly, at least for first-year residents. Now, though, it is seeking to again raise the limit, substantially.

The group said the 28-hour maximum is “based on new evidence, research and expert input.” Among the new evidence was a large survey of surgical outcomes published by The New England Journal of Medicine that found that for surgical residents, “Less-restrictive duty-hour policies were not associated with an increased rate of death or serious complications.”

The study, however, did not compare the actual hours worked by residents, only the guiding policies; and it didn’t take into account how mistakes made by exhausted trainees may have been prevented or rectified by nurses or colleagues. And having safeguards against error shouldn’t justify promoting error.

Letting first-year doctors work 28 hours, argues ACGME, “puts first-year residents on the same schedule with other residents, and is a commitment to team-based care and seamless continuity of care that promotes professionalism, empathy, and commitment among new physicians.”

In other words, the “tradition” and “professional culture” in hospitals trumps all. Is that, though, really reason enough to push young physicians up to, or beyond, reasonable limits of sleep deprivation?

And in the background here, too, is the fact that residents are an inexpensive source of labor for hospitals, compared to senior doctors.

Even though residents are licensed M.D.’s often working 80-hour weeks — and often on the least desirable tasks at the least desirable hours — they make relatively little money. Their per-hour wages are often less than those of most support staff at the hospital. When they complete their residency programs, the same doctors can make many times their residency wages. But as residents, they are a good deal for hospitals.

The reason that resident labor is so cheap is because residents’ salaries are in most cases paid by the federal government, drawn from Medicare and Medicaid. The cost to taxpayers is around $5 billion, though profit from the work of residents goes to the hospital. It has been estimated that hospitals can turn a profit on residents’ work of as much as $100,000 per resident. There are costs to hospitals, too, for running residency programs, but, in the end, they gain.

The FAA limits pilots’ flight time to eight or nine hours, depending on the start time of the pilot’s entire flight-duty period. And it mandates a 10-hour minimum rest period. prior to the flight duty, and that period must allow for eight hours of uninterrupted sleep.

Truck drivers in the U.S. are required to take a full 8 hours of rest in each 24-hour period, with 2 additional hours allowed for off-duty periods.

Pilots are responsible for the safety of the large number of passengers on their planes. And truck drivers’ errors can result in terrible road accidents. But medical residents, too, make decisions about people that can spell the difference between life and death.

The current 16-hour maximum shift is itself very demanding. But its establishment represented a movement in the right direction. Raising it to 28 is a major jump in the wrong one.