Young Docs Are Now Allowed To Work Up To 28 Hours Straight
Leading body has enacted a new rule that will let first-year interns work on less sleep
Update 3/10/17: The Accreditation Council for Graduate Medical Education, the professional body charged with regulating how young doctors receive training following medical school, has moved ahead with a controversial rule that will let first-year residents work as long as 28 hours straight. The decision, announced Friday during the ASCME’s annual education conference, will lift the previous 16-hour limit but will maintain the absolute weekly 80-hour limit for all residents.
The ACGME, despite fierce criticism from some doctors who have argued that all residents should have shorter work hours to avoid sleep deprivation, claim the revision will give doctors more flexibility and practical experience with long shifts while improving patient safety by reducing how often patients are transitioned between doctors. The rule change, along with other revisions, is set to be enacted later this July.
Doctors are drawing battle lines over what might seem like the strangest of rights — the right to work (or not work) while sleep deprived.
In an op-ed for the Washington Post on Wednesday, Harvard Medical School doctors Christopher Landrigan and Charles A. Czeisler took to task the professional body responsible for regulating how the nation’s doctors get trained, the Accreditation Council for Graduate Medical Education (ACGME). They specifically singled out a proposed rule change that would allow first-year residents to work longer hospital shifts. Under the new guidelines, residents could work a maximum of 24 straight hours (with four added hours allotted to help transition a patient’s care between doctors), up from the previous limit of 16 hours. In keeping with the current rules, they would still be barred from working longer than 80 hours per week, and they could only take on a max of two 28-hour shifts per week.
Landrigan and Czeisler argued, however, that these precautions would do little to lessen the harm the change will cause both beginning doctors and patients.
“Sleep-deprived doctors cannot safely care for patients or themselves,” they wrote. “An enormous body of science demonstrates that sleep deprivation impairs resident physicians’ performance as much as being legally drunk.”
The current rules were put in place in 2011, following a warring back and forth between doctors about the merits of long shifts, which could run 30 or more straight hours. In 2008, the National Academy of Medicine (then the Institute of Medicine), a government-funded, but independently run organization that offers advice on national health policy, seemingly settled the debate with a lengthy report that reviewed the existing evidence.
The report concluded that “revisions to medical residents’ workloads and duty hours are necessary to better protect patients against fatigue-related errors and to enhance the learning environment for doctors in training.” It recommended the 16-hour limit (or a 30-hour shift broken up by 5 hours of sleep halfway through) for all residents, though the ACGME’s eventual new policy only applied that to first-year residents.
In 2015, however, the ACGME embarked on a review of their policy, funding two separate trials that compared the two systems head to head.
One trial, looking at residents in a surgical unit, was published last year and found there were no substantial differences in patient outcomes and the doctors’ wellbeing between the two groups of doctors, though those with longer shifts did report feeling less able to enjoy their free time. And the ACGME has cited these results, along with other new research, as a rationale for their proposed changes, which were announced last late year.
According to Landrigan and Czeisler, though, that study was fatally flawed, mainly because surgical residents are fairly unimportant in the operating room, and have little sway over their patients’ health. The other trial, of residents in a broader internal medicine program, is still ongoing, and its findings won’t be published until 2019, according to the study’s registration information on Clinicaltrials.gov.
Even without these studies, the case for lengthier hours isn’t entirely empty. Supporters argue that shorter shifts mean residents have to transition care between patients more often, a handing-off process that could open the gate to medical errors. In a February blog post for Health Affairs by Dr. Thomas Nasca, ACGME’s CEO, he also argued that residents, particularly in specialties like neurosurgery, will have to face long hours routinely in their career, so the more experience they have with them early on, the better.
But Landrigan and Czeisler, also sleep specialists at the Brigham and Women’s Hospital in Boston, believe these justifications fall flat. “While botched handoffs are an important source of medical error,” they wrote, “the solution to poor handoffs is not to avoid them, but to improve them.”
As with most things involving healthcare, our European counterparts have treated the question of shift hours drastically different. In 1998, the European Union passed a series of regulations applicable to all professions, including medical residents, that limited total work hours to no more than 48 hours per week and no more than 13 hours of consecutive work in any given day. Currently, however, only 6 countries (out of 27) have consistently held to these standards among residents.
In an email to Vocativ, ACGME spokesperson Paige Amidon said the ACGME’s decision wasn’t made lightly or without input from others. “A comprehensive review of the available research, along with testimony from over 120 organizations has been collected,” she said. “In addition, at the end of last year, public comments were solicited on the proposed revisions over a 45-day period from a wide range of stakeholders.”
“The ACGME is committed to developing requirements that foster a clinical learning environment that meets the needs of patients, residents, fellows, and faculty,” she added.
According to Amidon, a date for when the ACGME’s finalized rules will be announced or formally implemented has yet to be released. In the proposed revisions, however, the changes were set to be implemented for the upcoming 2017-18 graduate class.