As I rode my bike home the morning after finishing my first 28-hour shift at the hospital where I had just started as an intern, I made a confident turn onto a one-way street. But I was going the wrong way, smack into the path of a car heading in the right direction. Luckily, everyone was fine: The driver honked, I swerved, then made it home and fell asleep. When I woke up that evening, I was shaken by the certainty with which I had biked directly into oncoming traffic. What other unsafe things could I have done after being awake for more than a day?
As a resident in a family medicine program, during parts of the year I spend every fourth day working a 28-hour shift. My friends training to be surgeons have it even harder, routinely working 24 hours on, then 24 hours off. Our work week is capped at 80 hours.
Working long hours has become the norm in my life, but my friends outside of medicine are shocked when they hear about my schedule. How can I possibly make safe medical decisions while sleepy, they ask. Or they say, “I wouldn’t want a doctor taking care of me who’s been awake for that long.”
But to many in earlier generations of doctors, my hours are cushy.
The work schedule of medical residents and interns (first-year residents) is the subject of a fierce debate in academic medicine. Some say that making medical decisions after being awake for long periods is not good for patients or their doctors. Others argue that long shifts help interns and residents become better doctors by understanding the course of patients’ illnesses. At the center of this issue is a question for which we have surprisingly little data: What is best for our patients?
I started thinking hard about the “duty hour debate,” as those of us who work in teaching hospitals call it, when I learned that I was an unwitting participant in a nationwide study called iCOMPARE that was being done to examine the effects of long shifts on the safety of hospitalized patients and the well-being of the first-year residents caring for them. I was a guinea pig in the experimental arm, meaning I could work shifts longer than 24 hours. Those in the control arm could work only a maximum of 16 hours straight. The weekly limit in both groups was 80 hours. (A similar trial, called FIRST, looked at work hours among interns in surgical specialties.)
The 16-hour cap on shifts in the control group is the norm for most American medical residents, under guidelines set out in 2011 by the Accreditation Council for American Graduate Medical Education. Just last Friday, however, the council proposed that all residency programs let their interns work 28-hour stretches. The proposal, which is open for public comment until Dec. 19, is big news for doctors-in-training.
My first 28-hour shift (the one preceding my wrong-way bicycle escapade) was one of the most stressful experiences of my professional life. I suddenly found myself acting as the go-to doctor covering 50 patients overnight. I remember shedding tears of relief and exhaustion when I finally shut the door to the call room around 3 a.m., only to be quickly summoned back to duty by another buzz of my iPhone.
I’ve made mistakes on these long shifts: ordered tests on the wrong patient, requested incorrect doses of medications, confused a Mr. Jones and a Mr. James. Most doctors I know say they, too, have made similar slipups when sleepy. There’s good evidence that cognitive impairment comes with sleep deprivation and, as much as physicians like to convince themselves otherwise, we aren’t immune.
But shifts that are too short can also be dangerous. The transition between teams, the so-called handoff when the day doctors go home and the night crew arrives or vice versa, is a uniquely vulnerable time for hospitalized patients. Suddenly, the providers who planned how to take care of a patient have left the hospital, and the new team is responsible for picking up midstream. It’s like stepping in to a movie that’s already half over. And just as certainly as I have made mistakes after being awake for more than 24 hours, I have also made mistakes when taking over the care of a complicated patient in the middle of his or her hospital stay.
Plenty of evidence has accumulated about the risks of sleep deprivation. But we don’t have much evidence about whether handoffs between teams are more or less dangerous than sleepy residents. We also don’t know if we have created a false opposition between the two. Perhaps if we improved communication during handoffs, used technology more effectively, and learned to be better team players, handoffs would become safer.
Residency programs have an educational mission, and many physician teachers make the argument that part of learning to be a doctor is following a patient over the course of his or her hospital stay, making independent management decisions, and seeing the consequences of those decisions. They argue that’s possible only during a long shift. These tradeoffs are what iCOMPARE and FIRST are trying to understand in a more rigorous way.
Preliminary results from FIRST were published earlier this year in the New England Journal of Medicine. The researchers concluded that long shifts for interns produce “noninferior” outcomes for patients — meaning they aren’t worse for patients than the short shifts. The iCOMPARE team finished collecting data this summer, and the results are yet to be reported. Even then, the debate will undoubtedly continue.
As a second year resident, I now take 28-hour calls without a supervisor by my side. Being in iCOMPARE prepared me well for this. Given that such shifts are routine for more experienced residents, I think it’s important for interns to do them. I also think that my increasing responsibilities will make me a better doctor. There is no substitute for making a difficult choice alone in the middle of the night. There is no substitute for looking my patient in the eye after my decision made him or her better — or worse. For these reasons, I’m in favor of the new guidelines allowing longer shifts.
But the idea that only one doctor can take responsibility for an individual patient — and so must always be available — is a myth, part of the outdated physician-as-God complex that degrades our profession and alienates our patients.
When we see ourselves as a team and communicate as one, and when we share responsibility for our patients and our work, those 28-hour shifts become a little more bearable and, I believe, safer. The choice should not between more handoffs and longer shifts. Instead, we should be working to make both better.
If we want to be effective and humane doctors, we need long hours with our patients and long hours with the rest of our lives.
Mara Gordon, MD, is a resident in the Department of Family Medicine and Community Health at the University of Pennsylvania.