Somewhere around the eighth hour of my 28-hour shift in the hospital, a nurse told me that a patient had just been transferred from the intensive care unit to my floor. I stopped by the patient’s room to introduce myself. It was just after lunchtime, and Ms. S’s room was overflowing with family members who had flown in to be nearby because she was in critical condition; they were now celebrating her improvement.
I chatted with Ms. S, examined her, reviewed her medications, and answered questions that she and her family had. At some point, the conversation turned nonmedical. Standing by the window, I remarked on the view of Boston’s Charles River below. I mentioned to the family that whoever was still in her room the next morning would be treated to a beautiful view of the boat-laden Charles at sunrise.
Ms. S’s mother, “Nana,” was pleased by that idea. She joked that I would likely be at home in bed, hours asleep, by the time the sun rose the next morning.
Not giving it too much thought, I lightheartedly corrected her. I told Ms. S and her family that I’d be working in the hospital all night. I’d seen the sunrise over the Charles on my way into the hospital that morning and would still have several hours left in my shift after tomorrow’s sunrise.
Although I made that statement to assure them that there would be continuity to Ms. S’s care, it didn’t have the desired effect. Nana liked boats and rivers. She did not like the idea of tired doctors taking care of her daughter.
Before I realized that Nana was worried, she politely asked me to explain how long I would be in the hospital and how much of that time I would be awake.
“Twenty-eight hours, ma’am, and likely all of it,” I answered.
Catching on to Nana’s concern, I tried to convince her that it wasn’t that bad. I’d slept well the night before. I would eat meals provided by the hospital. There was even a stash of orange juice, ice cream, and peanut butter I could dip into during the wee hours of the morning if I needed a bit more energy. But that explanation didn’t work. Nana, Ms. S, and her family remained concerned.
It isn’t terribly reassuring to know that doctors who might need to make life or death decisions about your health could be doing so after having been awake for so long. Would they be on top of their game at hour 16? What about hour 22? In medicine, the devil can be in the details — what if the doctor was too tired to notice something small that might not actually be that small?
But according to the organization that sets the rules on how long resident physicians like me are allowed to work, the Accreditation Council for Graduate Medical Education (ACGME), this is OK. And just so we are clear, as you read this, thousands of young resident physicians are working in hospitals for shifts lasting up to 28 hours every few days and providing care to thousands of Americans. From emergency departments to intensive care units to operating rooms, they often do this without sleep but with the blessing of the ACGME.
When I tell this to my patients, it comes as a shock to many of them. Some think I am joking. Most are concerned. The data seem to agree with them. If given a choice, many patients would prefer a well-rested physician over one who might be tired from a long shift. In a survey of 1,200 Americans, less than 1 percent of respondents said that doctors should work more than 24 hours, while 90 percent said that shifts should be limited to 16 hours or less.
I would love to think that my medical degree gives me some superhuman sense of stamina, but reality and physiology tell me otherwise. I vividly remember a morning when, after signing out to the oncoming team, I had forgotten where the exit to the hospital was, an exit I’d taken hundreds of times before. Luckily, a colleague saw me and walked me downstairs, buying me a cup of coffee in the process to make sure I didn’t fall asleep on my bicycle ride home — something I had once done when I closed my eyes while waiting for a stoplight to turn green.
That’s far less terrifying than situations in which residents get behind the wheel after a long shift only to end up in car accidents. Some walk away, others die.
But what can you expect? Sleep-deprivation of 24 hours or more is equivalent to a blood-alcohol content of 0.1 percent, the threshold for being legally drunk.
The topic of how long resident physicians can work on a given day remains one of the most controversial topics in modern medicine; the way America trains its doctors is heavily contested. In 2003, the ACGME first implemented policies that limited how long resident physicians could work: no more than 80 hours a week averaged over the course of a month. They did so in an attempt to limit medical errors that stemmed from overworked residents. These policies were revised in 2011, further restricting consecutive hours worked: Interns, the youngest doctors in training, couldn’t work shifts longer than 16 hours.
Despite the large body of scientific evidence demonstrating that tired resident physicians make more medical errors than well-rested ones, some groups have successfully argued that these policies should be relaxed. As of July 1, 2017, the ACGME removed the previous safeguard that limited interns to 16 hour shifts; they can now work shifts of up to 28 hours.
Nana’s scowl aside, 28 hour feels unsafe.
Most people would pause before boarding a plane with a pilot who hadn’t slept for the last 26 hours, or wouldn’t feel comfortable getting into a cab with a driver who had been awake for the same amount of time. Why should they feel any different when it comes to doctors?
Christopher Bennett is a resident physician in emergency medicine at Harvard Medical School and Massachusetts General Hospital.