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.
Rightfully so.
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.
I’m an older physician, rotating among EDs in four critical access hospitals in central Kentucky at age 68. In 1975, while in medical school in Seattle, I had an object lesson in the dangers of long shifts, in military aviation rather than in Medicine. I served in the Army in Vietnam and two years after my discharge in 1970 I left college to train for seven months at two Air Force schools to become a flight engineer in the Air Force Reserve on a C-141, a four engine cargo jet, an enlisted crew position. I continued doing this through 1986, long after graduating from medical school.
In 1975 the Military Airlift Command had a policy similar to the time-honored policy of scheduling house officers. With a regular crew, crew duty days were limited to 16 hours. With an “augmented crew”, consisting of three pilots, two fully qualified flight engineers and a navigator or two, the maximum crew duty day was limited to 24 hours. On March 20, 1975 the wisdom of that policy was sorely tested. The crew got up at Clark Air Base in the Philippines three hours prior to take-off on a five hour flight to Yokota Air Base, Japan. They offloaded cargo in Japan and were on the ground for three hours before leaving on an eight hour flight to McChord Air Force Base, Washington, 40 miles south of Seattle. Coming over the Olympic Mountains west of Seattle at 2 A.M. a tired air traffic controller cleared the exhausted pilot to “descend to and maintain 5000 feet.” The pilot responded, “descending to 5000 feet.” That was the last transmission. The plane struck a 7339 foot high peak, killing all 14 people on board. The peak is now known as “C-141 Peak.” The controller tried for the next hour to reach the plane, until he was relieved of duty. An alert crew would have double checked their maps to make sure the air traffic control instruction was safe. Fourteen people died for nothing as a result of this policy.
Dr.McIntyre,
First, thank you for your service to our country.
Second, I realize my original comment to this article may have been Inaccurate in generalizing the high burnout rate of emergency medicine physicians.
I guess the article itself however, struck me as ingenious. It’s author seems to imply that he had an epiphany of sorts while casually chatting with the mother of one of his sicker patients.
It seems, however, upon further review, that the same author has published a lot in the past about work hour restrictions and safety issues.
Again, no issue there, however in a casual reading of this article my first impression was that this young doctor in training and had a sort of bedside epiphany.
One final comment; speaking as an anesthesiologist, a specialty in medicine which is very often compared with “flying a plane “- I will say that while there are many similarities, comparison of physicians with pilots is still a weak one, in my view.
I can think back over countless times when I was using all of the knowledge, skills and resources available to me to stabilize a critical patient, and in none of those instances was my own life actually in danger, which is probably the most obvious difference between physicians and pilots operating in critical situations.
If our medical profession wishes to adopt many of the same restrictions which the aviation industry has applied for decades, then perhaps a mandatory retirement age? Which I believe restricts commercial pilots over 65, and prior to 2009 was mandated at age 60.
Thanks for your comments, Paul. The point of my commentary wasn’t to suggest that we adopt the same restrictions as exist in the aviation industry. Rather I was suggesting that if a mistake this glaring could me made by a pilot 19 hours into his crew duty day, when his own life was on the line along with 13 other lives, and could be made concurrently by a tired air traffic controller, why should we physicians believe we are immune to such serious errors made under similar or worse conditions of sleep deprivation. I’ve told co-workers tongue-in-cheek over the years that the difference between medical emergencies and in-flight emergencies is that in aviation when the patient dies you die too. I agree with you that the similarity between medicine and aviation is overblown. The biggest four differences are that in aviation: (1) everything is done by checklist, both normal procedures and emergency procedures, (2) medicine, unlike aviation, is based upon academic research with each physician having a lot of autonomy in applying that research to his or her practice. In aviation the procedures are set in stone, dictated by aircraft manufacturers and airline management. Pilots have to pass check rides on those procedures, both in the airplane and in the flight simulator at least annually to continue to fly. 3) Serious in-flight emergencies happen regularly only in the flight simulator. In real life a serious in-flight emergency, like Captain Sullenberger ditching his jumbo jet into the Hudson River, happen much less than once a career. 4) Commercial aviation, unlike medicine, isn’t all about diagnosing and treating malfunctions. Instead it is mostly about normal procedures, for which there really isn’t a close analogy in medicine, moving passengers and/or cargo from point A to point B. Taking care of emergencies is a very necessary but a secondary function.