Wake up call: Reforming medical resident duty hours

When Libby Zion, an 18-year old college freshman was rushed to New York Hospital on the night of October 4, 1984, she had a fever, chills and mysterious jerking symptoms. Following admission to the hospital, she was evaluated by two medical residents, who were unsure what exactly was wrong with her. They prescribed her meperidine, a sedative, and left to take care of the other 40 patients that they were assigned to. Later that night, Libby's temperature shot up to 107 degrees. Despite her deteriorating condition, she was never evaluated by the attending physician. She died of a cardiac arrest that night.

When Libby's father investigated his daughter's death, he found that the two residents who evaluated her had been on call for nearly 24 hours, and that many residents routinely worked up to 36 hour shifts. Their sleep-deprivation may have led them to miss the fact that the medication they prescribed Libby, meperidine, had known interactions with another medication she was taking, and might have contributed to her decline. Her father eventually sued the hospital for wrongful death, setting off a national debate on medical resident work hours and supervision that has lasted for almost 30 years.

Over the past several decades, a growing body of medical literature has suggested that sleep deprivation from working long hours in the hospital can lead to serious mistakes. One study found that surgical residents who had been up all night committed 20 percent more errors and took 14% longer to complete a surgical task than those who had gotten sleep the night before. Another found that the deterioration in hand-eye coordination after being up for 28 hours was similar to having a BAC of 0.1 percent (25 percent above the legal driving limit). In response to this research, the Accreditation Council for Graduate Medical Education (ACGME) proposed new guidelines last year that require first-year medical students to work a maximum of 80 hours a week, with shifts lasting no longer than 16 hours. This represents a drastic change to the regulations in place prior to July 2011, under which residents worked up to 30 hours in a single shift. With preventable medical errors raking $1 trillion in losses on the US healthcare system, the ACGME hoped that these new resident duty hour regulations would reduce medical errors while improving patient care and enhancing resident quality of life.

Unfortunately, a recent survey published in the New England Journal of Medicine suggests that these duty hour regulations have had little practical effect. The authors surveyed 6202 residents in 123 residency programs in 41 states, and found that overall, many areas that the new ACGME regulations had targeted for improvement remained unchanged. A majority of residents reported no change in the amount of rest they obtained (50.1 percent) and the total number of hours worked (58.9 percent), and a substantial portion reported a worsening of their work schedules (43.0 percent) and a decrease in the quality of their education (40.9 percent). In addition, senior residents reported a decrease in quality of life (49.7 percent), perhaps due to the shift of workload from first-year residents to more senior residents. Overall, more than twice as many residents surveyed disapproved of the regulations compared to those who approved of them (48.4 percent vs 22.9 percent).

Given these data, it is clear that greater reform is needed. Measures should be put into place that effectively ensure residents are getting enough sleep, and that their work schedules and quality of life are improving, rather than deteriorating under the new guidelines. Moreover, patient safety should always be at the forefront of the regulations to ensure that preventable medical errors are caught before they cause serious harm. Enforcing measures that incentivize the achievement of these goals will enhance both patient and physician quality of life.

This article is courtesy of The Huffington Post.