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The night that taught me just how dangerous 28-hour shifts for residents can be

The night that taught me just how dangerous 28-hour shifts for residents can be

Picture of Josephine Valenzuela
Photo: Oli Scarff/Getty Images
Photo: Oli Scarff/Getty Images

It was a drinking holiday in San Francisco, and I was working as a junior resident in the emergency department of the county’s trauma hospital. All night long, ambulance crews had been bringing intoxicated patients with various injuries. I had been working a lot of shifts and was frankly exhausted. My back ached. My current patient needed a procedure to drain multiple pockets of infection caused by injecting heroin, and we were not getting along well. The light in the room was flickering and poor, and she refused to move her legs to make it easier for me to see my scalpel incisions. On top of this, I was in a rush to finish before the next ambulance arrived.

Sure enough, after draining a few infected sites, my pager rang in my pocket. I would have to leave before I was finished with this patient to receive another ambulance. In a hurry, I grabbed the surgical scalpel and went to wrap it in sterile towels for when I could return. Instead, I sliced my left index finger. This meant all of the blood and pus that was on the scalpel was exposed to my bloodstream. This patient was known to have HIV and hepatitis. I would need to be tested and treated for those lifelong infections. Many hours later, after I transferred care of my patients, after giving blood samples in occupational health and starting powerful antiviral medications which would make me nauseous for weeks, after calling my husband to let him know the bad news, exhausted and in tears and facing yet another shift that night, I mixed up the gas and brake pedals in my car, backing into a concrete pole in the hospital’s parking garage. 

In a hurry, I grabbed the surgical scalpel and went to wrap it in sterile towels for when I could return. Instead, I sliced my left index finger. This meant all of the blood and pus that was on the scalpel was exposed to my bloodstream.

There’s no doubt in my mind that my exhaustion contributed to these multiple failures — the sliced finger, my emotional breakdown, and finally, the car accident. This should hardly come as a surprise. A plethora of research demonstrates that sleep deprivation is linked to cognitive impairment, degradation of motor skills, burnout and decreased empathy, and mood derangements. One Nature paper found 24 hours of wakefulness resulted in the same degree of impairment as a blood alcohol level of 0.10, well above the legal limit to drive in California. This is the reason that so many safety-sensitive occupations, from pilots to nurses to long-haul truckers, have already limited consecutive hours of work. 

Recognizing the potential for harm to patients caused by extreme fatigue, in 2011 the Accreditation Council for Graduate Medical Education (ACGME), which accredits programs to train doctors, imposed new “duty hours” limits for doctors in training: no more than 80 hours a week, at least one day off in seven, and a maximum of 16 hours of work in a row for first-year residents, or interns, fresh out of medical school. Prior to 2003, they could work up to 28 hours, like the more senior residents. 

Earlier this year, however, the council decided to reverse prior protections around these “extended” shifts, allowing interns to again work 28-hour shifts. The group cites a preliminary study that showed that for surgical residents, the 16-hour limit did not improve patient safety (the FIRST trial) on measures such as mortality or serious complications (the study did not assess whether the interns actually made more mistakes during extended shifts — other significant studies have in fact shown that tired residents do make more mistakes). The real reason for the reversal may be something vastly simpler: residents are the cheapest labor in the hospital, and by limiting the hours they work, hospitals lose money. I take home an average $20 per hour, and because I’m salaried, the more hours I work, the less I cost. To replace me with a nurse practitioner or another physician, the hospital would need to pay almost 10 times that amount. Hospitals put a tremendous amount of pressure on ACGME to extend resident work hours. Ignoring patient safety and resident advocacy groups, the council allowed these longer shifts. 

Currently there are some small studies showing a link between extended shifts and safety lapses like blood exposures and car accidents. A large ongoing study is tackling this question as well (Harvard’s Resident Sleep Study). If this research shows, as I suspect based on my own experience, that longer shifts put residents at risk, it will be interesting to see how ACGME responds. Apart from safety issues, very little work has been done on how sleep deprivation affects the learning of young doctors, which is, after all, the entire purpose of being a resident: to learn how to be a doctor. While ACGME purports to “set standards for U.S. graduate medical education,” their argument to extend work hours is not based on science at all — the neuroscience literature is very clear that sleep deprivation is detrimental to many kinds of learning and cognitive functions. Instead, it relies almost entirely on reports from residency programs, who have a strong financial interest in long work hours for residents. The limited objective research that they cite shows that cutting extended shifts actually improves resident attention without compromising patient safety. 

Ultimately, I tested negative for HIV and hepatitis. There was no lasting damage from the car accident either. I was incredibly lucky. Many of my fellow residents will not be. Exhausted, backs aching, gulping down coffee, we continue to report for 28-hour shifts. And starting in June, we will be joined by the new intern class, who will have graduated medical school just weeks earlier. It doesn’t take a doctor to understand that this isn’t safe for anyone. 

Dr. Josephine Valenzuela is an emergency medicine resident and Committee of Interns and Residents’ regional vice president for Northern California.

Comments

Picture of <span class="username">Guest (not verified)</span>

Thank you Dr. Valenzuela for speaking your mind against these new regulations imposed by the ACGME. I don't understand why such decision was made with ignoring patient safety and residency advocate group. I have been in utter disbelief since I hard the ban on 28 hr shifts for interns was lifted. This implies that the hospitals that pushed for this to be passed care more about the money, less about the patients, and certainly even lless about teaching their interns. There is so much logic that is being missed here, I scratch my head at how such a decision was made. There needs to be something done about this, the ACGME needs to know that there is a dramatic outpouring of opposition to this move and they are not doing the future doctors of the America any good by making healthcare a purely capitalist venture. Be strong and once again thank you for standing up for us.

Picture of <span class="username">Guest (not verified)</span>

Junior residents are extremely well protected. You have seniors, your attending, your chair, the acgme all available to back you up. Even the nurses are keeping an eye on you.

This is your chance to figure things out in a relatively safe environment. The more you see, the more you do, the more you learn. This includes being able to function at a high level when you're tired, hungry and things aren't going your way.

As someone who recently came out of training I am grateful for every case I participated in and I am so happy that I stayed late to do more and learn more. One day when it's the middle of the night and something goes wrong and everyone is looking at you, you will feel the same way.

Picture of <span class="username">Guest (not verified)</span>

No attending or nurse can protect you when you're falling asleep at the wheel driving home after a 28 hour shift or after you've accidentally stuck yourself during a procedure. I've made many mistakes and miscalculations that were caught by the nurse or pharmacist. There is a system in place to protect patients from sleep deprived residents, I agree. But residents are not safe from themselves. The issue is residents are also human beings that deserve safety, not just patients. I have seen many of my coresidents get into accidents driving home while they were sleep deprived. This type of treatment is inhumane. I agree with the article that it's all about money at the expense of resident decency. The ACGME is not on our side.

Picture of <span class="username">Guest (not verified)</span>

I know as a surgery resident I shouldn't be supporting writing like this. After all, the regular 28-30 hour shift is part of our right of passage; part of the hiddden agenda, and worn as a badge of pride. But I'd also be lying if I said that at hour 20 when my pager goes off I give the same quality of service to my patient that I do at hour 10.
I am a resident in Canada, and we have yet to move away from the 24-28 hour shift for any of our residents on call. But, ironically, the country is investing tons of resources into physician and resident wellness, to help reduce burn out rates. I say ironically, because it's almost common knowledge at this point that chronic sleep deprivation is a major contributor of burn out and depression. It's time to change the conversation.
Thank you for writing this

Picture of <span class="username">Guest (not verified)</span>

This is a regressive move by ACGME, the burn out rates would definitely increase and patient safety will be at stake .

Picture of <span class="username">Guest (not verified)</span>

"The real reason for the reversal may be something vastly simpler: residents are the cheapest labor in the hospital, and by limiting the hours they work, hospitals lose money." What exactly are you referring to here? I admire your enthusiasm to turn your anecdote into a cogent policy argument, but our 80-hour workweek hasn't changed and so this sentence makes no sense.

Picture of <span class="username">Guest (not verified)</span>

I absolutely agree that duty hours needs to be revisited as a discussion, and that special interests (from obviously interested parties - hospital admin, the government) need to be taken out of this discussion to find a fair balance between resident health and staffing levels. If more money needs to be provided, to hire more staff, then so be it.

That said, I do take issue with at least one thing in this article. The author claims to be an emergency medicine resident, working in the emergency department, when this incident occurred. ACGME duty hours for EM residents are far more stringent than they are for other parts of the hospital. When your next MI, aortic dissection, or trauma comes in, there can be no screwups; physicians need to be alert and attentive, not sleep deprived, slow, and fatigued. When EM residents are on 'off service' rotations, they are subject to the same duty hours as the receiving service has - so longer shift limits, 16-28 hour shifts, etc. It's therefore presumed that the author was not actually on an EM rotation during this timeframe - perhaps she was rotating on trauma surgery or another off-service team. If she was on an actual EM month, her program is blatantly and publically violating ACGME requirements for EM residencies, and should be investigated or suspended for compromising not only resident, but patient, safety.

Picture of <span class="username">Guest (not verified)</span>

When I was a medical student I crashed my car sleep deprived not once, but three times on my way home. Two other people in my class did as well in the same brutal rotation! At least as residents you are being PAID to work yourself to death and there is a modicum of respect and pity from society. As med students we were at the bottom of the social ladder in the hospital & PAYING money, debt money that is, just to get worked to death.

Here is an important question. Does the CEO of ACGME work as many hours as we do to ensure public safety? How about hospital CEOs, administrators?

Picture of <span class="username">Guest (not verified)</span>

Try exploring the term - "contemporary slavery" and you will smell something quite familiar. For those who do not want to do this homework, here is the one line summary: Residents are under debt bondage (don't tell me an amount large enough to cover the down payment for a million dollar house is not considered large); are coerced to work extended hours beyond the limit of physique (ACGME and hospitals don't care how tired you are! Know that residents do get in "trouble" if they honestly report work hours when they go beyond the hour limit); are not adequately compensated in a financial sense (one half of what NPs and PAs are paid?); are sold and used by hospitals as commodities to complete the required work (patient care is great, but how about the often meaningless note typing that are just to protect the CEO?); are constantly under the problem of food shortage (energy bars, nutritional drinks and coffee are not real meals), are under a work environment prone to the contagion of disease and exposure to dangers (well summarized in the article). Tell me this is different from contemporary slavery.

Picture of <span class="username">Guest (not verified)</span>

I've written about this issue as well on lifeofamedstudent.com, but am lucky to have never had the serious incidents you so bravely shared. The problem I have always fallen back to is, where will the line be drawn for "safe" limits. Personally, I feel 24hours should be the max, as that is the most you'll typically see in other first responser (EMTs, fire, etc) shifts. I do not agree there should be this 4 hour handoff period, which can be (and is) easily abused simply to allow more resident manpower in the morning with routine 28hour shifts. Thanks so much for sharing your story!

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