Sleepy doctors pose a hazard on road

Researchers who found that sleep-deprived medical residents can pose a danger to patients have discovered that these tired doctors also may present a hazard after they leave the hospital.

Sleep researchers at Brigham and Women's Hospital and the University of British Columbia followed 2,737 first-year residents, also called interns, for a year and found they had 58 car crashes after working extended shifts of about 32 hours. That comes out to more than one car crash for every 1,000 commutes, more than twice the rate when the interns drove home after working regular shifts of about 24 hours, according to a study published in today's New England Journal of Medicine.

"That's akin to letting someone get behind the wheel when you know they're drunk," said Dr. Charles Czeisler, chief of the division of sleep medicine at Brigham and Women's. "Yet hospitals are forcing interns to work these shifts."

The study, of residents working in teaching hospitals across the country, is part of a growing body of work examining their long hours. It adds to the pressure on hospitals to adopt changes. The medical profession has been slow to acknowledge the dangers of sleep deprivation among residents, who are in training, as well as among more experienced doctors.

Even though the Accreditation Council for Graduate Medical Education, which oversees physician training programs, adopted some limits on residents hours in July 2003, many researchers, including Czeisler, believe the restrictions are inadequate.

A residents' union has persuaded legislators to file bills in Massachusetts and other states requiring stricter limits. In Illinois, lawyers for a young woman severely disabled in a car crash in 1997 sued Rush University Medical Center, a case that has become a focal point for reformers. The woman's attorneys argue that the hospital is liable for allowing a resident to work nearly 34 straight hours, after which the resident fell asleep driving home and rear-ended a car the woman was riding in on the highway. The hospital's attorneys argue that the work hours were standard at the time, and that the hospital is not responsible for employees' behavior after they leave work.

One criticism of Czeisler's study is that it took place from May 2002 to May 2003, before the graduate council adopted the voluntary limits. But the council's guidelines allow residents to work up to 30 hours at one stretch, which is about the average the residents in the study worked while on extended shifts. The council limits total weekly hours to 80, averaged over four weeks.

Dr. David Leach, executive director of the graduate council, said that the organization surveyed 25,000 residents a year ago and found that 9 percent worked 30 consecutive hours at least once in the previous month. He indicated that the organization probably will restrict hours further, perhaps to 24 at one stretch. "This study will help refine our requirements," he said.

Many hospitals, including Brigham and Women's, are trying to cut back residents' hours on their own. But it's expensive to hire extra physicians' assistants and nurses to fill in. And the fewer hours residents work, the less training they receive treating patients.

Jaya Agrawal, a 28-year-old second-year resident at Brigham and Women's, said she has fallen asleep at the wheel at red lights. Last year, she said, she got into her first car accident when she was an intern. She had arrived at the hospital at 6 a.m., and worked until 2 a.m. the following morning. She slept for two hours at home before getting into her car to drive back to Brigham and Women's around 6 a.m. Crossing Commonwealth Avenue near Boston University, she drove up onto a concrete median strip. "I don't think I'd fallen asleep, but I was completely exhausted and out of it," she said.

"Almost every resident has a story about how they've nodded off while driving home," after an extended shift, said Simon Ahtaridis, Agrawal's fianc and a resident at Cambridge Hospital, who is active in the Committee of Interns and Residents, a nationwide union.

"One overnight isn't going to lead to problems. But once you start doing it day after day, month after month, that's going to make you prone to fall asleep behind the wheel," Ahtaridis said. "One surgery friend who got off duty started his car in the parking lot, fell asleep and when he woke up he was out of gas and it was time for him to go back to work."

Brigham and Women's has shortened some residents' extended shifts so that they don't admit patients after 10 p.m. But even so, Agrawal said, residents often don't finish their work until as late as 4 a.m., especially if they've admitted a patient at night and must wait for test results and write a treatment plan.

Several months ago, hospital executives told residents that Brigham and Women's would pay for cab fare if they were too tired to drive home. More residents are using the program, doctors said. But Agrawal said that "it requires people to be aware of how impaired they are, and often you don't realize it.

"This is not an easy issue," she added. "The volume of patients we're taking care of is going up, yet the number of people in training is the same. The question is where do you find additional manpower. Maybe part of the answer is having set shifts, rather than having us not go home until our work is done."

Dr. Andy Whittemore, the hospital's chief medical officer, said that he is developing a plan to limit all residents' shifts to no more than 16 hours, but that it's unclear how long it will take to find the money and hire the extra staff to put the plan in place. Meanwhile, the hospital has made smaller adjustments, such as prohibiting residents on duty for 24 hours or longer from ordering medications for patients. Three weeks ago, the surgery department started sending cabs to residents' homes in the morning to fetch them for longer shifts, and then sends them home in a taxi at night.

The residents who participated in the study reported their hours, car accidents, and near misses in monthly logs. Researchers confirmed the accidents by reviewing police reports, photographs, hospital emergency room records or car repair bills. Researchers were not able to confirm near misses. Over the year, residents reported 1,971 near misses after extended shifts. That comes out to more than 36 near misses per 1,000 commutes from the hospital, nearly six times the rate after a regular shift.

In a study published in October, Czeisler's group found that interns who worked 24 to 34 consecutive hours every three days committed 35 percent more serious medical errors than when they worked a maximum of 17 consecutive hours.

Dr. Andrew Warshaw, head of surgery at Massachusetts General Hospital, has warned about the disadvantages to education and continuity of care in limiting hours. He said today's study did not sway him. Residents who worked extremely long hours before the council guidelines went into place may account for a large number of accidents, thereby throwing off the results. He said the number of accidents overall seemed small.

"I don't know how that compares to the general population," he said. "There's smoke there but that doesn't necessarily mean there's fire."

In an editorial accompanying the article, transportation consultant C. Dennis Wylie argued that residents' work shifts are "egregiously beyond" current standards in other industries. In 2003, the Department of Transportation, for example, required truck drivers to have eight to 10 hours off-duty for every 24-hour period, he wrote.

But Leach, of the graduation council, said truck drivers and residents work in very different environments. "If I'm in a cab, isolated and by myself, just driving, 14 hours of that is very hard and monotonous. "Residents are physically walking around and can see a lot of different activities and engage in them. And they do get some sleep during their shifts."

Liz Kowalczyk can be reached at kowalczyk@globe.com.