ONE OF the biggest paradoxes of the hospital system is that it thrives on imposing grueling hours to doctors and nurses, in spite of compelling evidence that sleep deprivation makes humans less efficient and more prone to making mistakes. The new standards set by the Accreditation Council of Graduate Medical Education (ACGME) on residents’ working hours, which will trump older standards implemented in 2003, are, on balance, an important corrective. But they also represent a significant disruption of hospital practices, and should be implemented slowly, and carefully, with particular concern for preserving the continuity of care for desperately ill patients.
The new rules, which go into effect this summer, introduce longer rest periods after hospital duty, place limits on moonlighting, and, most controversially, limit first year residents’ shifts to a maximum of 16 hours, down from the typical 24 hours or more. The new standards essentially eliminate overnight shifts for first-year residents. Residency program directors across the nation aren’t happy, and some of their concerns are legitimate.
Continuity of care is the biggest worry: It could be less safe for patients to be handed over to a new resident at the 16-hour mark, rather than having a doctor who’s already familiar with the case stay through the morning shift. Cost is another big factor: according to the ACGME’s own estimates, implementing the new rules nationwide will cost anywhere from $300 million annually to over $1 billion, depending on how hospitals allocate staff to fill the hours not provided by the residents. Another valid concern, as voiced in a national survey of residents’ views of the new standards, published in the New England Journal of Medicine, is that “education and experience will be severely limited’’ with shorter shifts for first year residents. As learning on the job is such a key factor in medicine, this is indeed a possible drawback of the new standards.
Still, considering that most countries in Europe legally mandate 13-hour limits on doctor’s shifts, the new ACGME rules seem reasonable. They closely resemble 2008 recommendations from the Institute of Medicine, which is further reassuring. Studies abound documenting the effects of fatigue and lack of sleep on a doctor’s performance. Those who work shifts of 24 hours or more are at a higher risk of self-injuries while at work, suffering a car crash after work, or making serious medical errors on patients. The level of impairment after a 24-hour shift can be similar to a 0.1 percent blood alcohol level, above the legal limit for driving.
Nobody wants to place their lives in the hands of an exhausted physician — especially not a fatigued and less-experienced first year resident. Complying with the new standards will be economically and logistically challenging, but it’s the right thing to do. Hospitals should proceed with the implementation, with some appropriate cautions in place.