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The hospital can be a strange place over the holidays. This year, it was work as usual, save the nurses' station festooned with tree lights, the occasional jolt of festivity from teen-aged Christmas carolers fulfilling their volunteer requirements, the frenzy of activity that came on the Friday before the holiday - arranging for patients to get procedures, speaking with consulting specialists, making follow-up appointments - and the unsettling quiet that dropped during it.
I spent the past two weeks as the supervising resident for a team of five interns on a general medicine unit at Massachusetts General Hospital. One of my jobs was to oversee the admission, care, and discharge of the 20 patients on our team’s service, so I grew sensitive to trends.
Between 7:30 and 10 a.m. on a glacial late November morning, a tall white van lingers at a street corner in Boston's South End. I consult my iPhone one more time to confirm that I'm in the right place and knock on the vehicle's glass-paned door. Ritchie, with his oversized Las Vegas baseball cap and faint smell of cigarettes, ushers me inside and I settle in across from him on one of the grey-upholstered seats to await the van's more typical visitors.
Ritchie joined the Needle Exchange Van more than six years ago - after a midlife career change from furniture sales that was brought on by watching two friends and fellow Marine veterans start using, contract HIV, and die. My morning with Ritchie, part of a required residency rotation on addiction, offered a rare glimpse into patients' lives outside hospital walls and the important, if unsettling, work that complements our efforts as physicians.
Protected naptime is a luxury usually reserved for the under-five-year-old set. Might it also be a tool to combat our country's astoundingly high rates of medical errors?
Trainee fatigue has been a major focus of patient safety efforts since the mid 1980's, after 18-year-old Libby Zion died tragically from a drug interaction that may have been precipitated by residents working long hours. In 2003, the Accreditation Council for Graduate Medical Education (ACGME) required all residents to work no more than 80 hours a week. In 2009, a congressionally-mandated report from the Institute of Medicine called for interns to work no more than 16 hours at a time and for all residents to take a five hour nap during longer shifts. By the time I started my intern year in 2011, the ACGME had enacted the IOM recommendations - on top of the intern work hour restrictions and a cap of 24 hours for more senior residents, we were encouraged to take "strategic naps" and offered online tutorials on staying alert.