Drowsy Docs
A frightening study,
recently reported in the New England Journal of Medicine , found that
long-haul truck drivers frequently nod off on the road. An accompanying
NEJM editorial forcefully emphasized the safety importance of adequate
sleep. Yet, somehow medicine's premier journal ignored physician training, in
which residents work even longer hours without any sleep at all. If driving a
truck on five hours of sleep is dangerous, surely taking care of deathly ill
patients on no sleep is too.
The
trucking study found that, although long-haul drivers had at least eight hours
off a day, they slept only 4.8 hours on average--night-haulers just 3.8 hours.
It clearly wasn't enough. Surveillance videotape showed that 56 percent drifted
off for at least six minutes while traveling over 45 miles per hour. Drowsiness
was worst during the night and among those with the least amount of sleep. On
brain-wave recordings, two drivers even fell into light sleep--one for 8
minutes, 40 seconds. Fortunately, no one crashed. Nonetheless, sleepy truckers
were dangerously impaired.
The NEJM editorial hailed the study as yet more
evidence that sleep deprivation kills. Penned by Stanford sleep expert Dr.
William Dement, the editorial pointed to previous work showing sleep loss
harmed performance just as much as alcohol did. Truckers and pilots who work
drowsy, it said, are as dangerous as those who work drunk. And residents?
According to Dement, his original version did include residents, but
NEJM editors removed such references. Perhaps it was because of length,
he suggested. A more likely explanation is that the journal found it easier to
needle others than to take on its own profession. The NEJM declined to
comment.
In
residency, sleep deprivation, like illness and death, is a fact of life. Fresh
out of medical school, residents get on-the-job training performing day-to-day
patient care in academic hospitals. According to these hospitals, first-year
residents work 70- to 80-hour weeks and up to 30 days consecutively (and some
think these estimates understate the case). Residents routinely work 36-hour
stretches, often without sleep.
During my first two years of surgery residency,
I worked from 80 to 110 hours a week, depending on how busy things were.
Typically, I arrived at 5 a.m. and left at 7:30 p.m., except every third night
when I stayed to take care of patients while my team went home. Pages were
incessant: "Mrs. T just threw up," "The gallbladder lady isn't breathing very
well." I got sleep in snatches--some nights totaling four hours or more, others
none at all. Regardless, I operated through the next day like any other.
Constant
fatigue can't be good for patient care. In the infamous Libby Zion case in New
York City, in which an 18-year-old died while under a fatigued resident's care,
a 1984 grand jury denounced physician training as unsafe. Yet, over a decade
later, no rigorous research like the trucking study has been done. The limited
studies that exist bode poorly for good doctoring. Although tired residents
maintain reaction time and manual dexterity surprisingly well, they exhibit
memory deficits, difficulties thinking clearly, and decreased vigilance. They
also develop alarming levels of hostility toward patients.
These studies ring true to me. To be sure, I'm often amazed
at how well I can do on no sleep. When you're faced with a dying patient or a
difficult operation, adrenalin focuses your mind and marshals your energy. I
honestly think I'm dependable in clutch situations, even after 36 hours on the
job.
But I'm
also sure that routine care suffers. Good care for sick people depends on
attention to details--getting drug doses right, checking every lab result and
X-ray conscientiously, remembering a patient's allergies and old medical
problems. No matter how hard I try, I know my memory and vigilance fail when
I'm sleep-deprived. At times I was so tired that I gave nurses orders that I
later couldn't remember giving. Backup systems do catch mistakes. The computer
won't accept my drug orders if I prescribe the wrong dose or ignore an allergy.
Nurses remind me to check an X-ray or question me when my order doesn't seem
right. Nonetheless, many errors are not caught, and I know I have seriously
harmed patients because of fatigue.
I've felt the hostility, too. When you're
finally set to sleep or go home, nothing is more frustrating than a patient
having unexpected problems. Rest becomes a matter of personal survival, and
residents can be chillingly brusque with patients who need only time and
sympathy. Anger is so common that one Harvard residency program gives an
"award" each year to its angriest interns.
Can
anything be done? Hospitals could hire more residents, but that would increase
our physician glut. In fact, Congress banned hospitals from increasing resident
hires this year. Hospitals could hire physician assistants to handle calls that
don't require doctors, but that's expensive. Physician assistants get paid
twice a resident's $30,000 yearly salary for working only 40 hours a week. In
New York state, guidelines for an 80-hour maximum workweek were estimated to
increase staffing costs by a quarter-billion dollars per year. Exceptions were
quickly carved out (for example, surgical residents aren't included), and even
then many hospitals could not afford to stick to the guidelines.
Increasingly, hospitals use "cross coverage," in which a
fresh resident covers patients for several other residents at night. However, a
Harvard study showed that the covering residents made serious mistakes six
times more often than even fatigued residents. They had too many patients and,
with every patient new to them, didn't know important details. Tired doctors
may not provide the best care, but neither does a series of faceless doctors
working shifts.
Research by sleep experts, to
examine resident safety and to test solutions, is needed. In any other
circumstance, doctors would champion thorough, dispassionate investigation and
spare no expense to improve patients' lives. But on this subject, the medical
profession is asleep at the switch. If it doesn't wake up soon, another
scandalous case will inevitably surface, and the government will take matters
into its own hands.
