Doctors and nurses in the United States are pretty used to brutally long work days. But is it the only or best way to practice medicine in a hospital?
First of all, I think we should all ask the question, “How did we get here?” Well, the American practice of having doctors work long hours started with William Halsted, the first chief of surgery at Johns Hopkins in the 1890s and a founder of modern medical training. He required his residents to be on call 362 days a year for long shifts. It was only later revealed that Halsted powered his schedule with a cocaine addiction- a habit which 10%-12% of doctors are following today. (Concerned about continuity of care if your doctor goes to rehab? The state of California allows doctors rehab to continue seeing patients while they are undergoing treatment for substance abuse. Though nurses typically have to stop working until they can prove they are safe to return to work. But I digress…)
In 2011, the Accreditation Council for Graduate Medical Education shortened the shifts of residents for medical residents to a maximum of 16 hours at a time. This year though, the ACGME reversed its policy and put residents back on a maximum shift of 24 hours. One of the biggest reasons they cite is the need to ensure that residents who will need to be on long shifts will have that experience. Of course, most doctors won’t need ridiculously long shifts. (When was the last time you called a dermatologist, urologist, or your kid’s pediatrician at 3:00 AM in the morning? Though doctors in France still make house calls at all hours. )
The question then comes, should a doctor or nurse in an ER, ICU, PICU, NICU, burn unit, etc. really be working a 12, 16 or 24 hour shift?
How Normal Are 80 Hour Weeks For Doctors?
ACGME has placed the maximum a resident can work to be 80 a week. It’s interesting to note that in the European Union, doctors and residents are by law only supposed to work a maximum of 48 hours a week with a minimum daily consecutive rest period of 11 hours.
Long Shifts: Better or Worse for Patients?
If 24 hour shifts sound brutal, consider that up until the mid-1980’s, it was common for doctors and residents at hospitals to work for 36 hours straight. That changed in 1984 when an 18 year old girl named Libby Zion showed up in the emergency room at New York Hospital with a high fever and uncontrollable jerking. She was given Tylenol and some sedatives and restrained in bed. But her fever shot up to 108 degrees and she went into cardiac arrest and died.
Libby’s father was a newspaper columnist who was appalled that the intern on duty when his daughter died had been awake for 24 hours and that many doctors, residents and interns frequently worked 36 hour shifts. He wrote columns about the working conditions of doctors, a series of news stories followed and the work week for residents was capped at 80 hours.
The ACGME cites improving patient care as a reason why residents should be allowed to work 24 hour shifts. But with 97,000 people a year dying from medical errors, it’s certainly worth questioning if the old school method of long shifts is the way to go. And it’s not just doctors but nurses too. One study showed that when nurses worked 8-9 hour shifts as opposed to 10-11 hour shifts or 12-13 hour shifts, the nurses had less burnout and job dissatisfaction and patient satisfaction was actually higher.
And sleep deprived health professionals can make mistakes. One doctor described a time when as a resident he had just fallen asleep in a call room during a 36 hour shift. A nurse notified him of a 9 year old girl who was rapidly deteriorating from an asthma attack. He was so confused that he went into the bathroom, locked the door and started brushing his teeth instead of responding to the call. (Fortunately another doctor got the girl on a ventilator and she survived.)
Another case was the 2006 death of 16 year old Jasmine Gant when a nurse who had been voluntarily working sixteen hours straight failed to check a medication when she was preparing Jasmine for an epidural. She gave Jasmine the wrong medication causing cardiac arrest. Jasmine’s son was delivered by emergency c-section and is being raised by her mother.
Some large scale studies have found that cutting back to 80 hour work weeks for residents didn’t reduce mistakes. Though, I think we have to ask ourselves if 80 hours is enough of a reduction considering that other developed countries allow their doctors to work only half that in a week. Comparing 90-100 hours a week to 80 hours a week isn’t the same as comparing 80 hours a week to 48 hours a week.
But It’s Not Just Long Shifts Either…
It’s true that sleep deprivation can cause a person to be as impaired as being drunk. But in hospitals, it’s rarely so straightforward either. Libby Zion was taking several medications at the time of her death- even the most well-rested doctor would still need to inquire about medications.
In the case of Jasmine Gant, the nurse had failed to follow hospital procedure by scanning a bar code to check the right medication. This was a newer policy at the time for St. Mary’s Hospital in Madison, Wisconsin and it wasn’t well-enforced. The report also mentioned how nurses working in labor and delivery at St. Mary’s typically had many tasks to attend to and emphasized that the nurses needed to be ready for physicians’ needs: “Anesthesia staff in the past had expressed dissatisfaction with patients’ state of readiness for an epidural on their arrival on the unit. This dissatisfaction had placed considerable pressure on nurses to ensure that the patient was ready for the epidural before anesthesia staff arrived.”
Now, hospital staff always have a fine line to walk in priorities. Doctors do have to be able to provide care and there are so many nurses out there who do their best to ensure the safety of patients in their care. But it is disturbing that in this case, the emphasis on the convenience of the anesthesia staff created an environment that placed the patient’s safety second.
An environment in hospitals that emphasizes the safety of patients and respect for the health of doctors and nurses along with better case management and “hand-offs” is going to be necessary if we want to see health care in the United States crawl its way up to meet the standards of the rest of the developed world.