Doctors are about the closest thing we have to superheroes in real life. But must they also be super-human? Specifically, can people in the medical profession somehow get by on way less than the seven to nine hours a night that ordinary people require?
That's the operating assumption of the lifestyle expected of medical residents, med school graduates who spend three years learning the profession from supervising doctors. Under the current regulations for resident labor, these doctors-in-training work shifts up to 30 hours long.
It's tough to imagine how sleep-deprived residents can function well, but the phenomenon has been the norm for over a century. If you've ever spent a night in a hospital, you've probably been treated by someone who has pulled an all-nighter.
Occasionally, the issue has breached public consciousness: the high-profile case of Libby Zion, the 18-year-old college student who died after being treated by a fatigued intern and resident in 1984, is one instance. But more than 30 years later, a culture of sleep-deprived residents and doctors remains the norm.
In the past decade, American hospitals have experimented with letting residents work relatively more humane shifts, capped at 16 hours. But the efforts yielded few improvements in treatment or decreases in hospital errors.
The Accreditation Council for Graduate Medical Education (ACGME), the nonprofit council that oversees the graduate medical training programs in American hospitals, is in the middle of a multi-year evaluation of residency work-hour limits. In January, the body said it hoped to publish its recommendations by April 2016 for public comment. But this week, it said it needs more time to deliberate. It is awaiting input from ongoing studies and 63 constituent medical groups.
How Sleeplessness Became The Status Quo
That sleep deprivation may affect medical practice has been known conclusively for at least 45 years. A pioneering 1971 study in the New England Journal of Medicine found that interns made almost twice as many errors reading electrocardiograms after an extended (24 hours or more) work shift than after a night of sleep. They were also more likely to be depressed and unsociable. Back then, medical residency was akin to "indentured servitude," according to one report, and 100-hour workweeks were the norm.
Since then, other studies have shown that ultra-long shifts increase errors and attentional failures and that interns on 30-hour shifts make 36 percent more serious medical errors than those on 16-hour shifts, including things like administering drugs known to provoke an allergic reaction.
In 2003, in a significant overhaul, the ACGME reformed the schedule for all residency programs so that residents were not allowed to work more than 80 hours a week or more than 30 hours continuously. In 2011, it added a further stipulation that first-year residents could only work 16 consecutive hours and upper-year residents could only work 24 hours at a stretch. This standard continues today.
Around this time, Dr. Darshak Sanghavi, a pediatric cardiologist and medical writer, authored the article "The Phantom Menace of Sleep Deprived Doctors" in the New York Times magazine. He encapsulated the ongoing problem -- which continues in 2016 -- of resident labor reforms: a lot has changed relatively quickly, but it's been nearly impossible to demonstrate their positive effects.
How Sleep Deprivation Affects Residents
In 2009, a huge study of 14 million veterans and Medicare patients under the care of residents showed no improvements in the quality of care after the 2003 reforms. This ambiguity has fueled both sides of the work-hours debate: those who believe doctors perform better with more sleep and those who say it's fine to keep pushing their limits.
One issue with current studies is that regulations only count reported work hours, even though many residents may be working more than 80 hours off the books. In one survey of neurosurgery residents, 60 percent acknowledged that they underreport their hours, with a quarter doing so on a "regular" basis. So we may not be seeing effects of reforms simply because residents may not be observing them.
Dr. Christopher Landrigan, a Harvard Medical School professor and leading voice for work hour reform, thinks the 2003 regulations didn't go far enough, which is why their impact was not evident. After all, they still allowed shifts up to 30 hours, which is far beyond the workday of almost any other profession.
"Doctors think they’re a special class and not subject to normal limitations of physiology," he told the New York Times magazine.
Sleep deprivation has a well-documented negative impact on cognition and memory, fine motor skills, mood and reaction time. And that's just acute sleep deprivation, meaning the occasional all-nighter. Long-term sleep deprivation, like the kind medical residents may experience over the course of three years, can seriously damage memory, increase the risk of heart disease and even decrease a person's lifespan.
Still, several doctors have actually spoken in favor of ultra-long shifts, which they say is crucial to preparing doctors for their actual careers. Dr. Thomas Nasca, CEO of ACGME, maintains that long shifts are important because residents must learn to "recognize and manage" the fatigue they will encounter in their clinical practice, where hours are unregulated. But others, like Dr. Sanghavi, say there is a "yawning chasm" between the high-stress life of a resident and post-residency practice, when "most doctors practice in outpatient settings and work regular daytime hours."
Handing Off The Patient
A central issue in the debate of resident work hours is that of patient handoffs, when the responsibility for a patient is transferred from one resident to another. Shorter shifts mean more frequent handoffs. Advocates of longer shifts, like the author of a 2013 study on work hours, say that more handoffs could directly increase medical errors.
On the subject of handoffs, Dr. Charles Czeisler, a Harvard sleep researcher and a leading proponent of medical labor reform, suggested that the issue was a "smokescreen."
"We demonstrated a decade ago that ICU patients were much safer when patient care was transferred to a rested doctor rather than when resident physicians worked marathon shifts lasting for more than 24 hours," he told HuffPost.
Still, some argue that work-hour regulations aggravate the increased patient load at nearly every hospital in America. Their argument is that residents will rush to treat a large patient load before the end of their shift to avoid a handoff, leading to more careless work.
Another consideration is that shorter resident shifts may exacerbate the nation's current shortage of residents. If shorter shifts for everyone mean fewer hours of work overall, hospitals would need even more residents. As it stands, there are already too few residency positions for the rising number of med school graduates.
Is There A Better Way?
Wellness is a central subject of resident labor reforms, but work limits are just one component of that. A number of techniques at forward-thinking hospitals around the country point to other ways resident wellness can improve.
Dr. Ted Sectish of Boston Children's Hospital has pioneered educational interventions like mnemonics for better handoffs between shifts. This is important because if handoffs increase due to shorter resident shifts, handoff procedures must improve, in both accuracy and practicality.
In the tech realm, electronic handoff checklists could be more widely implemented. One such software for the iPad, called iPass, claims to have reduced handoff errors by 30 percent in trials. Yet only a small fraction of residency programs currently use iPASS, said Czeisler, although he hopes the encouraging results will prompt more hospitals to try it, instead of forcing resident physicians to work marathon shifts.
Some hospitals have also experimented with holistic wellness services for their staff. The Cleveland Clinic has a program called Code Lavender to address burnout: doctors and nurses can call on-demand "holistic nurses" who provide counseling, massages and snacks during emotionally exhausting times. And the top-ranked Mayo Clinic recently instituted a program to address physician burnout that includes mindfulness-based stress reduction, an on-campus healthy living center and opportunities for doctors to take a break and socialize together over a meal.
As research continues to probe the impact of work hours and sleep on the medical field, we will likely get more conclusive answers in the resident debate. But in the meantime, what does it mean for us, as a society, if we expect them to function as zombies? It's hard to imagine how doctors can take care of others without taking care of themselves first.