Residency program directors, who face new limits on duty hours in July, are beginning to face a growing body of evidence that links fatigued residents to medical errors.
At a conference for program directors Thursday, experts reported that lack of sleep leads residents to miss data, make faulty decisions, lose consciousness, become irritable with patients and staff, and get into car accidents after working long shifts.
Program directors, attending a Chicago meeting of the Accreditation Council for Graduate Medical Education, the group that has adopted the new limits, seemed impressed with the data. But they also voiced concerns that the hours limits would affect continuity of care, spread to other doctors and hospital staff, and implicate attending physicians in malpractice liability.
"This opens a can of worms," said Timothy Flynn, M.D., a vascular surgeon at Shands Health Care University of Florida in Gainesville, referring to concerns that other hospital staff would eventually have similar limits.
But sleep experts also suggested that the ACGME limits may not be low enough to allow for adequate rest.
The new limits call for 80 hours of duty a week, which can be raised to 88 hours a week; at least 10 hours rest between shifts; shifts no more than 24 hours long; one day off in seven; call no more than once every third night.
Although residents often have a chance to nap during long shifts, David Dinges, Ph.D., a professor of psychology in psychiatry and chief of the division of sleep and chronobiology at the University of Pennsylvania, said even 15 hours of continual wakefulness is too long.
While Dinges and other experts conceded that some people show little impairment with lack of sleep, scientists are beginning to understand that many people have definite limits that cannot be changed, as some program directors have maintained.
David Leach, M.D., executive director of the ACGME, said he was particularly concerned that residents have less time for sleep during shifts and about widespread reports at the meeting of residents getting into traffic accidents after shifts.
Sleep experts added that the new ACGME limits won't necessarily solve the problem of resident fatigue.
"Just because you're not working more than 80 hours doesn't mean you're going to sleep more," said Andrew L. Chesson Jr., M.D., associate dean of academic affairs and professor of neurology at Louisiana State University sleep disorders center.
The experts suggested a few countermeasures to avoid excessive fatigue:
- Get at least seven hours of sleep a night, particularly before overnight shifts.
- Take catnaps of about 15 minutes during a shift, but not longer, because deep sleep can make one groggy and unable to concentrate.
- Drink coffee or another form of caffeine, which kicks in after 15 to 30 minutes and lasts three to four hours.
- Pick up on signs of fatigue, such as blanking out, nodding off and making obvious mistakes.
- Don't drive home after a long shift.