New hours limits for residents that go into effect this July won't fully address the danger of overworked young doctors making medical errors, experts in sleep deprivation say. The limits set by the Accreditation Council for Graduate Medical Education, such as shifts of no more than 24 hours in length, still leave open the likelihood of severe sleep deprivation, according to experts gathered in early March at a forum on the new rules.
The meeting was hosted in Chicago by the ACGME, which also will enforce the new limits for 100,000 residents in 7,800 programs nationwide.
Other ACGME limits are:
- 80 hours of duty a week, which can be raised to 88 hours;
- at least 10 hours of rest between shifts; and
- call no more than once every third night.
While residents often take naps on a 24-hour shift, they report that sometimes they have to work straight through. And yet, even 20 hours of continuous wakefulness is too long for most people, says meeting presenter David Dinges, professor of psychology in psychiatry and chief of the division of sleep and chronobiology at the University of Pennsylvania, Philadelphia.
"The cortex (of the brain) is built for 15 to 16 hours of wakefulness," says Dinges, adding that those with sleep deprivation make errors in calculation and judgment, especially when they are under time pressure.
Experts at the meeting say a few studies in specialties such as anesthesiology have linked fatigue to medical errors, but the most palpable link seems to be to car accidents by residents after a long shift.
Kathryn Lane, vice president for academy affairs at Maimonides Medical Center in Brooklyn, N.Y., says seven surgery residents at her hospital were involved in traffic accidents in the past year, even though New York state has had hours limits similar to those the ACGME is proposing for about a decade.
ACGME Executive Director David Leach, M.D., says he was particularly worried about residents driving home after a long shift.
He also says residents today have less time for naps. Cost pressures mean that "we've pulled redundancy out of the system" and residents have more responsibilities, he says.
Program directors attending the meeting seemed impressed with evidence of the detrimental effects of long work hours, but many said the limits would affect continuity of care and eventually might become a standard for all 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, Fla.