Imagine yourself as a hospital patient. Your doctor walks in and lets out a long yawn. When you ask why he is so tired, he admits to working nonstop for the last 24 hours. He says that he works these marathon shifts many times a month.
Should you be concerned for your safety?
Increasing evidence suggests yes. Physicians who work marathon shifts -- those longer than 24 hours -- can cause real harm to patients, according to new research.
And physicians themselves say long hours can be detrimental to their performance.
"I have far too many memories of looking up the wrong drugs and catching myself just in time, of staring blankly at a nurse when asked to make a decision, of forcing friends to talk to me on the cell phone the whole way home so I wouldn't fall asleep at the wheel," said Dr. Jenny Blair, an emergency medicine resident at the University of Chicago.
"I have forgotten things, poked myself with a needle during a laceration repair," recalled Dr. Jeanette Hammerstein, an emergency room doctor at Hackley Health Care in Muskegon, Mich.
In a large study published in this week's issue of the journal Public Library of Science Medicine, researchers suggest that when doctors work five or more marathon shifts in a month, they are seven times more likely to make errors that harm patients -- and four times more likely to make errors that result in patient deaths.
"These marathon shifts, anytime that happens, is dangerous," said Dr. Charles Czeisler, chief of the division of sleep medicine at Brigham and Women's Hospital in Boston, and senior author of the study.
Researchers conducted a Web-based survey across the United States, in which 2,737 first-year doctors from different specialties completed 17,003 confidential monthly reports.
The study also found that these first-year doctors were more likely to fall asleep during rounds -- and even surgery -- when they worked five or more marathon shifts in a month.
Young Doctors Driven to the Edge of Exhaustion
Blair and Hammerstein aren't the only doctors who report that sleep deprivation has affected their performance.
"What I do remember is being bone-tired at 6 in the morning as I began a new day after being awake since 5 the previous morning. It's a horrible feeling that can make you cranky and angry," said Dr. Scott Terranella, at the University of Massachusetts in Worcester, Mass.
Dr. Amy Hennessy, of Virginia Commonwealth University School of Medicine, said marathon work hours made her a "more angry and emotional person."
"There were several days when I would get home and just start crying for the smallest reasons, or would just feel angry at my patients when they hadn't done anything wrong," said Hennessy.
There have been efforts to address the problem. In 2003, the Accreditation Council for Graduate Medical Education set work-hour limits for all residents -- doctors completing their specialty training -- in the United States. These regulations limit residents to work a maximum of 30 hours nonstop per shift and no more than 80 hours a week.
But the regulations still allow residents to work two 30-hour shifts a week and up to nine 30-hour shifts a month.
Are Marathon Work Hours Necessary for Patient Care?
While evidence mounts that marathon work hours increase medical errors and cause patients harm, not everyone agrees that work hours should be shortened. Some doctors argue that long shifts are essential for continuity of patient care.
For example, surgical complications can arise hours after an operation is completed.
"I believe that a patient is better off with a fatigued resident who is able to handle a postsurgical catastrophe because he was present at the surgery and knew what the surgical concerns were, than to have a rested resident who doesn't know the patient," said Dr. Joseph Fischer, surgeon in chief at Boston's Beth Israel Deaconess Hospital. He said a proper backup system -- with a more experienced surgeon -- is important when surgical residents work long hours.
When work shifts are shortened, patient handoffs -- transfer of patient care from one doctor to another -- occur more frequently.
"I've seen many errors, and actually a few patient deaths, that are due to the improper handoff of patient care," said Dr. Ben Musher at the University of Pennsylvania. "There is a trend toward residents not thinking of patients as their own because residency is becoming like shift work."
However, many residents believe they are asked to work marathon hours for other reasons.
"The reason residents are pushed to work these excessively long shifts is that they are considered cheap labor in a for-profit system of health care that is constantly pushed to its very limits to cover its ever-growing costs," said Terranella.
Patients Have the Right to Know
Since this is the largest study to date showing that marathon work hours contribute to patient harm -- including patient deaths -- patients may want to know how long their doctor has been working continuously.
"Patients have a right to know and to refuse care if the doctor has been awake for more than 24 hours," Czeisler said. "These data suggest that this is a human rights issue, because patients have never consented to these gravely increased risks."
"Who would knowingly put themselves in the hands of a doctor who had been awake and on the job for more than 24 hours?" said Terranella.
"You wouldn't choose to fly with a pilot under those circumstances, so why is it acceptable to let a surgeon cut into you?"
Rested and Well-Trained Doctors Wanted for Patient Safety
"Coming to work impaired for any reason is not acceptable," said Dr. Steven Howard, director of the Patient Safety Center of Inquiry at the Stanford University School of Medicine. "How do we change our society's culture to prioritize rest so that we can be optimally prepared to work?"
Some physicians have suggested better patient handoffs and longer residencies may be necessary.
"The challenges now are how to have healthy, safe, rested trainees that are well trained at the end of their training period," said Howard.
And experts said this study has important implications for patient safety and the current state of residency training.
"These data demonstrate that the standard practice of scheduling young doctors to work marathon shifts lasting 30 consecutive hours twice a week during their training presents a grave risk to the patients with whose care they are entrusted," said Czeisler.
The study discussed in this article can be accessed here.