05 Apr Sleep Deprivation: Dream or Reality Part 2: The Medical Field
Part 2: The medical field
Over the years, multiple studies in health care have shown an increase in inappropriate decision-making and an increase in surgical complications following on-call nights and sleep deprivation. These studies have led to changes in the medical training curriculum, with a decreased number of work hours per week, decreased on-call shifts per month, and in some subspecialties, a forced day off following on-call work. The Royal College of Physicians and surgeons of Canada has tried to balance the number of working hours versus their effect on sleep and learning capability.
Fundamentally, it is patient safety that sits at the heart of this concern over resident duty hours. In that line of thinking, Canada’s National Steering Committee on Resident Duty Hours in 2014 released its recommendation that the status quo of 24 or more hours without restorative sleep should be seriously avoided, and that new accreditation standards for Canadian training programs should be put in place to ensure they develop and implement fatigue management plans for their residents. While this decision intuitively makes sense, substantiating it with data has been difficult. When the Steering Committee reviewed studies from every country that had restricted the hours residents worked, they were unable to find any clear evidence that patient safety had improved in these countries.
The evidence about the effectiveness of restricting residency hours for patient safety reveals somewhat of a “paradox”. There is plenty of evidence for the health issues of fatigue, but when you take a further look into the correlation to errors that affect patient care, there is not any conclusive data.
The exact reason for this anomaly is not known, but there are several theories. One of these is that in many countries with limits on resident duty hours, residents could still be working very long hours in quantum – so the hour restrictions simply may not be sufficient. Another line of thinking is that even when countries enact meaningful restrictions, compliance rates are not always high in tandem, with little to no consequences for breaches.
Long hours and fatigue are only one cause of errors. For instance, if there are high levels of handovers there is some of the greatest risk of errors, as important information can get lost in the transfer. If resident on-call shifts are shortened so that the number of handovers is increased, any benefits to patient safety from reduced fatigue may be offset by increased errors resulting from more handovers.
The evidence is much clearer if one looks specifically at the impact of traditional duty hour models, according to the Steering Committee’s report. Longer hours are associated with higher rates of resident burnout and lower quality of life. Extended hours pose a risk to personal safety. Evidence indicates that residents who work longer hours experience much greater risk of being in a motor vehicle accident. Residents who have worked extended hours are also at higher risk of needle stick injuries and other work related injuries.
But there is a fine balance in ensuring high quality medical education while reducing training hours – one needs to look at the quality of medical training holistically. One of the chief reasons residents work such long hours is for them to gain experience and exposure to many diverse cases. Reducing the number of hours worked by residents runs the risk of producing less experienced doctors, who may not be ready for independent practice at the end of their residency. These concerns are particularly strong in surgery and other procedural specialties.
This leads some people to worry that restricting duty hours could lead to longer residencies. We also get in a very difficult area of funding, position for training, and increase expenses for the trainees. In Europe, where resident hours are restricted to 14 hour shifts and no more than 48 hours per week, training is significantly longer than in Canada. Instead of adding to the length of residencies or increasing reductions in resident duty hours, it may be worth reassessing the training all together – increasing the teaching of skills and decision-making processes earlier in residency. We may consider different models of flexibility with on-call schedules, still meeting on-call exposure and training teaching requirements.
While the National Steering Committee avoided recommending a ‘one size fits all’ approach for Canada, there is no doubt that the country’s residency programs are in for significant change in coming years. It remains to be seen whether this new approach will finally produce the gains in patient safety that have proved elusive in other jurisdictions.