The Doctor Is In (and In and In and In): 28-Hour Work ‘Day’ Proposed for Medical Residents

The Accreditation Council for Graduate Medical Education (ACGME) on Nov. 4 proposed a new set of requirements for the number of hours worked by resident physicians. The proposal removes the five-year-old, 16 consecutive-hour limit on first-year resident work shifts and allows them to work up to 28 hours straight without sleep, while caring for patients.

Public Citizen called the proposal “a dangerous step backward.”

“Study after study shows that sleep-deprived resident physicians are a danger to themselves, their patients and the public,” said Dr. Michael Carome, director of Public Citizen’s Health Research Group. “It’s disheartening to see the ACGME cave to pressure from organized medicine and let their misguided wishes trump public health.”

The ACGME instituted the 16-hour limit for first-year residents in 2011, in response to a 2009 report by the Institute of Medicine (IOM) that, based on an exhaustive review of the evidence on the harms of long work shifts, recommended that all residents be restricted to 16 consecutive-hour shifts. The IOM’s report pointed out that tired residents are more likely to injure themselves and their patients, in addition to being at increased risk of a motor vehicle accident when driving home while sleep-deprived.

The ACGME itself acknowledged at that time that interns “make more errors when working longer consecutive hours.”

The new proposal is at odds with a public opinion poll released in September, “Bipartisan Consensus: The Public Wants Well-Rested Medical Residents to Help Ensure Safe Patient Care,” commissioned by Public Citizen and conducted by Lake Research Partners, which revealed that more than four out of five Americans oppose any resident physician working more than 16 hours in a row without sleep. The results were overwhelmingly bipartisan and shared by all demographic groups.

Physicians Describe their Personal Experiences

Anonymous: “I am currently in my second year of fellowship training, and I went to a prestigious competitive residency training program. During my last year of residency, there was a change in our schedule. After a week of busy nightfloat, on Monday mornings we were required to go afternoon continuity clinic rather than having the day off as was previously the case. This fell within the rules of duty hours because, as residents, we were allowed to work 24 hours in a row.

“My continuity clinic involved me driving to clinic. On the way home, very exhausted, I was involved in a fatigue related car accident. Luckily, I did not suffer any physical injury, but it could have turned out differently.

“I brought the information to my chiefs and requested a change in the process. No changes were made or arrangement of rides or alteration in schedule, and I had to do this again three more times that year… At my exit interview with my program director, I brought up the fatigue-related accident as a concern that no changes were made, etc. It was at this point that the conversation with my program director made it evident that no changes would be made. I am concerned for another fatigue related accident that could lead to more serious injury.”

Anonymous: “During intern year at a program with a nominal 80-hour work week, I worked 100 hours per week for most of a month. During internal medicine clinic one day, I was interviewing a patient when I suddenly realized that I could not remember what I had already asked and what I had not yet asked.

"I excused myself abruptly and rushed down the hall where I collapsed on the bathroom floor. I leaned against the bathroom wall and felt relaxed for the first time in weeks. My face was wet and I realized I was sobbing. I was so unaware of how exhausted and impaired I had become. I cried because I was tired, and also because the patient I was seeing deserved better attention and care than I was capable of providing. I couldn't remember any details of his chest pain or risk factors for heart attack. I couldn't even remember his name or his face. Only that he was friendly and he trusted me…”

Betsy Greenleaf, D.O. (a physician practicing in New Jersey who was a general surgery resident in 1999-2001 and an obstetrics and gynecology resident in 2001-2004): “I remember in residency being so sleep deprived that I would pray to pass out so that I could get some rest. In general surgery residency, I had one week in which I worked 125 hours.... I did a weekend of 72 hours in which I only got 4 hours of sleep.

"I would also secretly hope to get in a car accident and maybe break a leg so that I would be forced to take off from work...just so I could get some rest... I have fallen asleep standing up in surgery and had witnessed my attending doctors fall asleep while doing surgery. I actually passed out at the end of a 36-hour shift and woke up on a stretcher in the recovery room.”

Karen Chase, M.D. (currently working part time as an emergency room physician and recently opened a solo clinic): “I was in residency at Finger Lakes Rural residency associated with Highland Hospital in Rochester, N.Y. in 1998-1999. I worked in at least five different hospitals that were up to an hour apart. We were limited by law to 28-hour shifts, but those could be separated by as little as 8 hours.

“I fell asleep at the wheel numerous times during residency. I learned to eat chips and other crunchy things to stay awake. I’d drive with the windows down, music blaring. I’d punch myself and slap my own face, bite my lip, chew or bite my fingers; anything to stay awake, but I'd drift off and awaken when I hit the side of the road. Or wake up as I drove onto the other side of the road. I should be dead. It’s a miracle I was not killed in a car accident. I quit after one year on the verge of suicide; I'm sure exhaustion contributed to that.”