Doctors and sleep deprivation

Busy over the summer
July 25, 2011
A little trip.
September 29, 2011

Hope you all are doing well.  An interesting article in the Globe and Mail caught my eye.
“24-hour shifts are a prescription for medical errors.”
http://www.theglobeandmail.com/life/health/new-health/andre-picard/24-hour-shifts-are-a-prescription-for-medical-errors/article2132662/

Basically this article summarizes fatigue and sleep deprivation and its deleterious effects.  In general I do not find these types of newspaper pieces very useful.  This particular writer typically presents things in an oversimplified, cut and dry fashion, and advocates for particular solutions as if they are straightforward, when in general they are anything but.  However, in this case, I agree with him.

Sleep deprivation I think is under-recognized as a cause of errors and avoidable accidents in general.  When I was in training I would have to stay up overnight then work the next day before sleeping mid-afternoon, finally after 30+ hours awake.  This was in Kingston, Ontario, although similar schedules are seen across the country.  While I do recognize the value of having seen many patients, perhaps by staying up late, the value of the morning after was always lost on me.  We were told we needed to see how our admissions did, but after no sleep or food and barely time to use the washroom, truth be told, we just wanted to ensure the patient would live and we would sort out the rest the next day!  The morning after, as senior residents, we would be grilled on our performance, and made to look bad in front of our peers, for forgetting to order trivial tests unrelated to the presenting symptoms, when we saw the patient at 3 in the morning!  While we do learn to work while tired, the need to sleep is basic human physiology, and I doubt very much you can train anyone out of it!

I am surprised this pattern persists.  As the author points out in his piece, we all recognize you perform poorly when you are tired, and if you can’t fly a plane or drive a truck more than 14-16 hours, why can you make life or death decisions? 

I think a big part of the reason these systems persist is economic.  As trainees you earn a flat yearly salary with no bonuses for being up late or doing overtime.  Thus there is no financial reason for the hospital to protect trainees from too many hours.  Trainees are used as cheap labour.  In many hospitals they are asked to do routine blood tests and other tasks that a fully-trained physician would never be asked to do.  This system avoids paying for technicians to draw blood etc.  (To be fair to Kingston, they did not do this too much.)  Attending physicians are supposed to supervise you.  Some were good, in my experience, but a lot just wanted to sleep through the night and would get angry with you if you called for advice, especially after midnight – they wanted you to “take care of it” and not bother them until the next morning.

In general I think medicine should be self-policing.  The average person has very little idea what a doctor faces in his or her daily life and what it is like being a doctor.  However in this case I think their is an argument for some external regulation.  I do recognize I gained something by seeing so many patients.  But the extremes to which our hours are taken in medical training, I think, is absurd, and puts patients and providers both at risk.  I, luckily, did not make any major errors because of fatigue, but certainly I heard of a few here and there.  I also knew resident colleagues who suffered major automotive accidents while driving home after a busy overnight shift.  I think a 24 hour max limit, or perhaps even smaller, needs to be in place.

What do you think?  Is this right?  Or do you think this is just part of the “dues” you have to pay when you enter a professional field?  Let me know your opinion!

2 Comments

  1. Anonymous says:

    Mmmm,

    As you pointed out earlier it is not cut and dry, I would agree with that.
    • Dues or hard work is not uncommon in any profession you are entering. I don’t disagree with the philosophy of people having to do it.
    • Is 24+ hours excessive? I tend to agree with that. When I use to work a production facility and things went wrong, a 24 hour shift could easily happen. And yes I think you are more prone to mistakes but you do manage to get the job done. Your focus does become very narrowed as all you want to do after a while is complete the task (or as you put it, ensure everyone lives)
    • A time limit might be a good idea, but it won’t be perfect. If a 16 hour limit is put in place then you would get 8 hours off and could be called back. Given common commute times you are going to be tired for your next 16 hour shift anyways.

    Might also be some truth in hospitals trying to keep expenses down. Lots of pressure on costs of the health system in Canada. That is a whole different subject that I wouldn’t have a clue how to address.

    Stephen Sutherland

  2. Very true Mr. Sutherland. There is certainly a big element of paying your dues in this training. I am glad it is over.

    I personally think 24 hours is a good upper limit for work. You get tired in the wee hours but can generally get enough done. There should be a focus though on handing over to the next doctor ASAP the next morning and getting out of there. Which there is not.

    16 hours is even better to avoid fatigue, but you have to be careful handing your patients to another physician. You can easily leave out something the next doctor needs to know to care for your patient well. This can be standardized to hopefully avoid this particular problem. As you point out though with a commute 8 hours is not much rest.

    Now that I am an attending I am not disturbed nearly as much on call (touch wood since I am on call tonight). With this being the case 24 hours is much more doable. But as a trainee there was often no sleep at all in this 24 hour period.

    Dr. V

Leave a Reply

Your email address will not be published.

Share via
Send this to a friend