Doctors and sleep deprivation

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!