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December 10, 2006

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Doctor fatigue hurting patients

Interns feel guilt, lose empathy

By William J. Cromie
Harvard News Office

How much sleep has she had? Interns who work marathon shifts of 24 hours or more make four times more deadly mistakes than colleagues who get enough sleep. (Staff file photo Justin Ide/Harvard News Office)

Too many 24-hour shifts worked by hospital interns cause medical mistakes that harm and may even kill patients, according to a new Harvard Medical School study. Doctors in training who fall asleep during surgery or while examining patients make four times more errors that cause deaths than their better-rested colleagues, the research reveals.

Young doctors also suffer from their mistakes with emotional problems that can haunt them for years. They admit that their distress includes fear, guilt, anger, humiliation, and decreased compassion. What's more, the distress coupled with reduced empathy can increase the odds of more medical errors and even alcohol and drug abuse.

"The evidence demonstrates that academic medicine is failing both doctors and patients by routinely requiring exhausted doctors to work marathon shifts," says Charles Czeisler, Baldino Professor of Sleep Medicine. "The human brain simply does not perform reliably for 24 consecutive hours without sleep."

Czeisler and his colleagues conducted a national survey of serious medical errors and their consequences as described by 2,737 interns in all medical specialties. Using a secure Web site, the interns - those in their first year of medical training - reported on their medical mistakes, fatigue-related and not, once a month for 11 months. They also answered questions about how many shifts of 24 consecutive hours or more they worked in a week.

Their answers showed that those who worked more than five marathon shifts in a month were seven times more likely to report significant medical errors than those who worked no extended shifts. Interns who put in between one and four extended shifts reported that potentially harmful errors were three times more likely than when they were well rested.

Interns who put in more than five 24- to 30-hour shifts in a month were involved in 300 percent more fatal errors than when they did not work extended shifts. They were also more likely to fall asleep during surgery, while examining patients, during hospital rounds, and during lectures or seminars. The latter "presents a grave risk to patients with whose care they are entrusted," Czeisler comments.

Deadly mistakes

These extended hours often exceed the time that interns in the United States are supposed to work. The Institute of Medicine, an advisory group in Washington, D.C., reported in 2000 that between 48,000 and 98,000 deaths each year were due to medical errors. As a result, the Accreditation Council for Graduate Medical Education, in 2003, came up with new work guidelines for doctors in training. But these guidelines still allow up to nine marathon shifts of as many as 30 consecutive hours in a month.

Czeisler (Staff file photo Jon Chase/Harvard News Office)

Czeisler insists that these standards are not enough to prevent harmful medical errors even if interns stick to them, which they don't. "Interns working extended shifts within the guidelines reported significant numbers of medical errors including those that resulted in adverse patient outcomes and fatalities," he and his colleagues reported online in the Public Library of Science (PloS) Medicine on Dec. 12.

What is more, most of the interns (83.6 percent) reported that, even in the year after the standards were introduced, they worked more hours than allowed. And the Harvard study shows that things have not gotten any better. "Even interns who worked less than the current limits, but who continued to work five to nine extended-duration shifts per month, had eight times greater odds of reporting preventable medical errors that harmed patients," Czeisler says. "These errors included more than four times [4.6] more fatalities than those committed by interns who did not work extended shifts."

The long hours and harmful mistakes can be as hard on doctors as on their patients. In the past, Czeisler and his colleagues at the Brigham and Women's Hospital and Harvard Medical School's Division of Sleep Medicine found that, after long shifts, interns get into more traffic accidents than nine-to-five workers.

They also stick themselves with needles, and lacerate themselves with scalpels and broken glass at increased rates (see Sept. 14-20, 2006, Gazette).

What can be done

The PloS report also catalogs mental injuries. "Admitting a medical error that causes harm creates significant emotional distress for physicians that can last days or years," according to the researchers. Such feelings can increase the odds of future medical errors, they say. "Without coping mechanisms, such as accepting responsibility, discussion with colleagues, and disclosure to patients, physicians may use dysfunctional methods of dealing with errors, such as alcohol and drug abuse," notes Laura Barger, a research fellow in medicine who is the lead author of the report.

Added to this is the possibility of deleterious effects on an intern's medical education. As the number of extended shifts increase, so do risks of falling asleep in lectures and on rounds. Adequate sleep plays a vital part in memory and learning. "The amount of sleep reported by most interns," Barger notes, "is less than that shown to be necessary to perform satisfactorily on cognitive tasks that are implicitly necessary for learning."

All of which brings up the big question, "What can be done about all those exhausted interns?"

Passing laws limiting work hours is an obvious solution. In Europe, a law requires that both doctors and doctors-in-training be given 11 hours off every day, effectively holding shift durations to 13 consecutive hours.

Working with the Sleep Research Society, an organization of more than 1,000 sleep scientists, and the National Sleep Foundation, Czeisler has helped put together model legislation that mandates a fixed maximum of 18 consecutive hours a day. It calls for no more than one 18-hour overnight shift a week. A bill to establish a commission that would formally consider such recommendations is now pending in the Massachusetts legislature, supported by state Sen. Richard Moore (see http://sleep.med.harvard.edu).

The two sleep organizations that sponsor this wake-up law also recommend that all doctors be required to notify their patients if they have slept less than two hours in the last 24. A nationwide poll conducted by the National Sleep Foundation found that 86 percent of people would feel anxious about their safety if their surgeons admitted they had been on duty more than 24 hours. Seventy percent, or more than two-thirds of those surveyed, said they would likely ask for a different doctor if this were the case.

"In light of what we now know," Czeisler says, "it's easy to reach the conclusion that a patient has the right to know if a physician is sleep deprived, so that he or she can decide whether or not they want to be treated by that physician."

Related links:

Link to study

Early risks reported

Demands on interns continues


Copyright 2006 by the President and Fellows of Harvard College