The arduous journey to become a medical doctor typically requires students to complete four years of medical school followed by a 3-7 year residency. Amid the latter half of this process, one is right to imagine overworked twenty-somethings staggering around the ER unit at 4 a.m. attempting to visit patients, complete patient reports and write prescriptions. What exactly are the current rules dictating resident’s shift work?
According to OP Med, “In 2011, the ACGME mandated that the shifts of first-year residents, known as interns, be limited to 16 hours. Second-year residents and beyond were permitted to provide continuous clinical care for 24 hours, with up to an additional four hours for hand-offs to other team members.”
In short, young doctors could anticipate facing a shift that lasts up to 28 hours. To reveal the irresponsibility of this widespread practice, I will trace its origins and unpack the effects of sleep deprivation on residents and patients alike.
The term “residency” originated from Dr. William Stewart Halsted, founder of the surgical training program at Johns Hopkins Hospital in 1889. In order to best learn the skills necessary for their career, Halsted believed trainees should physically reside in the hospital, committing themselves to extraordinarily long hours of training and patient care. His belief in this grueling practice takes an interesting turn after reading anecdotes from former colleagues that claim Halsted would infamously stay awake for days at a time, appearing to function at full capacity. How could he accomplish this sleep feat? After noticing his disturbing behavior in the clinic and reading his incomprehensible medical journal report, colleagues later discovered that Halsted was battling a cocaine addiction that was induced after a series of lab experiments he performed on himself earlier in his career.
Matthew Walker, in his book titled ‘Why We Sleep,” sums up the issue stating, “Halsted inserted his cocaine-infused wakefulness into the heart of Johns Hopkins’s surgical program, imposing a similarly unrealistic mentality of sleeplessness upon his residents for the duration of their training.”
It is astonishing how this practice has become the norm despite its illegitimate founding and the overwhelming amount of sleep science that we will now explore.
Before even considering an around the clock shift in the context of medicine, just imagine how you feel at 3 a.m. after returning home from a party on Friday night. Drowsy, stumbling and barely able to garner the energy to brush your teeth, you collapse into bed for a full night’s sleep. A medical resident does not share this privilege. Let’s say he or she begins a 24 hour shift at 9 a.m. Once 3 a.m. rolls around, the resident is expected to function for another six hours after having already completed 18 consecutive hours of work. Such a practice turns from tortuous to harmful when one considers that these residents have patients’ lives in their hands. Would you trust yourself to care for an ill patient after working for 18 consecutive hours? The obvious answer to that question is supported by some concerning data.
Walker, referencing the injurious consequences of these shifts, states that “Residents working a thirty-hour straight shift will commit 36 percent more serious medical errors, such as prescribing the wrong dose of a drug or leaving a surgical implement inside a patient, compared to those working 16 sixteen hours or less.” Even more frightening, sleeplessness permeates into the intensive care unit, where, “residents make 460 percent more diagnostic mistakes than when well rested after enough sleep.”
If my argument appears subjective thus far, perhaps a brief scan of the neuroscience data pertaining to sleep and human function will convince you. One study from NCBI showed, “Under the effects of sleep loss, people habitually more reflective and cautious become more impulsive and prone to risk-taking during decision making based on deliberative reasoning.”
Does this sound like a doctor you want caring for your children? Another study from BMC Neuroscience showed, “sleep deprivation to predominantly affect functions mediated by the prefrontal cortex, such as working memory. Together, these findings suggest that the restorative effect of sleep is especially relevant for the maintenance of functional connectivity of prefrontal brain regions.”
Halsted claimed long hours in the clinic would foster learning, yet the data has since debunked such nonsense. Without eight hours of sleep, residents’ brains cannot even form the neural connections necessary to consolidate what they have learned into memory. Branching further, after the 24 hour shift, sleep deprived residents must drive home in a state that is equivalent to having a 0.10% blood alcohol level, placing both themselves and other drivers in harm’s way.
If the foremost mission is patient care, why haven’t health institutions revised this destructive system? Is testing the endurance of residents at the expense of patients’ lives not malpractice? Leaders within the medical field must relinquish Halsted’s hazardous logic in place of healthy practices that are reflective of current data pertaining to sleep.