Is medical education better if residents are forced to get some sleep?

CLEVELAND, Ohio — Some medical residents have a new job requirement: sleep.

Internal medicine residents at Cleveland’s University Hospitals and the local VA Medical Center are required to take a three to four hour nap during their 30-hour shifts. Summa Health System in Akron has for years experimented by limiting internal medicine residents to 16-hour shifts — and most pull just 13 hours.

It’s part of an evolution — or revolution, depending on who you talk to — on how to manage the work hours of medicine’s youngest doctors.

The old-school philosophy made medical residents live at the hospital for a zombifying schedule that could top 110 hours a week. It was partly a belief in rigorous education, but also a rite of passage. Yet as more evidence has grown over sleep hygiene and linked sleep deprivation to medical errors, medicine is considering a cultural change.

Seven years ago residents’ work hours were capped at 80 hours a week — a decision many physicians have trouble accepting. The requirement also allowed for 12 hours off after the lengthiest shifts. Now health systems are moving on their own to adjust resident schedules even further.

“I always joked about the way we do things was like Stockholm syndrome: we identify with our captors,” said Dr. Keith Armitage, director of the Internal Medicine Residency Training Program at Case Western Reserve University’s College of Medicine, which coordinates residents at the Cleveland VA and University Hospitals.

University Hospitals and the VA in Cleveland started required sleep periods on their own in the hope of boosting morale and attracting more residents to their program.

Under the four-month-old pilot program, first-year internal medicine residents at both hospitals are now required to sign out for a nap during their shifts, usually in the wee hours between 2 and 6 a.m. Residents when they first start usually get a three-hour nap and as they get more accustomed to their schedules and work the nap expands to four, Armitage said. He would like the rest period to grow even more than that, to five hours and beyond.

A 30-hour internal medicine shift consists largely of checking in new patients and then monitoring them over the time they are in the hospital to provide one doctor to coordinate care. While there’s always downtime during that shift, Armitage pointed out there is a big difference between often-interrupted spot naps and a dedicated period of rest.

“The argument is that patients are well-served by the same person looking after them overnight and next day — even if they are fatigued,” Armitage said. “But you don’t want a tired doctor looking after you. You want someone fresh looking after you.”

It would seem a national mandate is likely. The Institute of Medicine late last year recommended protected sleep periods and work-hour limits. It wanted to cut the amount of time doctors could see patients during a 30-hours shift from 24 hours to 16 hours. In addition, it wanted a required five-hour sleep period between 10 p.m. and 8 a.m.

However, there’s been no decision by the Accreditation Council for Graduate Medical Education, which accredits residency programs in the United States. The ACGME is doing its own ongoing review of residents’ work hours.

There are both philosophical and logistical challenges to such changes. Shorter shifts increase the likelihood a patient will be handed off from one doctor to another, which is a clumsy and potentially dangerous way to manage patients (that’s one of the reasons the UH naps happen during a period with the least likelihood of patient interaction).

In addition, there’s the question whether, as work hours drop, the length of a medical residency should be extended in order for students to get the same experience as their program’s predecessors.

Summa Dr. Dave Sweet said the number of work hours for residents is down since the health system switched three years ago to shifts of no more than 16 hours.  Previously, internal medicine residents would work between to 70 to 75 hours out of the maximum 80. Now, the systems 48 residents work about 60 to 62 hours a week, said Sweet, Summa’s internal medicine residency program director.

Overwhelmingly most internal medicine residents at Summa about 13-hour sessions.

But statistics show that residents have seen about 10 percent more patients since the change, Sweet said. Part of that is due to logistical changes; Summa streamlined its scheduling so residents could maximize times they could see patients. Sweet said that the shorter shifts have helped, too.

In addition, Summa said tried to smooth handing off patients to different doctors by spending about two hours of their overlap time in discussing patients with an attending physician present. Overnight shifts typically stretch into 16 hours in ordered to manage patients.

“It hasn’t impeded their education,” Sweet said. “Now they are awake when they see patients.”

Now the trick is getting the medical community to believe it. Both Sweet and Armitage admit most doctors don’t like mandatory naps and shortened schedules. It also seems that many medical students are wary of shortened schedules. Reports as part of an ongoing review of residents’ work hours indicate residents dislike working fewer hours (pdf) because it cuts into their education.

Dr. Ron Conner, a third-year internal medicine resident at Summa, said his peers at other schools don’t like Summa’s system when they hear about it. Conner, though, said there’s almost an immediate buy-in once residents start the program.

“If you’re in a hospital for extended hours you become a servant to the task instead of thinking and learning,” Conner said.

But it’s not as if Conner is spending his free time sleeping. He’s used the extra time to work on a research study on the increase in coronary artery disease in AIDS patients and study for a master’s in public health. So he’s likely working just as hard on his own terms.

“I’m able to use my free time,” Conner countered. “I’m not working tired. It allows me to do my job and care for patients.”

[Photo courtesy of Flickr user pedrosimoes7]