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Rise of the Napturnist


 

The best sleep I ever got was in the winter of 1996. I remember it vividly. It was effortless, natural, blissful. I had swiftly slipped through the early phases of non-REM sleep, skillfully side-stepping alpha and theta waves, leaving myoclonic jerks in my wake. There was a brief hypnagogic dream involving sun-swept landscapes, playful butterflies, and a field of rhythmically blowing lavender that waved me further along on my slumbering voyage. And then, magically, I was basking in the pillowy splendor of stage 4 sleep, delta waves soothingly serenading me into hibernation.

I had found the celebrated state of suspended sensory and motor activity characterized by unconsciousness and loss of voluntary muscle movement.1 I was asleep.

I was an intern, had just worked 36 continuous hours, and was driving a car.

Data suggest that residents who sleep less than five hours per night are twice as likely to be sued, and significantly more likely to report adverse events and errors in patient care.

ACGME Outlines Resident Duty-Hours Changes

I was reminded of this incident on June 23, when I reviewed the freshly minted recommendations from the Accreditation Council for Graduate Medical Education (ACGME) task force regarding duty hours.2 This proposal follows on ACGME’s 2003 report, which enacted such national resident duty-hour standards as the 80-hour work week, the maximum 24-hour shift (plus six hours for administrative time), and the requirement for 10 hours off between shifts.

Like the 2003 report, which has played a large role in the rise of academic HM, the 2010 recommendations have major implications for academic hospitalists and our community brethren who will receive our residency graduates. As such, the reaction within the hospitalist community was immediate. Within minutes of ACGME’s notification, I was inundated with e-mail from colleagues both locally and nationally. Everyone was struggling with the repercussions. Was this good for resident education, a boon or bust for HM, a death knell for teaching hospitals?

So What’s in There?

This hotly anticipated report focuses its energy on four key elements of what the ACGME has morphed from “duty hours” into the resident “work environment”: resident supervision, handoffs of patient care, use of systems to enhance patient safety, and the effects of sleep on performance. Much of this is not really controversial and likely good for both residents and HM—an emphasis on systems-based practice, transitions of care, and expectations around communication.

The most discussed and controversial changes regard the move toward supervision and work hours that are customized to trainees’ levels. Unlike in the past, when the intern bore the brunt of the hours and patient duties, this proposal emphasizes graded supervision and duty-hour expectations. Practically, this means first-year residents will require closer supervision (whether by a resident or an attending has yet to be delineated) than more senior residents. Likewise, although all residents can only work a maximum of 80 hours averaged over four weeks (no change from 2003), the maximum shift length for interns will be limited to 16 hours. Upper-level residents will be limited to no more than 24 consecutive hours with an additional four hours for administrative work, but it is “strongly suggested” that residents working longer than 16 hours be provided with opportunities for “strategic napping.”

Read the Tea Leaves

I think these recommendations are rational and reasonable. To be sure, when these go into effect on July 1, 2011, they will have a tremendous impact on my residency program, my hospital, and my hospitalist faculty. My program, like most, likely will move toward a shift system of patient care, instead of overnight call. My hospital likely will have to expend millions of dollars annually to back-fill the work that residents would have done. My hospitalist group likely will have to expand our nonresident coverage both during the day and at night, inducing one of my partners to query, “Does this mean we’ll have to hire napturnists to cover the residents’ strategic nap time?”

It’s easy to deride these work environment changes, especially if we see the world through the uphill-in-the-snow-both-ways lenses most of us use to recollect (fondly?) our residency days. Yes, the field of medicine is losing a rite of passage many of us endured, and I too retrospectively feel the nostalgic tug of the long shifts, the seemingly insurmountable avalanche of admissions, and the autonomy in resident decision-making that made my training so valuable. But are we really against ensuring that residents are properly supervised, handoffs are more standardized, and systems are in place to protect the safety of our patients?

Sleep = Safety

The push behind limiting the maximum duration of work to 16 and 24 hours for interns and residents, respectively, stems from the growing body of literature regarding the detrimental effects of the fatigue and sleep deprivation that comes with long shifts. Not so shockingly, the data show that residents are sleepy. When administered the Epworth Sleepiness Score, residents appear sleepier than sleep apneic patients and nearly as sleepy as narcoleptics.3,4 In fact, they are so sleepy they often don’t even recognize when they are sleeping. One study showed that nearly half the time that anesthesia residents were asleep, they were unaware that they were actually sleeping.5

Further data suggest that residents who sleep less than five hours per night are twice as likely to be sued, and significantly more likely to report adverse events and errors in patient care.6 When comparing traditional, every-third-night call and 24- to 30-hour shifts with 16-hour shifts, the former staffing model is associated with 36% more serious errors than the latter.

Furthermore, there is a five-fold increase in the rate of serious diagnostic errors in the residents in the longer-shift group.7 And to finish where I began, residents who worked shifts that lasted more than 24 hours are more than twice as likely to crash their cars as those working less than 24-hour shifts. In fact, every additional extended-duration shift per month increases the chances of a car crash while commuting by 16%.8

So ask yourself this: If you were designing, from scratch, residency training today, would you really design a system similar to what we had 10 years ago? Like the one we have now? Would you ask residents, many just months out of medical school, to admit a dozen or more patients a day, stay awake for more than 30 hours, and care for the sickest, most frail patients without the assistance of more senior physicians?

The field of medicine is at a crossroads, and it faces many questions, not the least of which is how best to train our future physicians. The ACGME has published its proposal and given the public, including you, until Aug. 9 to voice your comments. These are big issues to ponder.

Maybe you should sleep on it. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

References

  1. Sleep. Wikipedia website. Available at: http://en.wikipedia.org/wiki/Sleep. Accessed July 10, 2010.
  2. Nasca TJ, Day SH, Amis S. The new recommendations on duty hours from the ACGME task force. New England Journal of Medicine website. Available at: content.nejm.org/cgi/content/full/NEJMsb1005800. Accessed July 2, 2010.
  3. Mustafa M, Erokwu N, Ebose I, Strohl K. Sleep problems and the risk for sleep disorders in an outpatient veteran population. Sleep & Breathing. 2005;9:57-63.
  4. Papp KK, Stoller EP, Sage P, et al. The effects of sleep loss and fatigue on resident-physicians: a multi-institutional, mixed-method study. Acad Med. 2005; 79:394-406.
  5. Howard SK, Gaba DM, Rosekind MR, Zaracone VP. The risks and implications of excessive daytime sleepiness in resident physicians. Acad Med. 2002; 77:1019-1025.
  6. Baldwin DC, Daugherty SR. Sleep deprivation and fatigue in residency training: results of a national survey of 1st- and 2nd-year residents. Sleep. 2004;27:371-372.
  7. Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med. 2004;18:1838-1848.
  8. Barger LK, Cade BE, Ayas NT, et al. Extended work shifts and the risk of motor vehicle crashes among interns. N Engl J Med. 2005;352:125-134.

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