Young doctors could work 28 hours straight under new plan, despite possible dangers

The private group that oversees physician training in the United States has proposed rolling back rules so that young doctors just out of medical school can work shifts as long as 28 hours.

The proposal relaxes work restrictions put in place in 2011 when mounting evidence showed that exhausted residents - the term for doctors in training - were endangering patients and themselves. Currently, first-year residents are restricted to 16-hour shifts.

Studies show that residents make more potentially deadly errors in caring for patients the longer they work.

The extended shifts also expose residents to an increased risk of car accidents as they drive home from work. At the University of California, Los Angeles, nearly 20 percent of residents said in a 2007 survey that they had fallen asleep while driving because of work-related fatigue.

Doctors pushing for the change say the current shift limits can jeopardize patients by forcing residents to leave at critical times. They also say grueling hours prepare trainees for the future, when they will practice unsupervised.

"Training to become a practicing physician can be compared to training for a marathon," said Thomas Nasca, chief executive of the Accreditation Council for Graduate Medical Education, in announcing the proposed change. "With enough experience comes resilience and the ability to perform under expected, sometimes challenging conditions."

The council is collecting comments on the proposal until late Monday at acgme.org. A final vote is expected in February.

Some physicians and consumer groups have blasted the proposal, pointing out that it goes against the findings of a year-long review by the Institute of Medicine, which concluded in 2009 that having doctors work more than 16 consecutive hours was dangerous for both patients and doctors.

"This is deeply troubling," said Charles Czeisler, a professor at Harvard's Brigham & Women's Hospital, who has studied what happens as residents work extended hours. "It is very well established that staying awake for 24 hours severely degrades performance."

In one trial, Czeisler and his colleagues found that interns - residents in their first year - working in the Intensive Care Unit for 24 hours or more made 36 percent more serious medical errors than those working shorter shifts.

At times, the Harvard researchers found residents sleeping while standing up, Czeisler said.

Under the council's proposal, interns would have the same 28-hour limit as residents with more experience.

The proposal would also let all residents work longer than 28 straight hours in rare cases in which they are needed for a patient's care with no need to document why the extended hours were necessary. And it would eliminate a requirement that residents get at least eight hours off after shifts of less than 24 hours.

The plan, however, keeps rules in place that say residents cannot work more than 80 hours a week, averaged over four weeks.

"We aren't changing the total number of hours a resident is working," Nasca said.

And because residents are at risk of depression and anxiety, in part because of their long hours, hospitals must begin providing 24-hour access to affordable mental health treatment for them under the plan.

Not long ago, there were few limits on how long doctors in training could work. In the early 20th century, trainees often lived in the hospital after graduating from medical school - which is why they are called residents.

But the death of 18-year-old Libby Zion in a New York City hospital in 1984 raised questions about the system. Zion's father learned that his daughter's primary doctors had been two residents who were caring for dozens of patients that day with little supervision.

"You don't need kindergarten," her father Sidney Zion wrote in a New York Times op-ed piece, "to know that a resident working a 36-hour shift is in no condition to make any kind of judgment call - forget about life-or-death."

As a result of the Zion case, New York state passed a 1989 law banning residents from working more than 80 hours a week or shifts of more than 24 hours.

The council, which accredits graduate medical education programs, adopted similar nationwide rules in 2003. And after the Institute of Medicine detailed the dangers of the long hours, the council went another step in 2011 by prohibiting first-year residents from working longer than 16-hour shifts.

Surgeons have been especially critical of the restrictions, which have at times required residents to leave a surgical team in the middle of an operation.

"They had to leave because their clock was up," said Karl Bilimoria, a professor of surgery at Northwestern, "and clearly no one wanted that to happen."

He said that while practicing surgeons only "sometimes" work more than 24 hours, "you have to understand how to handle those hours."

The restrictions on how many hours the young doctors can work have also been expensive to teaching hospitals, which had to hire more staff to do work once performed by the physician trainees.

"Residents represent free labor," said Andrew Schumacher, a resident at Kaiser Permanente in Los Angeles.

Schumacher noted that four hospital executives sit on the council's 35-member board that will vote on the proposal. He said he believes those executives have a conflict of interest that could influence their vote.

Medicare pays the teaching hospitals as much as $130,000 or more a year for each resident. The hospitals then pay residents just a fraction of that, with many receiving a salary of around $60,000, with no overtime. After covering the cost of the residents' benefits, the hospitals can use the money for other purposes.

Nasca said the council had "extensive" policies in place to deal with any potential conflicts.

The hospitals have tried to help residents manage the demanding shifts. At UCLA, residents are taught to recognize when they are sleep deprived, according to a slide presentation on the university's website. The signs of sleep deprivation include dozing off while writing notes or reviewing patients' medications, and poor memory or judgment.

The UCLA residents are told that lack of sleep can cause hostility, high blood pressure and a higher risk of car accidents on the drive home. One tip, according to the presentation, is to drink coffee 30 minutes before driving home.

Tami Dennis, a UCLA spokeswoman, said the university was committed to a program that "trains and coaches residents on the issues of patient safety."

"Any resident who needs sleep, even those within their duty limits, are offered rides to their homes, paid for by the hospital," she said.

The council proposed relaxing the rules after a study led by Bilimoria, the Northwestern surgeon, concluded there was no difference for surgery patients' safety when hospitals allowed residents to work longer than the current national limits.

The year-long study involved 117 residency programs at hospitals across the country. About 9 percent of patients died or had serious complications after surgery whether the hospitals followed the shift limits or not.

The study had been planned by the council and two national surgical societies after the extra restrictions were added in 2011.

But some doctors say the study was poorly designed.

"These were trials run by physicians who wanted to see the rules overturned," said Sammy Almashat at Public Citizen's Health Research Group.

"We don't let pilots stay awake for 28-hour shifts," he added, "because we know the consequences."

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