IOM Panel Recommends Medical Residents Get Five Hours Of Uninterrupted Sleep After Working 16 Hours

Main Category: Medical Students / Training
Also Included In: Sleep / Sleep Disorders / Insomnia;  Public Health
Article Date: 04 Dec 2008 - 3:00 PDT

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Medical residents working a 30-hour shift should get a five-hour, uninterrupted break to sleep after working 16 hours, an Institute of Medicine panel recommended on Tuesday, the AP/Houston Chronicle reports (AP/Houston Chronicle, 12/2). The panel comprises physicians, sleep researchers and quality assurance experts (Brown, Washington Post, 12/3). According to a report released by the panel, "considerable scientific evidence that 30 hours of continuous time awake, as permitted and common in current resident work schedules, can result in fatigue." The report also states, "The science on sleep and human performance is clear that fatigue makes error more likely to occur" (Powell, Akron Beacon Journal, 12/3).

The Accreditation Council for Graduate Medical Education, which oversees residency programs, in 2003 capped residents' working hours to 80 hours per week averaged over four weeks and shifts of no more than 30 hours at a time (Rubin, USA Today, 12/3). The panel did not recommend changing those limits, but it said that violations of the 80-hour per week cap frequently occur and are under-reported (Rosetta, Salt Lake Tribune, 12/3).

In addition to the mandatory sleep breaks, the panel called for greater supervision of residents, a ban against working additional jobs and assigning tasks such as drawing blood to other hospital workers to give residents more time for patient care (Parker-Pope, New York Times, 12/3). The panel also recommended that residents receive one full day off per week and at least two days off in a row each month (Washington Post, 12/3).

IOM staff briefed the House Energy and Commerce Committee and the House Oversight and Government Reform Committee on the report Monday. While the report did not recommend that Congress take any action, panel member Brian Lindberg, executive director of the Consumer Coalition for Quality Health Care, said, "I have faith that they'll step in if necessary" (Weyl, CQ HealthBeat, 12/2).

Cost
The panel did not propose how to finance the estimated $1.7 billion in additional costs to cover patient care during mandatory sleep time and shift changes. The panel said that medical schools, hospitals, the Department of Veterans Affairs and additional "stakeholders" in graduate medical training should meet to discuss the issue. Lindberg said, "We know there is a cost to this," but "if you look at the totality of the recommendations, there is the potential for efficiencies in the system and savings from reduction in errors and harm." He added, "In the long run, it won't cost as much as one might estimate" (New York Times, 12/3).

Michael Johns, a physician and chancellor of Emory University who led the panel, said, "Our overarching conclusion is that the science clearly shows that fatigue increases the chances of errors, and residents often work long hours, without rest and regular time off." However, the panel found it impossible "to assess the current level of all risks to patients or the degree to which fatigued residents contribute to patient harm," though they said fatigue is "clearly a factor" (Washington Post, 12/3).

Comments
James Bean, president of the American Association of Neurological Surgeons, in a statement said that the panel "has failed to adequately consider the key patient safety issues -- the considerable risks associated with too many patient handoffs and lack of continuity of care in complex neurosurgical disease or injury cases."

Brian Hurley, president of the American Medical Student Association, said, "The IOM report recognizes the current shortcomings in monitoring and enforcement of work hour regulations, though the report offers little in the way of concrete plans for ensuring hospital adherence to duty hours."

Peter Lurie, deputy director of Public Citizen's Health Research Group, said, "I think it's fundamentally a missed opportunity to force organized medicine to take this problem seriously," adding that he has "no confidence" that the ACGME will be more effective of enforcing regulations. He added, "I think the federal government needs to step in" (CQ HealthBeat, 12/2).

The report is available online.

NBC's "Nightly News" on Tuesday reported on the panel recommendations. The segment includes comments from sleep deprivation researcher Charles Czeisler of Brigham and Women's Hospital (Bazell, "Nightly News," NBC, 12/2).

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