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The traditional 24-30 hour work shifts of physicians-in-training greatly increases the risk of injury both to physicians themselves and their patients. In a series of studies published since 2004, schedules built on a foundation of 24-hour shifts have been found to increase the risk of provider occupational injuries as well as serious medical errors and patient injuries. As medical errors cause between 44,000 and 98,000 deaths each year in the U.S. (Institute of Medicine, 1999), implementation of systems that reduce the risk of errors is a major public health concern.
Physicians-in-training working traditional schedules with recurrent 24-hour shifts:
Professional regulations implemented to date have been inadequate to address this problem. 84% of interns nationwide are non-compliant with the work hour limits of the Accreditation Council of Graduate Medical Education (ACGME) (Landrigan et al, JAMA 2006), which allow regular shifts of up to 30 hours in a row (including time for transitions of care), and 80 hours of work per week (averaged over each 4-week period). Even were compliance perfect, however, these limits would be insufficient.
Work shifts of 30 consecutive hours unquestionably lead to profound performance decrements, and greatly exceed U.S. hours of service regulations in the airline industry and trucking, as well as work hour limits for physicians in Europe, where work of more than 13 hours in a row or 48-56 hours per week is prohibited by law. In light of the evolution of data regarding the dangers of residents’ ubiquitous sleep deprivation, an evidence-based redesign of current resident work schedules is needed urgently. Such a redesign must incorporate infrastructural improvements to minimize errors due to care discontinuities and optimize medical education. An essential first step, however, is the implementation of safe work limits.
In 2004, the Sleep Research Society assembled the SRS Presidential Task Force on Sleep and Public Policy to develop model legislation regarding physician-in-training work hours. The central provisions of the Task Force’s recommendations are:
The taskforce also recommended that the following issues be considered in development of Safe Work Hours Legislation:
Evidence-based limitation of resident-physicians’ work hours has been endorsed by the National Sleep Foundation and the Sleep Research Society. Given the scope of the patient safety epidemic in the United States, and the extremely high number of errors attributable to traditional 24-hour work shifts, reduction of providers’ consecutive work hours represents a major opportunity for the sleep medicine and science community to effect public health improvements.
To translate the above findings into effective health policy, the recommendations outlined above must be taken up by policymakers as well as the scientific community. In Massachusetts , Senator Richard Moore has introduced legislation to develop a committee that would formally consider introducing work hour limits for residents. At the federal level, Congressman John Conyers has repeatedly introduced legislation to reduce resident work hours. Further State and Federal efforts incorporating up-to-date evidence and the recommendation of the SRS Presidential Taskforce will be needed, however, to advance legislation promoting safe work hours for physicians-in-training.
The Sleep Research Society supports passage of Safe Resident Work Hours Legislation across the United States. We invite the participation of SRS members interested in championing this crucial issue. If you are interested in joining this initiative and/or working on Safe Resident Work Hours Legislation, please send your contact information to Nick Cekosh, SRS Coordinator.