Sleep -- a tricky subject

If you know anything about medical residencies, you probably know one thing: Residents work a lot. A LOT.

The current duty hour regulations, which went into effect in 2003, changed residency training from a cowboy operation of working as many hours as you could, and being proud of it, to a series of mandates regarding how long a resident could be at work. If programs are following the rules (and many, including surgery and Ob/Gyn programs, don't), here is what residents are doing:

Working no more than 80 hours per week, averaged over 4 weeks
Working no more than 30 hours in a row, plus an allowance of 6 additional hours for didactic/educational activities (like lectures)
Having 10 hours off between shifts
Getting one day (a 24-hour period) off per week, averaged over 4 weeks
Taking overnight call no more than every three days, on average

These regulations were created to address the issue of patient safety, which can be compromised when residents are fatigued, and at the critical time known as "handoffs," which is when one team hands over care to another care at the start of a new day or shift, according to studies. To accommodate these regulations, many residency programs adopted what is known as a "night float" system. It works a little differently in different specialties, but here is what the Ob/Gyn model I am most familiar with consists of:

As a resident, you are on one of a few services: labor and delivery, GYN oncology, benign GYN surgery, continuity clinic, or reproductive endocrinology/infertility. All except the first two are outpatient rotations, meaning they're mostly office-based or otherwise don't need coverage in the middle of the night by an in-hospital person. Labor and delivery, on the other hand, needs staffing 24/7. So one set of residents (generally one person from each training year) makes up the day team, working 7a-5p Monday-Friday, and another set of residents makes up the night team, working 5p-7a Sunday night through Thursday night. Then both of those sets of residents are off for the weekend and the residents on the other services take call for the weekend -- one team will finish their Friday work then stay Friday night until Saturday morning, have Saturday off, and work Sunday during the day again. Another set of residents will have Friday night off but take 24-hour call from Saturday morning to Sunday morning. Because of the number of residents in the program, you rotate through the call schedule and generally have 1 full weekend off per month. You switch services after a month, so you would do a whole month of night float (or day shift) at a time.

This past week, as many major newspapers reported, the Institute of Medicine published a report about resident duty hours and fatigue, and created a new set of suggested guidelines for duty hours.

Panel calls for changes in doctor training, NY Times, 12/2
Expert panel seeks changes in training of medical residents, NY Times, 12/2
Medical residents must sleep after 16 hours, experts urge, Washington Post, 12/3
Does more sleep make for better doctors?, NY Times, 12/4
The Catch-22 of catching z's, ACP Internist (the American College of internists) blog, 12/5

Here is the full IoM report, and here is a table summarizing the recommended changes. There will still be an 80-hour cap, but after working for 16 hours there will be a mandatory 5-hour nap period. The averaging rule will be removed for call frequency and time off frequency (call no more than every three nights, period, and a true one day off per week), and you will need 12 hours off after a night shift instead of 10. These recommendations were made based on more studies of fatigue and safety.

Initially, this sounds great. Less work, more sleep.

But there's another stipulation: Whereas before there were no rules about the number of nights you could work in a row, now there is. After working 4 nights in a row, you would now have to have 48 hours off. That sort of throws a wrench in the whole night float system.

Say you work night float Sunday night to Wednesday night, meaning you're done at, say, 7 am on Thursday morning. Now you have to take 48 hours off, which puts you at 7 am Saturday morning. I highly, highly doubt any program would have you take off an additional 10 hours until Saturday evening to do nights again (for a total of 58 hours off), which means when you get back to work Saturday morning, you're now on a daytime schedule. And in the meantime, there had to be another team to cover nights since Thursday night.

Asking around, it seems one of the only logical things to do is to have two night float teams, because that's the only way to cover 7 nights in a week. This will be a problem for many Ob/Gyn programs, because they don't take a ton of residents per year, so your available manpower is very tightly controlled. The bigger problem? That means I will go from doing 4 nights in a row to going back to a daytime schedule. The only thing that makes night float manageable is the fact that after a few days, your body gets completely used to being up at night and asleep during the day, and you do it for a month straight. Now, switching around every few days will screw your sleep cycle up tremendously. Plus, on a true call service, being required to stop working after 16 hours means you will have to have even more patient handoffs, which in itself is one of the risk factors for medical errors being made.

The AMA has already applauded the new recommendations, which means it is carrying a lot of weight and could realistically be put into effect in the near future. From a system standpoint, it definitely sounds great to let residents get more sleep. I did a month of night float this year, and with exactly 10 hours off after my shift, all I had time to do was go home, take a shower, and sleep. I didn't go grocery shopping or anything social for a month. But I was wide awake every night. During call services, it can definitely be hard to work for 30 hours straight, and I, as a student, usually get to get at least a few hours of sleep. There's no doubt sleep is good.

But if getting sleep means increasing the number of patient handoffs, I'm not sure the tradeoff is sound. If I'm tired, I still know, when asked by a nurse at 3 am, what that patient's story is and can address the nurse's concerns. If I hand off my patient to another resident, I do so with just a short written paragraph summary of the patient, his/her diagnosis, history, and issues, and maybe a 2-3 minute verbal summary of the same, and the covering resident almost invariably doesn't know as many details about my patient as I do, which means she might give the nurse the wrong order when she calls.

To have enough residents to fund two night float teams, plus cover everything else that needs to be covered, we're going to need more residents. I'm fine with that; there's already a predicted physician shortage, so medical schools are increasing their class size, and it only makes sense that residency spots should increase as well. But guess who pays for more residents: You. I'm going to be paid by the federal government, through the Medicaid system. So do you want to pay for more residents? When you can't even pay for your own medical care and might be on the brink of going on Medicaid yourself, given the economic situation we're in? Well, thank you if you do, but I can't imagine the government is going to be able to come up with the estimated $1.7 billion needed to make this happen any time soon, and I'm applying for residency NOW. With the current number of residents per year.

I worry about these regulations from a personal standpoint, too. Doing four nights in a row, then switching to a daytime schedule, would suck for my circadian rhythm and make working during the day all that much harder, I'm sure. Plus, there is a LOT I need to learn in my four years of residency, and even under the current duty hour regulations there are a lot of rumblings that residents can't learn all the Ob/Gyn they need to in four years. It takes time and a lot of practice to be a good surgeon, and being a good surgeon is a very important part of Ob/Gyn. Unfortunately (from a training standpoint), because we are doing fewer and fewer hysterectomies (because we can treat those problems medically first), there are already limited opportunities to practice before graduating, and if more of those opportunities are lost by being at home, well, that's going to be a problem. I'm not saying I want to be operating after being awake for 25 hours, but at some point, if duty hours on a weekly basis are limited, then the only logical thing will be to extend the number of years required in a training program. Working 80 hours a week and being fatigued for 4 years is going to suck; I really don't want someone to make me do five. Really.

The absolute most annoying part about all of this? It's happening now, while I'm applying to residency. That means that all the programs I've already interviewed at, they may have given me a schedule that's completely different than what they will have to effect on July 1. And I'm sure they can't give me any concrete answers about what they might or might not do. If I were already in residency, I would be able to give feedback to my program to help enact the new regulations in a way that made sense. If I were one year later in my training, I would apply next year when the programs had their new schedules in place and I could evaluate them objectively. Now, everything's a mess.

So I'm not sure if it's really that good a plan. A few more hours of sleep on a regular basis when there is a real risk it might still cause medical errors, at the risk of extending my training by another year? I'm really not trying to sound like one of those old, uphill-both-ways physicians, because I really hate when they bitch and moan about how poor my training is going to be now that I "work so little" compared to what they did. I'm pretty sure I'm being pretty damn selfish in not wanting a 5-year residency. What to do?

Me, I'm going to write a letter to my lawmakers after finals are over. You should, too.

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More posts to come soon. I still have stories from pediatric surgery to share, and plus I have fun ones from neurology now, too. I have a post percolating in my brain with my tips for airline travel with carry-on luggage. I have to tell you about how all of my residency interviews have been going, and I promise I will post my recommendations for treating common colds and bugs with over-the-counter medicines effectively (only 1 year late!). I of course also have plenty of other commentary on the medical news to share, also. In the meantime, I have to unpack from my most recent interview trip, repack for winter break, do a ton of laundry, clean up the apartment in preparation for being gone for three weeks (!), and, oh yeah, learn all of neurology. By Thursday.

One article I'll share with you now, though: A great piece from the Washington Post a couple weeks ago, a huge feature about what a medical student goes through to decide if she wants to become an abortion provider. They're many of the same issues I've dealt with, and it was interesting to have someone put my thoughts down on paper for me like that without even realizing it. A Hard Choice.