When Policy Meets Physiology

Lockley, et. al. “When Policy Meets Physiology: The Challenge of Reducing Resident Work Hours.” Clinical Orthopaedics and Related Research, Aug. 2006, 449.  (Download in PDF)

It is an unfortunate truth that “residency programs routinely make evidence-based decisions in clinical practice and even in selecting trainees, but have appeared reluctant to rely on such data to develop safe resident work hour schedules that are optimal for both training and patient care.” This is the contention of a team of Harvard researchers in an article published in the August 2006 issue of Clinical Orthopaedics and Related Research, entitled, “When Policy Meets Physiology.” Taking aim at ACGME work hour regulations allowing shifts of 24 consecutive hours or more, the article unleashes a comprehensive battery of scientific evidence on the performance effects of sleep deprivation and fatigue to an audience that has been hesitant in the past to embrace work hour limits.

Evidence belies the current standard

Representing a continuing effort by the Harvard Work Hours Health and Safety Group to advocate an evidence-based reform of the current work hours status quo, the article outlines how the undisputed physiological principals of Sleep Medicine regarding alertness and performance are violated by the 24 hour on-call shifts permitted by the ACGME. The article also systematically reviews previous studies of resident physicians, reporting that resident physicians working schedules with shifts of 24 consecutive hours or longer face increased risk of motor vehicle crash, attentional failure, and committing serious medical errors.  

Calling for the abolition of such long shifts, the Harvard team writes, “Collectively, the findings to date … strongly demonstrate the risk to both residents and patients of continuing to permit extended durations work shifts of 24 hours or more.” Observing how human physiological limits are acknowledged in other professions, they note, “whereas federal regulations limit the number of consecutive hours that truck drivers can drive or pilots can fly to reduce this risk, postgraduate medical professionals are currently allowed to work [long shifts], and to drive after their shifts.”   

Whose concerns are being promoted?

The Harvard researchers cite a 2002 survey by the National Sleep Foundation that found that 86% of respondents would suffer anxiety about their safety if they learned their surgeon had been on duty for more than 24 straight hours, with 60% of respondents predicting that such a procedure would be unlikely to go well under such circumstances.

Hypothesizing about why the medical profession is resistant to acknowledge the mounting scientific evidence supporting reduced work hours, the Harvard team speculates that, “although the raison d’etre of residents is to receive graduate education, it can be argued that residents provide an inexpensive labor source, the advantages of which are multiplied by permitting excessive work hours.”

Nonetheless, for these Harvard researchers, “the challenge to the medical and surgical professions is to replace conjecture with evidence and take a proactive role in finding workable solutions to eliminate extended shifts.”