Tuesday, December 12, 2006

Of Interns, Residents, and Sleep Deprivation---A Hippocratic Conundrum

The hospital with which my agency is affiliated is a teaching facility. I fully support teaching hospitals and the vital service which they provide as training grounds for almost-minted doctors, and I try my best to be friendly and helpful with med students, interns and residents with whom I come into contact. The second-year residents who actually take on a caseload at the clinic cause me no end of frustration, however. While they leave for two months at a time for rotations through the ICU and OR, I'm left holding the bag, trying to figure out how to move forward with a patient's care when these clinicians are otherwise engaged and en absentia.

Those interns and residents who choose to specialize in Community Medicine frequently cycle through our health center, and I am often asked to take some of those docs-to-be out into the wilds of the city for a realistic community experience. On one occasion, I brought a quite sheltered medical student on a home visit which turned ugly, the irate patient (with a history of violence towards medical providers) making threatening gestures and behaving in a very unstable manner. I wasn't sure if there was a firearm in the house or not, but my patient's alleged connections to drug dealers and a certain underworld element added to the sense of danger and excitement. That medical student sure got an eyeful, and he probably went on to specialize in something safe, far removed from drug-infested apartments and wild-eyed patients seeking Xanax. Luckily, no one was hurt, I kept myself between the student and the patient, and eventually talked my patient into an ambulance after dialing 911 as I followed him out into the street as he yelled and gesticulated, arms waving wildly. In retrospect, he was quite high and we were at great risk. Live and learn. Emphasis on "live".

Apropos of medical residents and interns, I heard a story today on NPR detailing the travails of medical interns as they negotiate the 30 to 36-hour shifts often thrust upon them. Even though regulations were put into place several years ago to limit interns to 80 hour work-weeks with mandatory 10-hour rest periods between shifts, these standards are not enforced and wannabe doctors log inhuman hours, their sleep-deprivation often putting patients---and other clinicians---at risk.

Numerous articles detail increased risks of medical errors, job-related injuries, increased incidence of car accidents, and most interns reporting having exceeded the limits put in place in 2003. A study at Harvard Medical School showed that "staying awake for 24 consecutive hours induces decrements in human performance similar to a blood alcohol level of 0.1 percent." The NPR story bandied about statistics that the risk of errors increases 700% when interns work 30-hour marathon shifts, and that the risk of fatal errors triples. One anonymous intern reported actually falling asleep while performing a cardiac exam, his head literally hitting the patient's chest. The Harvard study reported by NPR used instruments attached to the interns and residents to monitor their sleep/wake cycles, much like the instruments used to monitor astronauts' sleep cycles in space. The results are cold comfort.

As a nurse, not only am I concerned for my patients who are hospitalized, I am concerned for my medical colleagues who are undergoing such an "education", for the drivers on the road at risk of accidents caused by sleepy interns, and for other employees who may experience injuries---such as needle sticks---when working alongside a sleep-deprived resident. Even when residents are rested, I still occasionally need to correct small errors or point out discrepancies to the precepting doctors at the health center. How many errors could be avoided if the 2003 guidelines---or even stricter edicts---were actually enforced and obeyed?

Many sources state that a "culture of suffering" among generations of doctors keeps this practice alive. There is a sense that "if we could do it, they can do it" mentality, subsequent generations tormenting their juniors with the same long hours and deprivations which they survived during their own residencies. This smacks of fraternity-style initiation practices which fail to advance the cause---better doctors---without incurring great risk of harm. A conundrum of Hippocratic hypocrisy presents itself. That said, doctors used to smoke in exam rooms and nurses' stations---did we keep doing that just because it had always been so? Something needs to change, and when thousands of patient deaths are attributable to medical errors due to fatigue, a public health crisis looms before us with a horrendous human cost.

Although many residents and interns and student nurses perform their duties very well, I have reminded patients who were uncomfortable being seen by a student that they have a right to refuse such care, demanding a staff doctor. As a student nurse, I was once or twice in the position of being told that I could not provide care to a patient, a "real nurse" having been requested. We must all recognize that subsequent generations of doctors and nurses must learn patient care in the real world with hands-on experience at every turn, and only this will create the generation of providers which we will continue to need ad infinitum. Still, when avoidable death, injury and illness result from the poor management of such programs, patients and staff suffer the very real consequences.

Something must be done. Multiple studies have all yielded the same results: our medical interns and residents work too hard for too many hours, and provide hands-on care for our mothers, sisters, lovers, and children in debilitated physical and mental states . A 700% risk of unavoidable errors is unacceptable, and we will all continue to pray that it is not us---or our loved ones---suffering needlessly from medical bravado and hubris. Education is crucial, but human life trumps all.
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