Were the Authors Also Sleep-Deprived?

A recent report, Resident Duty Hours: Enhancing Sleep, Supervision, and Safety, released yesterday by the Institute of Medicine of the National Academies, has been getting a lot of press for its call to reduce the hours that medical residents work. It’s a worthy cause: sleep-deprived residents make serious mistakes, and in many cases, the 30+ hour shifts they work are a result of tradition, cost-cutting, and inefficient use of doctors’ time, rather than actual delivery of quality care and good education. But the IOM report makes recommendations so off-the-wall they could actually make sleep-deprivation problems worse.

Take the proposed rule prohibiting residents from working more than four consecutive night shifts. That sounds superficially like a great idea; how would you like to work four night shifts in a row? The problem here is that putting a resident on a long string of night shifts is actually one of the most merciful ways to hand them out. The reason a night shift probably sounds awful to you is that you’re used to being up during the day. The reason night shifts are hard on residents is the disruption of toggling between diurnal and nocturnal schedules. The resident who pulls night float for two weeks or a month gets a chance to adjust; the other residents get consistent daytime shifts. Everyone is more alert.

Similarly, the report’s proposal for five-hour naps mid-shift is just batty. Note that the naps are required to be scheduled between 10 PM and 8 AM. Under the current on-call system, residents working overnight can take naps between calls but remain on-duty; under the proposed one, when you’re on your five-hour nap, you’re off-limits. Ooookay, then, so who takes care of the patients while the resident is off napping? And keep in mind that waking up the napper to ask questions about a patient is strictly verboten.

You can see where this is going. The hospital now needs to bring someone else on-shift, in the middle of the night. So they’re messing up an additional doctor’s sleep schedule—and that doctor is almost certainly going to be another resident. What’s more, when Dr. Sleepyhead goes off for a nap, her patients need to be handed off to Dr. Backup; when she returns five hours later, Dr. Backup will be handing them back. That’s two breaks in the continuity of care—and continuity of care was supposed to be the whole bugbear justifying the long shift in the first place.

We could have a serious conversation about the lengths of residents’ shifts. If we did, we might say that the 12-hour shifts currently worked by doctors in emergency rooms provide high-quality care by alert residents. We might say that 14-hour shifts, or 16-hour, or 18-hour ones provide acceptable tradeoffs between resident alertness and continuity of care. We might even candidly admit that longer shifts are a necessary evil justified by the severe budget pressures hospitals operate under. But one thing we would not do, if we were being serious, is to pretend that a 30-hour shift can be made to work by plugging a nap into the middle of it. That “compromise” truly is a Solomonic one.

And that is why this report is not serious—indeed, it is such an unserious report that it makes one question the seriousness of the medical professionals whose names it bears. The report clings to a set of proposals that could be boiled down to “People should sleep at night, dammit!” The result, unfortunately, is to discredit the agenda it was meant to advance. The authors have a lot of penance to do; I’d recommend a month of 80-hour weeks. Naps or no naps.