24-hour shifts are a prescription for medical errors

The Globe and Mail

How safe would you feel if the pilot landing the plane you were on was 23 hours into her 24-hour shift?

And how confident would you feel about the quality of care if the doctor treating your child in the emergency room was staggering to the end of his 24-hour shift?

In aviation, the rules are strict: No crew member may be on duty for more than 14 consecutive hours and there are rest requirements. For medical residents – who do a lot of the heavy lifting in hospitals – 24-hour shifts are still the norm. But, thankfully for patients, that is changing.

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In June, a Quebec labour arbitrator ruled on a grievance by former medical resident (now hematologist) Alain Bestawros.

Arbitrator Jean-Pierre Lussier said the 24-hour shifts pose a danger to residents’ health and therefore violate Section 7 of the Canadian Charter of Rights and Freedoms (which ensures security of the person) and Section 46 of the Quebec Charter of Rights and Freedoms (which requires “fair and reasonable conditions of employment”). He gave the employer, the McGill University Health Centre, six months to move to a system in which 16-hour shifts are the maximum allowed. The hospital is appealing.

While the ruling applies to a single hospital, you can expect the 24-hour norm to be challenged in every province, particularly because the U.S. Accreditation Council for Graduate Medical Education recently limited residents to 16-hour shifts (at least in the first year of residency) and European countries have moved to a 13-hour maximum.

Although Canada is an outlier on this issue, you can expect fierce resistance from hospitals and many veteran physicians.

There is no small amount of machismo in medicine. Many physicians behave as if they were immune from the normal limitations of physiology and their training allowed them to perform superhuman feats.

For many docs, working 80-hour weeks is a point of pride, and they consider the newer generation of aspiring physicians, who espouse concepts such as work-life balance, soft and lacking dedication.

Beyond the tradition – and 24-hour on-call shifts are uncomfortably similar to the tradition of hazing in frat houses – there is also a belief that working obscenely long hours will leave doctors “battle-ready.” Residents essentially learn to swim by being thrown in the deep end.

It’s true that hospital medicine can be demanding – particularly in trauma, obstetrics and emergency surgery. But the idea that crises occur in the middle of the night is exaggerated: One study showed that only 10 per cent of the work demanded of residents on overnight shifts was actually essential.

The notion that someone can be trained not to be fatigued is also ludicrous – there is little scientific evidence to back it up.

Yet the evidence of the dangers of fatigue – to doctors and their patients – presented at the Quebec arbitration was sobering.

Charles Czeisler, a Harvard University sleep specialist, said everyone’s biological clock is different but no one can escape the cumulative effects of fatigue.

Medical residents work about six 24-hour shifts a month, in addition to their regular 12- to 16-hour shifts. It is not unusual for a surgical resident to work a 24-hour shift, grab a nap, then work in a clinic all day. In the name of education, aspiring medical professionals are chronically sleep-deprived.

Dr. Czeisler cited chilling data comparing medical errors made during 24-hour shifts and 16-hour shifts. Residents working around-the-clock made 36 per cent more serious, life-threatening mistakes and five times as many diagnostic errors as those on shorter shifts. One in 20 residents said there had been a fatigue-related fatality during one of their 24-hour shifts. Residents were also 2.4 times more likely to be involved in a motor vehicle crash when heading home from a 24-hour shift than from a shorter shift.

Bottom line: Lack of sleep kills. That’s why pilots, nuclear power workers, truckers, railway engineers and bus drivers all have legislated shift limits.

But in health care, we don’t tend to take deaths by medical error seriously. If we did, there wouldn’t be up to 24,000 of those deaths a year in Canada (the upper estimate that appeared in the landmark Baker-Norton study of adverse events in hospitals). The continued existence of 24-hour shifts is a striking example of contempt for patient safety. Shorter shifts will create scheduling and staffing headaches for hospitals, so patient safety be damned seems to be the prevailing attitude.

That being said, it is important to note that long work hours are not the sole source of errors, and that shorter shifts for residents are not a panacea.

As the McGill University Health Centre pointed out at the arbitration hearing, reducing residents’ hours will affect continuity of care because it will increase “handovers” – the transfer of patients to the incoming shift with an exchange of crucial information. It’s in these handovers that an inordinate number of screw-ups occur.

But surely the solution to that problem is to teach residents to communicate better. Few institutions have a standardized process for relaying information. Instead of paper charts and informal chats, there need to be electronic records and checklists.

Shorter hours will likely also require an extension in the length of training. In Britain, the maximum resident shift was dramatically reduced from 32 hours to 13. (The work week is also capped at 48 hours.) That meant extending training by one year and opening more spots in medical schools.

High-quality medical care costs money. That is no surprise. But high-quality – and humane – medical training should also pay dividends for patients and the medical system.

Patients – particularly those on the receiving end of dubious care by sleep-deprived doctors – are the ones who seem to have been forgotten in this discussion.

Follow on Twitter: @picardonhealth

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