Harvard Doctor: Return To 28-Hour Shifts For Medical Interns Is Good — Except When It's Not
As anyone who follows medical education knows, the group that sets rules for trainee doctors has just ruled that interns can again work up to 28-hour shifts. This move came after years of limiting intern shifts to 16 hours in order to improve patient safety.
The decision, based on a clinical trial that did not demonstrate improved patient outcomes with shorter hours, was widely anticipated. It has been and will be met with enormous controversy — for example, two local experts weigh in under the headline "A health care change that could prove catastrophic" in the Washington Post.
This controversy is completely unsurprising. That's because these long shifts are both a good and a bad thing, and whenever there are mixed results from a decision, you're bound to find fervent supporters of both sides.
We could go through the studies of the negative effects of sleep deprivation on critical decision making (which are quite valid). Or, on the other side, the challenges of communicating critical components of a patient's case to an incoming doctor starting a new shift (which also create opportunities for errors). Instead, let me simply share my experience as a medical house officer in the late 1980s.
We were on call every third or fourth night as interns, always with a second or third-year resident supervising our work. Shifts typically were about 28 hours long. There was no "night float," an additional doctor who could help take new admissions or pages overnight. We grabbed sleep in hospital call rooms during the (we hoped) quieter overnight hours.
And with the caveat that this will be the very definition of anecdotal, and no doubt distorted by selective memories — here are the good and the bad of this experience, at least as I remember it.
First, the good:
• Patients really appreciated that you were there for them. After doing an admission, we would invariably say something along the lines of, "We'll be back later to check in on how you're doing," or, "I'll come back and explain your test results" or, "When your wife/husband/son/daughter arrives, just tell the nurse to page me, and I'll come back if they have any questions." And we could do this because there was a timelessness to the on-call nights that allowed this to happen. Patients loved this.
• The continuity in the acute care setting was invaluable. If the patient needed attention overnight, you were the one who attended to them as the person who did the admission and knew them best — not the person to whom you'd given a sign-out. There was no need to check a sign-out, no need to repeat the patient interview, no need to reinvent the wheel.
• The experience fostered ownership of the case. The admitting intern became the de facto doctor of the patient he or she admitted. When critical test results came back, consultants came by, or family members needed an update, it was obvious who should be called. The motivation to get to know your patients well under these circumstances was powerful — appropriately so. Today, in the course of a typical work week, there could easily be three to five "Responding Clinicians" listed sequentially for each patient as each house officer goes through their shifts. "I'm just covering," they say. Sound familiar?
• It was extraordinarily educational to observe the clinical course of illness first-hand. If you admitted someone with congestive heart failure, or rapid atrial fibrillation, or pneumonia, or a stroke, or severe cellulitis, the very process of seeing these conditions evolve over the first day of hospitalization taught us a lot about acute illnesses. Were our treatments working? If not, should they be changed? That small abnormality on the admission chest X-ray in the patient with shortness of breath — is that more important than we thought? The cellulitis is worse. Does the surgical service need to be consulted? You never forget these lessons.
• It fostered remarkable team spirit. Everyone who trained in that era remembers the fun of the midnight meal with your admitting team — interns, residents, medical students — where, miraculously, hospital cafeteria food became the most delicious cuisine in the world. Talk about team bonding. There was nothing like this highly caloric break from a tough night on call to recharge the physical and emotional batteries. One of my residents (OK, it was this guy; he's now a Harvard professor of medicine) always made sure he taught us at least one key medical thing during these meals. One night it was about how malignancies affected blood clotting, knowledge I then used the next day to help a patient and his family understand what was happening to him, and why. And the next day, when you were "post-call," your team did everything they could to help you leave the hospital early.
And now, the bad:
• You were tired — a lot. Being tired is uncomfortable, annoying and from a health perspective, really not good for you. Innumerable studies have linked sleep deprivation to poor health outcomes. Why should interns be exempt? (Answer: We weren't.)
• Fatigue could lead to mistakes. This is why it is absolutely critical that interns have supervision, both from more experienced residents and from attending physicians. (Sorry, none of this "intern autonomy is more important than patient safety" crap.) Are these mistakes from fatigue worse, or more numerous, than those made from increasing pass-offs to covering physicians? I don't know, but anyone who says that they are somehow different and can avoid errors due to fatigue is about as convincing as someone who says they can text and drive at the same time.
• It wasn't great for the home life. My (then-future) wife was an intern in pediatrics at the same time, and there were definitely times when our call schedules were out of sync and hence we saw each other rarely, or only in the post-call haze where all we wanted was sleep. It was not a lot of fun. For people with significant others not in medicine, or who had kids, it was much harder. For people trying to meet someone outside of the medical field? Good luck.
• It completely messed up work-life balance. Books? Movies? Working out? That musical instrument you enjoyed playing? Those gourmet meals you once cooked? Forget it. They all went into the "later" category. Internship was probably the only year of my life I barely followed baseball at all. (As my family and friends could tell you, this is almost as inconceivable as my giving up oxygen.)
• It created an 'us versus them' mentality. After a while, the wear and tear of internship with long shifts made us feel different, separate, tougher, superior to the people who weren't doing it, or hadn't done it. And I'm convinced this is why, since the beginning of recorded time, graduates of tough medical internships look at less-experienced interns and find them not worthy. It's a completely unfair judgment, of course. Or worse, the long hours and fatigue could made us look at the patients not as the human beings we should be trying to help, but as components of assembly line work.
It's this last point that, as an intern, bothered me the most. One mid-winter night — I was already a six-month "seasoned" intern — I'd finally had some time to sleep in the hospital call room. Then at 2 a.m., my beeper awakened me, indicating I had another admission waiting for me in the Emergency Room.
It was a man in his 60s with metastatic lung cancer, brought in by his daughter because he was having seizures. The oncologists had already told him that there was no more therapy available. It promised to be a very challenging admission, one filled with both difficult medical decisions and tough discussions about death and dying.
And my first thought? Not, "how can I help this poor man?" Not, "how can I console his daughter?" who was crying in a chair beside his bed. It was, "why did he have to get sick during my call night?"
I don't know if this would have happened anyway if I'd had shorter intern shifts. Or if this thought — which I, of course, didn't share with them — ultimately had any influence on the bond I formed with him and his family over his ensuing hospitalization and transition to hospice. Remember, this was my patient. No passing off to a new doctor in the morning.
But it sure felt bad to think that way.
So, welcome back, 28-hour intern shifts. It's both good — and bad — to see you again.
Dr. Paul E. Sax is clinical director of the Division of Infectious Diseases at Brigham and Women’s Hospital, and a professor at Harvard Medical School.
Radio Boston's segment on the upcoming new shift limits: