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Today's medical training -- better or worse for patients?

By A. Chris Gajilan
CNN
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(CNN) -- The phone rang. It was the middle of the night.

Christopher Landrigan, then a 27-year-old doctor in training, answered.

"Chris, you need to get up. This girl needs to be intubated right away," a fellow second-year resident told him. Landrigan has no recollection of that phone call. The next thing he remembers is being shaken awake from his short nap in the intensive care unit by the same-second year resident. Vaguely, he remembers picking up his toothbrush and going to the washroom. (Watch new doctors working around the clock -- 2:40)

He emerged five minutes later to find out that another doctor had stepped in to intubate the 9-year-old asthmatic girl. Luckily, no one was hurt.

"It was really an epiphany for me. That's when I said, 'Is this really a rational way to be providing care?' I started to think critically about resident work hours," says Landrigan.

It's been 10 years since that night. Now, Landrigan is the director of sleep and patient safety at Brigham and Women's Hospital in Boston, Massachusetts. He and his group of researchers have just published two new studies in the Journal of the American Medical Association this week.

One study found that interns, commonly known as first-year residents, working more than 20 consecutive hours had a 61 percent higher risk of accidentally stabbing themselves with a needle or scalpel compared with their risk during the first 12 hours of a shift.

That study adds to mounting evidence suggesting that longer resident work hours are unsafe for both doctor and patients. In fact, the Harvard Work Hours, Health and Safety Group has published several eye-opening findings. Residents working these marathon shifts of 24 hours commit 36 percent more serious medical errors; five times as many serious diagnostic mistakes; and their risk of having a motor vehicle crash while driving home from work increases by 168 percent when compared with 16-hour shifts or less.

It's almost a cliché that doctors in training are chronically overworked. Even 10 years ago, Dr. Landrigan's wife shuttled him back and forth during his residency. "She refused to allow me to drive because she was concerned about me getting into a car crash from fatigue." During Landrigan's training, it was common for residents to be scheduled to work for 24 to 33 hours, and it was highly uncommon to get any sleep at all during that shift.

The term resident dates back to a time when doctors in training actually lived in the hospital. Today's medical education system has roots reaching back to the 1890s. Dr. William Stewart Halstead began the first formal surgical training program in the United States at Johns Hopkins Hospital in Baltimore, Maryland. He is widely considered one of the founders of the American residency training system. But in March 2005, the New England Journal of Medicine published an article profiling Halstead's addiction to cocaine throughout much of his medical career, suggesting that even at the system's beginnings, residents pushed themselves beyond the normal limits of the human body.

Dr. Charles Czeisler is a professor of sleep medicine at the Harvard Medical School researching shift hours in a broad range of professions. "The hospital at that time, 100 years ago, or 50 years ago, was a very different place than it is today. Sleep really wasn't an issue because the intensive care units didn't exist, the labs were closed at night, they did not have the volume or the acuity of patients as they do today."

While doctors such as Czeisler say today's medical training system is antiquated, it was only in 2003 that any guidelines were put into place.

In the face of pending federal legislation, the Accreditation Council for Graduate Medical Education enacted its own guidelines. The rules say that today's doctors in training can work no more than 30 consecutive hours, twice a week. A resident's workweek cannot exceed 80 hours when averaged over four weeks. They must have at least one in seven days off when averaged over the same period.

"There is no other industry in the United States or anywhere else in the world where 100,000 people are being scheduled to work 30 consecutive hours twice a week and those are the limits that are not even being honored today," says Czeisler.

A study from the Brigham and Women's group finds that 84 percent of first-year residents, when asked anonymously, reported exceeding the work-hour restrictions during the first year after implementation of the new guidelines. By comparison, numbers from the Accreditation Council for Graduate Medical Education numbers show that only 3 percent of residents reported working in excess of the rules.

To be sure, many doctors in training say they want to stay beyond their hours to follow up with their patients -- to analyze their lab results, to see the outcome of a surgery or intervention. The amount of knowledge and experience gained in those five to seven years of residency is immeasurable.

But aside from the new rules preventing new doctors from staying, Dr. Landrigan says that many residents feel pressure to falsify their hours. "There is a disincentive for both the residents and the programs themselves to report violations to the ACGME....If a program were to report that they were in violation, they would be at risk of being shut down."

Landrigan and Czeisler point to the case of Dr. Troy Madsen, then 28, who was in his first year of residency in 2003-2004, the first year of the new rules. Madsen reported working a 34-hour shift that exceeded ACGME limits during his first week of residency. The ACGME temporarily suspended the Johns Hopkins program with a threat of losing accreditation for its internal medicine residency program.

Madsen says that he was ostracized from the program and eventually felt that he had to move to the Ohio State University residency program. Johns Hopkins Hospital denies that Madsen was pushed out of the program. In a statement, officials said, "Senior level faculty members within the department met with Dr. Madsen on a regular basis and made many, many attempts to induce him to remain. Dr. Madsen left of his own accord."

No professional medical organization will go on record against regulation of work hours. But there is concern among individual doctors over continuity of care for the patient and the quality of medical training.

Landrigan says those concerns are unfounded. "I think there's a natural tendency to say, 'If I've gone through this and I've turned out a good physician then this must be the right way to do it.'...There's not any evidence to support that these types of marathon shifts are essential in order to convey good medical learning."

A. Chris Gajilan is a senior producer with the CNN Medical Unit.

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Dr. Charles Czeisler, left, and Dr. Christopher Landrigan have studied the effects of sleep deprivation on medical training.

HEALTH LIBRARY

In association with MayoClinic.com
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