October 31, 2015

Some first-year doctors are working 30 hours in a row at dozens of hospitals around the country in a test of work-hour limits that were imposed in 2011 because of fears that inexperienced, sleep-deprived physicians might jeopardize patients.

The 30-hour shifts, which were banned four years ago, are one element of a $9 million research project partly funded by the National Institutes of Health to determine the best way to train novice physicians while maintaining patient care.

The arrangement is reviving one of the oldest debates in the education of physicians: whether they learn best when subjected to brutally long and difficult working conditions, whether their patients have a right to know about it, and whether physicians and patients can be kept safe.

Critics of the study, some young doctors among them, argue that exhausted physicians can make mistakes that cost lives. But the researchers and some experts say the work limits force more handoffs of patients from physician to physician, which are more dangerous than leaving them in the care of sleep-deprived doctors.

[Doctors fear caps for residents may be bad medicine]

To change the doctors’ work hours, the researchers obtained permission from the organization that regulates physician training. And because it involves actual patients, the study also needed approval from the ethics panel at the University of Pennsylvania, which is leading the research. That panel deemed the study’s risk to patients and new doctors minimal, and said hospitals did not have to inform either.

David Harari and Jeff Clark, first-year residents in psychiatry at the University of Washington School of Medicine, said that the risk is more than minimal. They have told the school’s ethics panel they were not informed that they could be working as much as 30 ­­­hours at a time when they interviewed for their jobs and that their patients are unaware of it.

(Psychiatry residents study internal medicine during their first post-graduate year. A University of Washington official said internal medicine residents were notified about the trial, but psychiatry residents were not.)

“It’s really hard to function for 30 hours in a row,” said Harari, who was interviewed after a 30-hour shift during which he was responsible for six patients and got about 2  1/2 hours of sleep. “I’m not aware that I’ve made a mistake yet, and I hope that never happens.”

Sidney M. Wolfe, co-founder of Public Citizen’s Health Research Group, which in 2001 tried to persuade the federal government to regulate new doctors’ work hours, agreed there are risks in longer hours. “From my perspective, it seems both patients and doctors have to be involved [in consenting], and both patients and doctors need to be able to opt out.” He said that is unlikely or impossible because of the way this study is designed.

But Mildred Solomon, president of the Hastings Center, a nonpartisan research institute that studies ethical questions in health care, strongly endorsed the research. “We haven’t really studied whether [restrictions on work hours] made a difference or not, not in this kind of rigorous way,” she said. “And I think we need to find out.”

Long confined to academic medical circles, the issue burst into public view after the 1984 death of Libby Zion, the 18-year-old daughter of influential New York lawyer and journalist Sidney Zion. Libby Zion was being treated for an undiagnosed problem by an overworked first-year doctor at a New York hospital when she went into cardiac arrest and died.

A grand jury took up the case but declined to issue criminal charges. New York state eventually passed a law limiting residents’ work hours. As a result, no New York hospital can participate in the current study.

[U.S. faces 90,000 doctor shortage by 2025, medical school association warns]

In 2011, after a study by the prestigious Institute of Medicine, the Accreditation Council for Graduate Medical Education banned 30-hour work shifts for all trainees and prohibited first-year physicians from working more than 16 hours consecutively, with a few minor exceptions.

But some involved in training newly graduated physicians — known as “residents” at hospitals — say the work-hour limits have made staffing needlessly difficult. They said they believe that a novice learns best by following a case in the critical 36 hours after a patient is first admitted and that patients are better served, as well.


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