To sleep or not to sleep; that is the question
Yesterday during our weekly Grand Rounds lecture we heard from an expert in the area of sleep deprivation, patient safety, and resident duty hours. When I was a resident the typical work scenario was to report to work at 7AM one day, work all day, all night, and all the next day, then go home and do it all again 2 days later. Several years ago, maybe around 2002, some bad outcomes combined with increasing sleep deprivation data caused the ACGME, the organization that regulates medical residency training, to decide to limit the number of hours interns (first year residents) can work consecutively. Data show that performance declines after 12 hours of work and drops off precipitously at 20, so the ACGME chose 16 hours as a non-scientific middle ground. This, accompanied by a requirement to work no more than 80 hours per week and other more detailed restrictions, was supposed to decrease fatigue-related medical errors. Well, it hasn’t really, or it has in some places but not others. Another problem has been uncovered in the process of trying to reduce fatigue-related injury. It turns out that the multiple hand-offs of patient care required by the duty hours rules have negatively affected patient safety as well.
Doctors keep a lot of stuff in their heads. They decide on a diagnosis to go with but keep other possibilities in the backs of their minds. They note a blood pressure reading and remind themselves to follow-up in an hour. They remember that Mrs. X had a heart rhythm problem after her last dose of drug Y and that you are adjusting her dose every 8 hours. This and a million other things. Especially if you are an intern since it is your job to keep track of all the minutiae. All this stuff cannot possibly be written down. It’s sort of like being a mother. A mother (or father) has eight things going on in their heads at the same time: what’s for dinner, Suzy has soccer at 3, Tommy’s been saying his tooth hurts, I need to pay that bill, Elmer’s been hitting people and needs to be talked to, etc. etc. If you ask this mother to write down everything she’s thinking, she’ll leave stuff out guaranteed. Or she’ll try to give you only the big picture even though it’s the details that matter the most.
People have been trying various things to mitigate the hand-over gaps. Programs have tried hand-off checklists and education. Many places have created on-line tools to help. One of the biggest problems with computers is that data has to be entered into them. Right? If you could just mind-meld with your computer and transfer all the stuff in your head into your laptop it would be a much more useful device. Interns spend a lot of time, 30% in one study, generating documents that contain all the information they can possibly think of that might help the next person take care of their patients. You see residents in hospitals running around with a sheaf of papers covered with very small script and scribbled with cryptic notes in the margins. That’s their brain, essentially.
Why am I telling you this? Hospitalized patients these days are complex and residents have many patients to keep track of. The higher the number of different people taking care of one person the more things are likely to fall through the cracks. You, the patient, can help. As much as you can you or your advocate should know what the doctor or team is thinking about your case, what they are planning, what tests they have ordered and what the results are, and roughly what’s supposed to happen day to day. These things are your doctor’s or team’s responsibility, but things get missed for all the reasons I have mentioned. Eventually we’ll figure out a system that works. Until then, remember: MEDICINE IS NOT AN EXACT SCIENCE, EVERY PATIENT IS DIFFERENT, and BE YOUR OWN ADVOCATE.