The Effect of Long Working Hours and Overtime on patient care and care providers;
Long hours and working overnight are common in many professions and a prominent feature of Medical Residency—an important position held by a doctor during their training program to learn the basic professional skills for the medical practice, gain clinical knowledge in diverse emergency, ambulatory and inpatient settings. To meet these goals that will ensure maximum exposure are recommended to the Resident trainees. During my Residency (four decades back), the limit on daily/weekly work hours in the institutions I worked was—there was no limit. At that time, I didn't quite realize doctors’ duty hours must be managed in such a way that they do not in any way endanger their health or the health of patients until post Residency. Post Residency, when I started taking calls as a specialist, attending a couple of long continuous hospital sessions of exceeding more than 12 hours conducting major operations especially during night, I felt asleep many times at the wheel driving home luckily while waiting at traffic lights, it was a 10 second nasty honk which woke me up. I can say without doubt that in retrospect the system of long working hours without rest is dangerous and unethical. The question remains has anything changed since then?
What happens if you don’t get enough rest or sleep? From our scientific knowledge of physiology we know the harmful impact of fatigue on brain is all too clear more profound is on judgment and alertness. An area near the front of brain is responsible for logical reasoning and complex thought but it also seems particularly vulnerable to sleep deprivation. Reports published in “Traffic Psychology and Behaviour,” the scientists believe episodes of micro sleeps (black outs) occur when a person has a significant sleep deprivation. The brain automatically shuts down, falling into a sleep state for a period that can last from a second to half a minute. The person falls asleep no matter what activity he or she is engaged in. With false perception of alertness person affected have such a hard time recognizing their own fatigue and level of impairment. Like the drunk driver who thinks he or she is just fine to drive, the tired driver is not always the best judge of his or her ability to operate a vehicle safely. Many of my accident victims’ narrated similar experience to me on their arrival at accident and emergency department.
Many studies in reputed medical journals have shown that poor sleep can affect your performance as much as alcohol and staying awake for just 17 to 19 hours uninterrupted affects the performance more than a blood-alcohol level of 0.05 percent (the level considered legally drunk in most western European countries). This level of impairment slows an individual's reaction time by about 50 percent compared to someone who is well rested of continuous wakefulness. Imagine one sleepless night of twenty-four hours can impair performance as much as equivalent to a blood-alcohol level of 0.10 percent, (beyond the legal limit to drive in west) while doctors in similar brain status continue handling the human lives. “Drowsy or drunk, the effects are similar affects brain alertness and performance,” says Dr. Landrigan a health care expert. In one of the studies on this subject about 5-36 percent of all Resident doctor’s errors were attributed to fatigue. Residents made twice as many errors in picking up vital signs for diagnosis, or reading ECGs after being awake for 24 hours. According to IOM, 2009 report, “Surgical residents who had been awake all night made 20 percent more errors in completing a simulated laparoscopic surgical task than those who had a full night’s sleep.” Not only susceptibility to error but according to BCMJ, 2008 report, “There is a significantly decrease in cognition/ability to learn by doctors who had previous day sleepless duties, higher rate of falling asleep during teaching lectures. Residents reported a higher rate of injury (exposure to contaminated bodily fluids, percutaneous injuries) when fatigued, 2-3 times more likely to be involved in a motor vehicle crash while returning home after working an average of 30 hr shifts.
Do we need to change our curriculum in light of recent scientific evidence? All institutions including health care system strive to provide safe and quality services and update practice in the light of evidence from research, although on these issues aviation industry has moved much ahead with zero tolerance on fatigue or drunkenness. Whether you're behind the wheel of an automobile or aero plane, working on heavy machinery or human body-you're a police officer, doctor, nurse, driver or mechanic, fatigue, sleep deprivation, just like alcohol drowsiness can sneak up when you least expect it. It can affect an individual's ability to stay alert harder to assess or to perform a sensitive task safely and competently then there's a very good chance that in the line of duty you may be exposing other folks to risk as well.
In west the organization overseeing medical education programme (ACGME) reformed resident workweeks duty hour following death of 18 year-old college freshman where an inquiry into the case revealed that two sleep deprived residents were a causal factor in the death, resident work schedules frequently varied widely in institutions, 90 hours less, or more per week, made up of 30-36 hour shifts with no provision of rest or night off post 24 hours duty unfortunately not without generating criticism and concern within the medical community that training could be compromised.
The way forward is to live the dream of a quality, preventive and safe health care. Of course, no one wants a fatigued demoralized doctor as his/her first responder. But the more relevant issue today is not whether you prefer a tired drowsy doctor that knows you or a doctor who is fit and alert.
In my mind, it is about to provide safe and good quality health care and update practice in the light of evidence from research.Author is a Senior Surgeon and Healthcare Expert on Hospital Quality and Patient Safety Standards. He can be mailed at drfiazfazili@gmail.com
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