Efficacy of physician work restrictions evaluated

The Institute of Medicine reports that about 98,000 people die every year from medical errors. Many would argue that some of those errors are made by doctors whose judgment has been impaired by exhaustion. However, lack of sleep does not always lead to poor patient care, and physicians’ work hours may not be the only problem when it comes to the medical errors.

In 1984, a patient named Libby Zion died at the New York State Hospital supposedly due to inadequate patient care from a sleep-deprived physician. Zion came to the emergency room with a high fever and strange jerking motions. Two physicians were in charge of taking care of Zion. One of the residents gave her Demerol, a sedative, to control the jerking motions. However, Zion’s symptoms continued and the physician gave her another sedative, Haldol, and restrained her to her bed. Before she died, Zion’s temperature increased to 107 degrees Fahrenheit, despite efforts to combat the fever.

When Zion’s father learned that his daughter’s doctors had been on duty for 24 hours without adequate sleep, he sued the hospitals and the doctors. He wrote an op-ed published by The New York Times, asserting that residents working a 36-hour shift cannot make adequate judgments about a patient’s condition.

The father’s lawyers argued that fatigue and inexperience contributed to the poor judgment that ultimately killed his daughter. In 1986, a grand jury ruled that Zion’s physicians contributed to her death by prescribing improper drugs and failing to perform proper diagnostic tests. In response, New York State adopted the Libby Zion law in 1989, which limited resident physicians in New York State hospitals to 80 work hours per week. In addition, the Accrediting Council for Graduate Medical Education (ACGME) has launched a new guideline restricting work hours to 16 hours maximum per shift for interns and 30 hours maximum per shift for residents.

A study published in 2004 by The New England Journal of Medicine indicates the negative effect of sleep deprivation on physicians’ performance. Interns that worked more than 80 hours per week made 36 percent more errors than those that worked less than 80 hours per week. Common errors included ordering drug overdoses, misdiagnosis on a disease and drawing fluid from the wrong lung. In addition, severe fatigue appears to reduce the degree of improvement in various psychomotor skill tests such as the King-Devick Test, which measures the speed and accuracy of eye movements. There was less improvement in reading speed for residents on duty than for residents off duty.

The results from the above studies are compelling; however, reduction in physicians’ work hours does not necessarily translate into a decline in medical errors. The studies that show a correlation of sleep deprivation and medical errors are done in controlled environments with a limited number of subjects. In the real world, not everything is controllable.

A study published in The New England Journal of Medicine in 2010 shows that the number of medical errors continues to persist even after the implementation of the 16-hour restriction by the ACGME.

This statewide study looking at patient visits to 10 North Carolina hospitals showed that there was almost no evidence that the rate of patient mistreatment had decreased. Although there was a modest reduction in preventable harms, the level did not reach statistical significance.

In addition, trauma surgeries performed by sleep-deprived residents did not in any way differ from those performed by well-rested physicians. A 2010 study from the Journal of Surgical Research showed that acute care surgical operations performed at night by unrested residents had favorable outcomes similar to those performed during the day.

Patients that received treatments during the daytime had the same overall rates of morbidity and mortality when compared with patients that received treatments during the night. Sleep loss, therefore, may not be proportional to a physician’s ability to treat patients in all cases.

Moreover, restricting work hours may not solve the problem. A 2011 New York Times article by Dashak Sanghavi of University of Massachusetts Medical School provides an insight about other possible sources. He asserted that work hour limitations lead to an increase in patient handoffs because doctors have less time and continuity with their patients.

After one doctor leaves, the incoming resident has to learn about the patient in a short period of time. This discontinuity in the physician-patient relationship and physician-physician communication may be harmful for the patients. The shortened duration of training for residents due to work restrictions may also be a risk factor.

Zion’s death was a consequence of numerous flaws in the healthcare system. Policy makers concerned with patient safety will need to examine the many factors, including patient continuity and reduced training time, that may cause medical errors.