1: “All of us know that nurses and doctors work long, consecutive hours,” Dr. Matthew Walker writes in Why We Sleep: Unlocking the Power of Sleep and Dreams.
“And none more so than doctors during their resident training years,” he notes.
Why do we require doctors to learn their profession in this grueling, sleepless way?
“The answer originates with the esteemed physician William Stewart Halsted, MD,” Matthew explains.
Back in 1889, William was the founder of the surgical training program at Johns Hopkins Hospital in Baltimore, Maryland.
“As chief of the Department of Surgery, his influence was considerable, and his beliefs about how young doctors must apply themselves to medicine, formidable,” Matthew writes.
The term medical “residency” came from William’s notion that doctors should live in the hospital for much of their training. The goal was for them to commit fully to their surgical skills and medical knowledge training.
William believed that sleep “was a dispensable luxury that detracted from the ability to work and learn,” Matthew notes.
As a result, the residents were expected to work long, consecutive work shifts, both day and night.
“His mentality was difficult to argue with, since he himself practiced what he preached,” Matthew writes, “being renowned for a seemingly superhuman ability to stay awake for apparently days on end without any fatigue.”
2: After William died, however, a startling fact came to light that helps explain “the maniacal structure of his residency program and his ability to forgo sleep,” Matthew observes.
William was a cocaine addict. A habit that started before he arrived at Johns Hopkins.
“Colleagues noticed [William’s] odd and disturbing behaviors in the years before and after his arrival at Johns Hopkins,” Matthew notes. “This included excusing himself from the operating theater while he was supervising residents during surgical procedures, leaving the young doctors to complete the operation on their own.
“At other times, Halsted was not able to operate himself because his hands were shaking so much, the cause of which he tried to pass off as a cigarette addiction.”
William wanted to beat his cocaine habit. “Ashamed and nervous that his colleagues would discover the truth, he entered a rehabilitation clinic under his first and middle name, rather than using his surname,” Matthew writes.
This first effort at stopping his habit was unsuccessful. He continued to try different solutions. At one hospital, he was given morphine to help with the pain and discomfort of cocaine withdrawal.
He “subsequently emerged from the ‘rehabilitation’ program with both a cocaine addiction and a morphine addiction,” Matthew writes.
William “inserted his cocaine-infused wakefulness into the heart of Johns Hopkins’s surgical program,” he observes, “imposing a similarly unrealistic mentality of sleeplessness upon his residents for the duration of their training.
“The exhausting residency program, which persists in one form or another throughout all U.S. medical schools to this day, has left countless patients hurt or dead in its wake—and likely residents, too.
“That may sound like an unfair charge to level considering the wonderful, lifesaving work our committed and caring young doctors and medical staff perform, but it is a provable one.”
3: For many years, medical schools required medical residents to work two or three thirty-hour shifts per week.
“The injurious consequences are well documented,” Matthew notes. “Residents working a thirty-hour-straight shift will commit 36 percent more serious medical errors, such as prescribing the wrong dose of a drug or leaving a surgical implement inside of a patient, compared with those working sixteen hours or less.
“Additionally, after a thirty-hour shift without sleep, residents make 460 percent more diagnostic mistakes in the intensive care unit when well rested after enough sleep.
“Throughout the course of their residency, one in five medical residents will make a sleepless-related medical error that causes significant, liable harm to a patient. One in twenty residents will kill a patient due to a lack of sleep.
“Since there are over 100,000 residents currently in training in U.S. medical programs, this means that many hundreds of people—sons, daughters, husbands, wives, grandparents, brothers, sisters-are needlessly losing their lives every year because residents are not allowed to get the sleep they need.”
Medical errors are the third-leading cause of death in the U.S. after heart attacks and cancer. “Sleeplessness undoubtedly plays a role in those lives lost,” Matthew observes.
The impact of sleeplessness does not stop when the resident leaves the hospital.
“When a sleep-deprived resident finishes a long shift, such as a stint in the E.R. trying to save victims of car accidents, and then gets into their own car to drive home,” Matthew writes, “their chances of being involved in a motor vehicle accident are increased by 168 percent because of fatigue.”
Facing government threats, the Accreditation Council for Graduate Medical Education made the following changes in 2003: First-year residents would be limited to (1) working no more than an 80-hour week (which still averages out at 11.5 hours per day for seven days straight), (2) working no more than 24 hours nonstop, and (3) performing one overnight on-call shift every third night.
Note the specific wording regarding first-year residents and not those in later years of a medical residency.
“That revised schedule still far exceeds the brain’s ability to perform optimally,” Matthew writes. Errors, mistakes, and deaths continued in response to the anemic diet of sleep they were being fed while training.”
More tomorrow.
___________________________
Reflection: What is surprising and not surprising about the hours medical residents work?
Action: Before any elective medical procedure, ask how many hours the doctor has slept.