V i v i a n  S o n g
Freelance writer
Freelance writer
Sleep deprived med students


Published in The Toronto Sun and Sun  Media papers, September, 2007.

They are apprentices of perhaps the world's most noble of professions.

They are the cream of Canada's crop, brilliant minds that are able to decode the complexities of the human body. They work to cheat death and buy the dying more time.

But in order to be deemed worthy, medical residents themselves are expected to defy the needs of the human body and save others on 24-hour call shifts.

While other industries understand that fatigue poses a safety risk to both themselves and those they serve, doctor trainees manning emergency rooms and intensive care units must make life and death decisions often with little to no sleep.

In a 2002 study published in the New England Journal of Medicine, researcher David Gaba points out that "other hazardous industries have not waited for absolute proof of risk due to operator fatigue."

Airline pilots, truckers and nuclear power plant operators are all mandated by strict work rules and maximum duty days -- none of which allow for 24-hour duty days. Pilot fatigue is routinely examined during plane-crash investigations as a possible contributing factor.

"If we were to impose such investigative techniques to error analysis in health care, fatigue would certainly be cited as a contributing factor in many adverse cases," Gaba writes in a separate commentary on fatigue.

In Canada, resident work-hours vary between provinces as outlined in their collective agreements. But generally doctor trainees can be on-call in hospital one in four days for 24-hour shifts.

On average, work-weeks are set at 60-hour maximums across the country. The U.S. allows for 80-hour weeks, while Europe is moving from 56-hour weeks to 48 hours as of 2009.

It's during the 24-hour shifts that interns are supposed to gain their most valuable training. Though they are able to consult attending doctors, residents are left to work largely independently on the hospital floor.

But studies have shown that interns coming off a marathon 24-hour shift display symptoms which correspond roughly to that of a drunk driver.

According to a study out of Harvard University, residents who worked 24 hours or more were found to be twice as likely to get in a car crash and six times more likely to report a near-miss accident while driving home, compared to working shorter shifts.

That's why the Professional Association of Residents of Alberta successfully negotiated taxi vouchers for their interns in the last collective agreement, said Dr. Milli Gupta from Edmonton.

"Change is slowly happening across the country," said the PARA president. "There's a lot of talk about medical safety and people are becoming more aware."

But not everyone is convinced. Dr. Dervesh Varma, president of the Canadian Association of Interns and Residents, dismissed studies equating fatigue with drunkenness as alarmist.

"It doesn't do justice to residents," he said from Saskatoon. "We have a system to ensure the protection of patients."

Residents don't run the show, he added, as they can consult attending physicians who are ultimately responsible for patients.

"There were days I was tired but I always felt throughout my training that I could come forward and be well-supported by my attendings (if I was tired)."

But medical training has been defined by a culture of bravado, where admitting fatigue can be a sign of weakness.

"Residents will tend to get stoic and feel that they have to tough it out. They may not acknowledge this to themselves or each other," said Dr. Allan Peterkin, author of Staying Human During Residency Training, whose fourth edition will be released next year.

"The culture of medicine sort of encourages you to tough it out as a rite of passage."

But no one is invincible.

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"It's no big surprise that the most common times for medication errors in hospital settings ... is usually during the middle of the night when we are at the lowest point of our biological clock," said Dr. Adam Moscovitch, director of the Calgary-based Canadian Sleep Institute.

Human performance plummets between 2 a.m. and 6 a.m., he said, and most people can work for a maximum of 12 hours before showing signs of decline.

Sleep-deprived doctors also made one-third more medical errors during extended shifts than they did during shorter work days in a 2004 study led by Harvard researchers Steven Lockley and Dr. Charles Czeisler.

Examples included one intern who was about to insert a tube into the left side of a patient's chest until a senior resident informed them it was to go in the right side. Another resident ordered an antidiuretic drip at a rate that would have amounted to an overdose by a factor of 10 had not the nurse intercepted the order.

Meanwhile, a Canadian study looked at the physiological responses of 11 senior fellows at Toronto's Hospital for Sick Children. Author Christopher Parshuram found doctors worked on average 69 hours a week, slept less than two hours, walked 6.3 km and performed invasive procedures for two-thirds of their shift. Dehydration was common among the participants and heart abnormalities were also detected.

The consequences, researchers conclude, are threefold: fatigue may cause patient harm, affect residents' mental health and compromise training.

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Dr. William Halsted is often described as the father of modern surgery. He is credited with starting the first formal surgical residency trainingprogram in the U.S. in the late 1800s.

But he's also known for having accidentally transformed into an addict when he used himself as a human guinea pig while studying cocaine as an anaesthetic.

If cocaine is a stimulant, could it be that the modern residency program is built on a prototype that stretches the human body beyond its normal limits?

Critics are resigned that reform is unlikely, given a pressing doctor shortage and the lack of legal precedents. Fatigue is rarely cited in medical malpractice suits because it's difficult to prove, said Robert Roth, a medical malpractice lawyer in Toronto.

The Libby Zion case in 1984 is the most commonly cited court case, where the plaintiff, Zion's father, claimed his 18-year-old daughter died because of inadequate care from overworked medical staff. There was no criminal indictment but the grand jury criticized resident training and staffing. The result was legislation that limited a doctor's ER shift to a maximum of 12 hours in New York state.

"If you're too exhausted to deal with a patient, you must ethically declare that, and then it's up to the system to come up with an alternative pathway or care," said Dr. Derek Puddester, director of the faculty wellness program at the University of Ottawa's faculty of medicine, where he's also an associate professor of psychiatry.

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Twenty-four-hour on-call shifts also give students a broad spectrum of cases and valuable learning experience.

"Residents need to be on-site to see the course of an illness," Peterkin points out. "When someone is acutely ill, that state fluctuates."

Though fatigue may endanger patient safety, so too does increased number of handovers, advocates point out, rupturing continuity of care.

Residents are also cheap labour for hospitals at a time when doctor shortages are rampant.

But fatigue-related second-guessing can also result in the ordering of more tests and procedures and contribute to longer hospital stays, costing hospitals money as well.

"The more tired you are, the more hesitant you are in your decision- making ... and the more likely you are to order more tests," Moscovitch said. "But when you're well-rested then your level of confidence in your decision-making abilities is also much better."

Observers agree, however, there's been a growing emphasis on physician well-being over the last 10 years. Wellness programs are popping up in med schools while collective agreements limit exploitation of excessive work hours.

"The medical culture has changed so much in a positive way," Puddester said. "We're seeing more realistic boundaries on work hours."

Peterkin recalls, for instance, nodding off during a counselling session with a patient.

"I was mortified. I was lucky, the patient was really kind," he chuckled.

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DUTY PERIODS

Maximum duty periods in other industries which are mandated

- Truckers: Maximum of 13 hours of driving in a 15-hour duty period

- Marine industry: Current regulations impose a minimum of 6 consecutive hours of rest per 24-hour period. Many watchkeepers operate on a six hours on/off schedule over 28 days

- Airline pilots: Maximum of 14 consecutive hours of flight duty in 24 hours

- Rail: Maximum of 18 hours per day of duty time

Source: Transport Canada


Sleep deprived

It was the rare time that Dr. Ryan Van Wert was able to close his eyes that night. For a few brief seconds, in a bid to block out a noisy emergency room, the young doctor closed his lids and shut the world out.

But lo, 'twas not of sugarplum fairies the doctor dreamt, but of heart murmurs and heart beats that danced in his head.

"I'm sure it's as solid as ever," says the 64-year-old patient, giving a hearty rap to his own chest, after the doctor's fluttering lids snap open.

It's around 11 p.m. on a Friday night in one of Canada's busiest emergency rooms. St. Michael's Hospital lies in the heart of Toronto, an inner city centre which treats the most critically ill and complex patients in Ontario.

Van Wert is the senior resident on the floor and is on hour 15 of his 28-hour shift. He is in charge of two medical students and two first-year residents. He's also the go-to doc for six patients in the ER and about 60 patients on the 14th floor of internal medicine.

Right now, though, he is needed by a patient with congestive heart failure -- and the late-night munchies.

"When do I get my sandwich?" asks the patient.

"The nurses should be coming around with them soon," he says soothingly.

Earlier that afternoon, Van Wert also had to assuage demanding customers when a nurse sought his help for a patient who lashed out at nurses on the 14th floor. He's already tended to an unco-operative patient in the advanced stages of HIV and a pager that's been going off on average every 20 minutes.

Upon first meeting Van Wert in the afternoon, he is wide-eyed and clean shaven. But 15 hours and six consults into his shift, his stubble has grown and he lets escape the first yawn of the night. It's 12:25 a.m. and he has another 12 hours to go.

Doctor-hood is not for the weak -- it's to tend to the weak.

"Certainly there is a heavy workload during certain rotations. But as a resident, you learn by doing. The hours you put in are the hours you learn," he says simply.

Van Wert cheerfully accepts 24-hour shift days as part of his medical training.

He also accepts that as senior resident, he must master the art of multitasking. After tending to an 82-year-old stroke patient, he switches gears to a rectal cancer patient with shortness of breath. Van Wert picks the brain of the junior resident he assigned to the consult. Each intern has been assigned one of six cases and must present a full report to review with Van Wert.

"We're telling a story here. People want to know the end of the story," he says to the student assigned to the stroke.

This is a slow day for the ER. Normally a Friday night brings in about 10 cases. By 2 a.m. they have six.

And the ending to Van Wert's own story?

After getting home on Saturday, he went back on Sunday for another 28-hour shift.

"The reality is people get sick at any time of day. One way or another, someone's going to have to be in the hospital every day and night."

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VITALS

Name: Dr. Ryan Van Wert

Age: 28

Education: University of Toronto

Position: Second-year resident

Current rotation: Internal medicine

 

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