Why Do Doctors Work Such Long Hour Shifts?

A question that has popped into my head many times in the past is ...

Why do doctors work such long hours?

I'm talking about the medical residents that typically work 24 hours shifts. Not having ever been a doctor myself, I could not answer this question.

So alright. I'm going to sit down in front of my computer and exercise the Google search engine to its max and see if I can get to the bottom of this question.

One of the best writing on this subject that I was able to find was found archived at the Agency for Healthcare Research and Quality linked here.

It was written by Ashish K. Jha, M.D. (University of California, San Francisco School of Medicine), Bradford W. Duncan, M.D. (Stanford University School of Medicine), and David W. Bates, M.D., M.Sc.(Harvard Medical School). So it will be hereafter referred to as the "Jha, Duncan, Bates paper" and referenced with a superscript note [1].

It says ...

"Fatigue and sleep deprivation are common among medical personnel. Long work-hours are a tradition during residency, with most interns and residents working 80 to 100 hours a week, often 36 hours at a time. During these shifts their sleep is limited, and is usually interrupted."[1]

In the book Adrenal Fatigue, the author provides a glimpse into the life of a doctor:

"During the first two years of medical school they learn approximately 25,000 new words, staying up many late nights to do so. At the end of the four years of study, they graduate and become residents in a specialized area of study, working between 80 and 110 hours per week, sometimes under a great deal of pressure from superiors and other students. By the time they graduate and finish their residency, they are often up to one hundred thousand dollars in debt and emotionally isolated. Over two-thirds of those who are married, end up divorced by the end of their residency." [page 16]

Long Hours and Shift Work Increases Heart Disease

The question of why doctors work such long hours popped into my head when I was reading Dr. Mark Hyman's The UltraMind Solution book where he writes of his experience of how his "brain broke" ...

"That rhythmic life broke down, as it does for all physicians in training, when I entered the hospital and started pushing my body and mind beyond their limits with regular thirty-six-hour shifts on top of an occasional sixty-hour shift (Friday morning to Monday evening!) When I went to practice as a small-town family doctor in Idaho, I worked a shortened schedule of only eighty hours a week..." [page 8]

MSNBC reports of a study that shows working more than 11 hours per day increases the risk of heart disease by 67%.

A little math here... Since there are only 7 days in a week. An 80-hour work week means you've already exceeded 11 hours of work per day. And an 100-hour work week is equivalent to 14-hour work days.

Undoubtedly, some of these work occurred during the night. Study of night shift work shows that shift work can increase cardiac risk by 40% -- reference found on National Institute of Health website.

This is because ...

"shift workers have disturbances in their circadian rhythm, as measured by changes in their melatonin and cortisol levels. ... leading to greater cumulative sleep deprivation. Shift workers have poorer quality of sleep, marked by less REM sleep, and are less likely to feel refreshed after awaking"[1]

Surely, doctors are aware of these studies. Right?

That's why later on page 169, Dr. Hyman writes ...

"when I learned that shift work (like I did in when I worked in the emergency room) leads to a shortened life expectancy, I quit."

Sleep Deprivation Affect Cognitive Performance

The question had also popped into my head when I was researching the effects of sleep deprivation on judgment. Sleep is third most important for health after food choice and exercise.

The Jha, Duncan, Bates paper says ...

"If the sleep debt continues over 5 to 10 days, they are rarely maximally alert and at some point general performance, and particularly cognitive performance, become verifiably worse."[1]

Long hours increases the chance of doctors being sleep-deprived. And most people certainly would not want to have a sleep-deprived doctor operating on them.

Attempts to determine whether sleep deprivation affects doctors judgment in clinical settings were mixed. The Jha, Duncan, Bates paper says ...

"Using standardized testing, investigators have found that after a night of call, sleep deprived physicians may have worse language and numeric skills, retention of information, short-term memory, and concentration. Performance on standardized tests may not reflect performance in medical situations. ... after a night without sleep, surgeons were slower and more prone to errors on the simulator than those who had a normal night of sleep. ... those who had been on call and were sleep deprived scored less well on simulated critical events. ... as the 24-hour study period progressed, physicians were more likely to make errors during a simulated triage test and while intubating a mannequin. However, other studies have failed to find an effect of sleep deprivation on cognitive performance by resident physicians."[1]

Doctors Hours Reduced

It would seem logical to restrict the number of hours that doctors work so they have more time to relax and be refreshed when they see the next patient. After all, the law restricts the number of hours that truck drivers can drive in the name of safety.

In fact, regulations to reduce the number of doctors have been enacted and other are in the works.

In 1989, New York State says that residents can only work 80 hours a week with a longest continuous shift of only 24 hours. And you have to have at least 8 hours between shifts.[1]

MSNBC reports that legislation is under way to reduce the shift-length of first year doctors in residency training down from 24 hours to 16 hours. But residents in second year can still do 24-hour shifts.

That sounds like good news -- that is if the regulations were followed. Jha, Duncan, Bates paper writes ...

"Despite these regulations, unannounced inspections of 12 teaching hospitals in New York State in March 1998 found 37% of all residents worked more than 85 hours per week, 20% of all residents and 60% of surgical residents worked more than 95 hours per week, and 38% of all residents and 67% of all surgical residents worked more than 24 consecutive hours. In 2000, 8% of programs and institutions reviewed by the Accreditation Council for Graduate Medical Education were cited as being in violation of their work-hour requirements. Work-hour violations were noted in general surgery (35%), pediatrics (16%), internal medicine (10%) and other training programs as well."[1]

Some argue that reduction in doctors hours would negatively affect intern education and lead to poorer patient care due to the discontinuity of care by the same doctor. However, a study cited on BMJ.com[2] concluded the following ...

"Reducing working hours to less than 80 a week has not adversely affected outcomes in patient or postgraduate training in the US." [BMJ 2011; 342:d1580 doi: 10.1136/bmj.d1580 (Published 22 March 2011)]

The Jha, Duncan, Bates paper concludes similarly ...

"some authors have expressed concern that restriction of resident physician work-hours may lead to poorer quality training and decreased professionalism among doctors. They argue that restricted working hours will decrease a sense of obligation to patients and will sanction self-interest over the well-being of patients. However, there are no data to substantiate these concerns."[1]

Emergency physician Dr. Diane Gorgas writes in 2010 that we need to have a balance in her article "Doctors in training work long hours for a reason". It is sometime difficult to reduce hours when hospitals are short on staff and strapped on finances.

Another doctor, Merlin Lowe MD, provides his perspective in the 2009 article "Have Resident Work Hour Restrictions Compromised Training - a Pediatrician’s Perspective"

Conclusion

Ultimately long-shifts are unavoidable because some complex surgery and operations can take 12 to 20 hours long. Continuity of care by the same doctor is also an important consideration. The important of sleep on the body should be kept in mind so that strategies can be applied to mitigate the negative effects of sleep deprivation.

The Jha, Duncan, Bates paper comments...

"Although data from non-medical fields suggest that sleep deprivation leads to poor job performance, this link has not yet been established in medicine. ... Limits on physician duty hours must account for potentially detrimental effects of discontinuity in patient care. Forward rather than backward shift rotation, education about good sleep hygiene, and strategic napping before or during shifts may reduce fatigue and improve performance."[1]

Another article that may be of interest is "Doctors Moonlighting"

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