American medical school students who are graduating this spring and have been successfully matched to residency programs are anticipating the challenges ahead of them—including one that their predecessors have not contended with for several years: the 24-hour shift.
After issuing common program requirements in 2011 that barred first-year physicians from working shifts exceeding 16 hours, the Accreditation Council for Graduate Medical Education (ACGME) recently reverted to prior requirements that permitted them to work up to 24 hours.
The 2011 ACGME ruling emerged from concerns that shifts of up to 24 hours were too onerous for new medical school graduates, and that patient safety could be endangered by sleep deprivation.
Recent clinical studies show, however, that there is no correlation between less restrictive duty hours and a higher incidence of serious mistakes among residents. A Feb. 25, 2016 New England Journal of Medicine report on a large randomized trial of general surgery residency programs, for example, suggested there was potential for greater continuity of care because residents would have more time to attend to patients throughout their entire course of hospitalized treatment.
This report supports the view of a number of young physicians who recently completed, or will soon complete, their residencies. All members of the AMA’s Resident and Fellow Section, they spoke with AMA Wire® about the recent ACGME change and the advice they would give to new medical school graduates who will work 24-hour shifts.
Asked whether they preferred the 16-hour shifts they worked as first-year residents or the 24-hour assignments they worked in later years, the majority opted for the longer shift.
“I thought the 24-hour shift was easier,” said Jordan Warchol, MD, who completed her residency in emergency medicine last year at the University of Nebraska Medical Center in Omaha. Dr. Warchol is now a fellow in health policy at George Washington University School of Medicine & Health Sciences, where she will earn a master’s degree in public health. “I could provide better care because I was there for the duration.”
That sentiment was shared by Scott Leikin, DO, a third-year internal medicine resident at Chicago’s Presence Saint Joseph Hospital. Dr. Leikin said longer hours do far more than enhance patient care: They advance young physicians’ understanding of a disease’s etiology.
“You will see the pathology in its acute phase,” he said, “and over the 24 hours, you will have a much clearer understanding of the condition.”
There are also practical advantages, said Dr. Warchol.
“When you’re on a 16-hour shift that ends Monday at 11 p.m., you still have to come back to the hospital on Tuesday at 7 a.m.,” she noted. “When you’re on a 24-hour shift, you leave on Tuesday at 7 a.m., and you don’t have to report back for duty until Wednesday. That is a better arrangement. You have the rest of the day to do things.”
Samuel Mathis, MD, in his final year as a family medicine resident at Memorial Hermann Southwest Hospital in Houston, expressed a minority opinion.
“Research has shown that someone who has been awake for 24 hours resembles a person who has been drinking,” he said, referring to studies that show significantly sleep-deprived subjects have motor-skills performances similar to those with a blood-alcohol content of at least 0.05 percent. “Why would we put first-years in that situation? We should protect them and let them learn what they have to learn.”
Dr. Mathis did acknowledge, however, that the ACGME change in requirements was here to stay so it was imperative that first-year residents learn how to cope with 24-hour shifts as effectively as possible. He, Drs. Warchol and Leikin, and Bradley Burmeister, MD, a third-year emergency medicine resident at the Medical College of Wisconsin Affiliated Hospitals, offered the following suggestions:
Take it easy the day before your upcoming 24-hour shift. “Make sure that you get a good night’s rest the night before so that you can be at the top of your game,” said Dr. Mathis. Engage in activities that allow you to shift gears but do not tax you, said Dr. Burmeister, who likes to bicycle on his days off and grow vegetables in a community garden. “Be in the fresh air. Go to Target. Go to dinner with friends. Run errands. Clean your house. Spend time with your kids,” said Dr. Warchol. “I work out with weight lifting,” said Dr. Leikin. “It’s my way of relaxing and turning my brain off.”
During your 24-hour shift, take care of yourself. “Drink lots of water, especially if you’re using caffeine,” said Dr. Burmeister. “Carry healthful snacks. Be aware of when you’re tired so that you can continue to make good decisions for your patients. If you travel a distance after your shift, consider a short nap at the hospital or in your car before driving.” Dr. Mathis added that exercise could prove restorative during longer shifts. “Take the stairs rather than the elevator,” he recommended. “I was lucky. I had a gym at my hospital so I could do 20 minutes on a treadmill.”
Use your 24-hour shifts to build professional relationships. “The importance of building professional relationships cannot be overstated,” said Dr. Leikin. “You become close to your colleagues. These are the people you will be working with for three years. The teamwork and camaraderie are extremely important. So is interpersonal communication. Many of the nurses and techs have tons of experience, and they can help first-year residents dramatically. Talk to them. Ask them what they think.”
The AMA has policy, adopted in 2014, that supports a limit of 80 total weekly duty hours for residents, with no scheduled on-call assignments exceeding 24 hours.