A few weeks ago, I admitted Mr. C to the Johns Hopkins Hospital for a life-threatening infection. I spent the beginning of my 28-hour shift trying to stabilize him as his organs began to fail. Mr. C was too sick to speak for himself, so I collected medical records from other hospitals he had visited to learn more about his medical history. As I read, I thought of new possible diagnoses and performed additional tests. I definitively diagnosed him just as the overnight component of my shift ended, and I worked with members of my team to initiate a plan. The patient was complicated, but my shift was just long enough to figure out his disease.
I am a first-year physician at one of 63 hospitals taking part in a study, known as iCOMPARE, examining the effect of work hour restrictions on patient safety as well as the well-being and education of first-year internal medicine doctors. Participating hospitals have been randomized to either limit their first year doctors to 16-hour shifts or to have no restrictions on the length of shifts, though all programs are forbidden from allowing physicians to work longer than 80 hours per week. The study has recently faced attention in the media related to the safety of first year doctors working up to 30 hours per shift.
I work 26- to 30-hour shifts every four to five days. During the 30-hour shifts, known as the "on call" day, I admit new patients. When I bring someone into the hospital on my call shift, I become an expert on the patient's medical history and current illness. I then serve as the patient's primary doctor throughout his or her hospital stay. Mistakes are avoided and the quality and the safety of care are improved.
In contrast, when doctors cannot work more than 16 hours per shift, hospitals rely upon a day and night team of physicians. At the end of shifts, teams "hand off" their patients to the oncoming doctor. On general medicine floors, we learn about as many as 30 patients, often for the very first time, and average only one minute per patient, according to recent studies. Details are inevitably left out.
Because of human error, handoffs are risky. Researchers have found that mistakes are often linked to physician handoffs, with one study finding that they happen up to five times more often with covering, night-team physicians who rely heavily on handoffs when providing care.
With Mr. C, a 16-hour schedule would have forced me to hand off to a new physician halfway through his extensive work up, interrupting his care while he remained extremely sick. Because the oncoming physician would not have known the patient as well, the diagnosis would have been delayed with potentially life-altering consequences.
Handoffs are inevitable; physicians cannot work 24 hours a day, seven days a week. But it is important to minimize them and to preserve continuity of care. It is the best way to improve patient safety in the hospital. And this is exactly what extended shifts accomplish.
The major argument against extended shifts is fatigue. Being tired is uncomfortable, a surprise to nobody. But I dislike the fatigue argument. I'm more likely to remember important aspects of a patient's care if I developed a relationship with a patient over a 30-hour shift than if I learned about the patient for the first time through a handoff. A recent study further found that doctors working 24-hour shifts were no more fatigued than those working only 12-hour shifts.
Fatigue can be detrimental in cardiac arrests and breathing emergencies, when quick thinking is a must. But hospitals understand the research on fatigue and have an experienced and well-rested senior physician always available in these situations. We are trained to ask for help whenever we feel even the least bit uncomfortable and, in my case, I have always been supported by a well-rested colleague when making crucial decisions.
At the start of my first year as a physician, I was a supporter of the 16-hour schedule but have since evolved. Now, I tell folks that I would prefer my loved ones be seen at a hospital with 30-hour call. Through my experience with both schedules, I simply believe that this schedule is safer. We'll have to wait for the results of the iCOMPARE study to see if the evidence supports my experience, but I am confident that it will.
Dr. Calvin M. Kagan is a first-year internal medicine resident physician at The Johns Hopkins Hospital; his email is firstname.lastname@example.org.