Fatigue – Doctors Would Know Better With More Rest

The IGDA is the International Game Developers Association, which includes all those people who create videogames, from programmers to testers to artists and many, many more. The linked article is a quasi-response to another post in which someone said to be the spouse of an Electronic Arts employee said that programmers were working mandatory 87.5 hour workweeks. The author of the article writes, not strictly about videogames, but about workers in general. He refers to several items in the history of the 40-hour workweek, tracing the development and changes in hours over time. The takeaway: the perception that hours can be costlessly increased for salaried knowledge workers is false, and in a big way. Productivity declines rapidly, such that the work done in 8 60-hour weeks actually approximates that completed in 8 40-hour weeks. That’s a pretty amazing drop-off, and it’s one that deserves further study beyond what’s cited in the article.

A profession is defined by three things: specialized knowledge, a public trust, and an ethical code enforced by self-government. In this first of three posts related to the fatigue brought on by long hours and little sleep, we explore the article as it relates to the medical profession. Doctors have been debating the issue of 24-hour shifts in earnest over the past several years. Doctors are almost certainly committing professional errors, by which we mean breaches of ethics codes governing the profession, if not actual malpractice, by rigidly sticking to the 24 hours on/off rules and long hours for interns & residents. While that field is slowly asking the right questions, they don’t seem terribly concerned about moving on, even for the sake of the patients. Nurses work similar odd schedules, typically 3x 12 hour shifts and then overtime after that. Both argue that continuity of care is a moderating factor, and so that should indeed be taken into consideration, but the number of accidents is certainly a knowable number, even if the alternative isn’t. But given the number of institutions in the country, and the world, there should be some comparative data.

This article http://www.ncbi.nlm.nih.gov/pubmed/15509817 notes that residents made substantially more errors when on a 24-hour shift schedule. We think this is reason enough for the public to demand changes, but the real concern is why aren’t doctors and hospitals taking this more seriously. Since this article was published, there have been articles in the medical journals and related forums outlining the risks, and the AMA has taken some steps to recognize the problems, although they are too slight to be described as mitigating the potential harm to patients (the proposed maximum is 80 hours/week. From a professional ethics perspective, particularly one that starts with thou shalt do no harm, we don’t understand why doctors don’t feel compelled to make the necessary changes. The arguments for the long shift are weak when measured against preventable harm: continuity of care is a common excuse, and “toughening” up residents is another.

Continuity of care makes more sense with nurses, who often work three 12-hour shifts per night, and can be assigned in ratios as low as 1:1. Doctors, on the other hand, are typically running from patient to patient on rounds in-between emergencies and urgent consults. Similarly, nurses typically have more varied work duties, allowing them to somewhat tailor their current task to their alertness level whereas residents can be called on to make the most difficult decisions of their shift at anytime, whether hour 1 or hour 21.

Toughening up residents is a faux argument. The grueling schedule is entirely man-made. This is not a situation at all like military special operations training courses, such as the US Army Ranger School, where sleep deprivation is a specific part of the program to increase stress and help these future leaders learn how they and their soldiers react under some of the conditions they will face on the battlefield. But that’s training, and no military leader would deliberately handicap troops in battle by depriving them of sleep in the absence of a mission-critical requirement. The more you sweat in training, the less you bleed in combat.

(We contemplated asking family members who are now at the chief resident level, but we decided it was a little too combative to call them unprofessional to their faces.)