Sleep deprivation is hazardous to pilots and truck drivers. That’s why they have restricted hours in the cockpit and behind the wheel. Doctors, on the other hand, don’t have mandatory restricted hours on call and at night. What they have instead are nicknames like “Jack Bauer”—after the main character in the Fox TV show 24. “Jack Bauer” is British hospital slang for a physician who is awake and taking care of patients despite being up for more than 24 hours.
That we invent slang for a sleep deprived colleague rather than tackle the problem is strong evidence that we doctors are so inured to its impact, we can’t even recognize it.
“I can function doing what I do with very little sleep, almost robotically,” said an attending obstetrician-gynecologist who phoned Minnesota Public Radio’s The Daily Show—on which I was a guest talking about medical errors. At the time of the call, the OBGYN was doing a Jack Bauer—he’d been up for 24 hours watching over a woman in labor—and was about to perform a Caesarean section. “I don’t know if sleep deprivation is a big deal for me,” the OBGYN went on to say with little doubt in his voice, “beyond the fact that it’s just not pleasant to be tired.”
“Just part of the job” is the prevailing attitude among doctors in practice when it comes to sleep deprivation. Part martyr and part hero, it’s welded into the culture of medicine.
Contrast again the OBGYN’s work life with that of pilots. In Dec. 2011, the Federal Aviation Association (FAA) released new regulations prohibiting pilots from getting less than 10 hours off between shifts. The rationale? A mountain of evidence showing a concrete link between sleep deprivation and pilot error.
On May 31, 2009, an Air France plane crashed into the Atlantic, killing all 228 people on board. A judicial report found that the pilot had slept just one hour prior to the flight. Also in 2009, Continental Connection Flight 188 crashed just outside of Buffalo, killing 49 passengers. The pilot had reportedly pulled an all-nighter before take-off. A 2012 National Sleep Foundation survey had one in five pilots admitting that they had made a serious error due to sleep deprivation.
Since regulators restrict pilot hours, you’d think that medical authorities would have done the same thing with MDs. Except they haven’t. Right now, across most specialties of medicine, there are no sleep or work-hour guidelines. None.
The strongest push to send sleepy doctors to bed has come from The Joint Commission, the organization that accredits more than 20,000 health care organizations across the US. In a Dec. 2011 report on health care worker fatigue and patient safety, the Commission said, “The link between health care worker fatigue and adverse events is well documented.”
In a Nov. 2007 report on health provider fatigue and patient safety, the Commission concluded, “To reduce the unacceptably high rate of preventable fatigue-related medical error and injuries among health care workers, the United States must establish and enforce safe work-hour limits.”
The Joint Commission has the power to demand that hospitals restrict the number of hours doctors work. So far, it hasn’t. Likewise, state boards of medicine—the people who license doctors—have not made adequate sleep a condition of licensure.
Doctors themselves show no sign of getting the message. The American College of Obstetricians and Gynecologists (ACOG) is a typical example. In a March 2012 Committee Opinion on Fatigue and Patient Safety, ACOG wrote this: “Additional research on the effects of fatigue on experienced practicing obstetrician-gynecologists is necessary before specific national guidelines that are evidence-based can be promulgated to improve overall patient safety and care.”
Confused? It helps if you can decode the secret language of doctors. There’s slang like “Jack Bauer.” Then again, there is coded technical jargon like “evidence-based.” The phrase comes from evidence-based medicine, a form of practice that says doctors should make test and treatment decisions based on evidence from well-designed clinical studies. That’s the dictionary meaning.
The hidden or coded meaning of “evidence-based” is that it gives doctors permission to adopt, in my opinion, a passive aggressive approach to a new and potentially threatening idea.
Who, in their right mind, would object to making sound judgments based on evidence—as the ACOG did? The benefit to doctors of urging more research is that they can run out the clock for months or even years until studies prove conclusively that sleep deprivation is a patient killer. Not only that, but it’s the doctors themselves, armed with special knowledge and expertise, that get to be the arbiters of the evidence.
As ideas go, few are more threatening to doctors than telling them that their long-tolerated habit of sleep deprivation is killing patients—and that failure to clean up their act will have consequences. It kind of changes everything.
Despite the obvious risks, many doctors like working nights. Overnight premiums make them more lucrative than day shifts. There’s professional cache in earning the nickname “Jack Bauer.” Your colleagues think you’re tough enough to stand the heat. And, you get to call residents less committed than you were back in the day.
But the evidence that sleep deprivation harms patients is clear. A 2009 study found an increased rate of complications among attending surgeons who operate after sleeping less than six hours. A 2006 study found that extended hours awake at night caused a 300% increase in preventable mistakes that led to a patient’s death.
So why don’t doctors accept that the link exists?
For one thing, unlike aviation disasters, in which investigators routinely ask about pilot fatigue, it is unusual for those investigating medical disasters to do the same. But that doesn’t prove the link doesn’t exist.
For another, we don’t have scientific data on the impact of sleep deprivation on attending physicians and surgeons because researchers have focused their attention instead on an easier get: residents—young physicians who are doing post-graduate training in hospital in preparation for becoming attending physicians in their own right.
There are valid reasons for that. In 1984, Libby Zion, an 18 year-old freshman college student, died in the hospital from a lethal combination of prescription drugs, some of which were ordered by the residents who looked after her. A state investigation concluded the long hours worked by the residents played a role in the young woman’s death.
That case led to caps in the number of hours per day and number of hours per week that residents work. It also spurred much research into the impact of long hours on residents—yet did little to spur research on people already in practice, like me.
Studies on residents have provided mixed conclusions. There are indications that long hours predispose the young doctors to errors. But so far, reducing duty hours that residents are permitted to work have done little to improve the well being of residents or patients.
I don’t think we should accept at face value the conclusion that reducing resident hours does nothing to improve patient safety. Still, many seasoned physicians doubt the wisdom of cutting back duty hours at all—not for their residents and certainly not for them.
And what do they gain by being sleep deprived? I find it hard to believe that the higher income that comes from being up all hours of the night is worth the cost to their wellbeing and that of their patients. I know of sleep deprived colleagues who made catastrophic mistakes on their patients. I know of residents who have fallen asleep standing up in the operating room while assisting at four in the morning. And I know of doctors who have veered off the road after a night on call and crashed their car into a tree.
We need to stop denying the effects of sleep deprivation, or treating it like a right of passage. It is time to learn from pilots and truck drivers and assume that a sleep deprived doctor is dangerous. We need to change the system by eliminating call hours and moving toward shift work. We need to hire additional staff on overlapping shifts to relieve fatigued doctors so that they can go home.
We need to explore any option that improves alertness—even pills. When I work at night, I take modafinil, a medication that is approved by the FDA for use in shift workers. I know a lot of colleagues who use it. I find that I can think better and remember much more of what my patients tell me when I take it. I function much better than my colleagues who sanctimoniously eschew medications. I can’t imagine authorities forcing docs to take pills to stay awake; but I can see them compelling us to take reasonable steps to assure that we are as alert as possible.
But not anytime soon, unless there’s a greater sense of urgency at the regulatory level. I suggest you ask the orthopedic surgeon about to replace mom’s hip, or the OBGYN about to assist at your daughter’s birth just how many hours of sleep he or she has had. The answer just might save a life.
Dr. Jack Bauer will see you now. That is, as soon as he wakes up.