The night that taught me just how dangerous 28-hour shifts for residents can be

It was a drinking holiday in San Francisco, and I was working as a junior resident in the emergency department of the county’s trauma hospital. All night long, ambulance crews had been bringing intoxicated patients with various injuries. I had been working a lot of shifts and was frankly exhausted. My back ached. My current patient needed a procedure to drain multiple pockets of infection caused by injecting heroin, and we were not getting along well. The light in the room was flickering and poor, and she refused to move her legs to make it easier for me to see my scalpel incisions. On top of this, I was in a rush to finish before the next ambulance arrived.

Sure enough, after draining a few infected sites, my pager rang in my pocket. I would have to leave before I was finished with this patient to receive another ambulance. In a hurry, I grabbed the surgical scalpel and went to wrap it in sterile towels for when I could return. Instead, I sliced my left index finger. This meant all of the blood and pus that was on the scalpel was exposed to my bloodstream. This patient was known to have HIV and hepatitis. I would need to be tested and treated for those lifelong infections. Many hours later, after I transferred care of my patients, after giving blood samples in occupational health and starting powerful antiviral medications which would make me nauseous for weeks, after calling my husband to let him know the bad news, exhausted and in tears and facing yet another shift that night, I mixed up the gas and brake pedals in my car, backing into a concrete pole in the hospital’s parking garage. 

In a hurry, I grabbed the surgical scalpel and went to wrap it in sterile towels for when I could return. Instead, I sliced my left index finger. This meant all of the blood and pus that was on the scalpel was exposed to my bloodstream.

There’s no doubt in my mind that my exhaustion contributed to these multiple failures — the sliced finger, my emotional breakdown, and finally, the car accident. This should hardly come as a surprise. A plethora of research demonstrates that sleep deprivation is linked to cognitive impairment, degradation of motor skills, burnout and decreased empathy, and mood derangements. One Nature paper found 24 hours of wakefulness resulted in the same degree of impairment as a blood alcohol level of 0.10, well above the legal limit to drive in California. This is the reason that so many safety-sensitive occupations, from pilots to nurses to long-haul truckers, have already limited consecutive hours of work. 

Recognizing the potential for harm to patients caused by extreme fatigue, in 2011 the Accreditation Council for Graduate Medical Education (ACGME), which accredits programs to train doctors, imposed new “duty hours” limits for doctors in training: no more than 80 hours a week, at least one day off in seven, and a maximum of 16 hours of work in a row for first-year residents, or interns, fresh out of medical school. Prior to 2003, they could work up to 28 hours, like the more senior residents. 

Earlier this year, however, the council decided to reverse prior protections around these “extended” shifts, allowing interns to again work 28-hour shifts. The group cites a preliminary study that showed that for surgical residents, the 16-hour limit did not improve patient safety (the FIRST trial) on measures such as mortality or serious complications (the study did not assess whether the interns actually made more mistakes during extended shifts — other significant studies have in fact shown that tired residents do make more mistakes). The real reason for the reversal may be something vastly simpler: residents are the cheapest labor in the hospital, and by limiting the hours they work, hospitals lose money. I take home an average $20 per hour, and because I’m salaried, the more hours I work, the less I cost. To replace me with a nurse practitioner or another physician, the hospital would need to pay almost 10 times that amount. Hospitals put a tremendous amount of pressure on ACGME to extend resident work hours. Ignoring patient safety and resident advocacy groups, the council allowed these longer shifts. 

Currently there are some small studies showing a link between extended shifts and safety lapses like blood exposures and car accidents. A large ongoing study is tackling this question as well (Harvard’s Resident Sleep Study). If this research shows, as I suspect based on my own experience, that longer shifts put residents at risk, it will be interesting to see how ACGME responds. Apart from safety issues, very little work has been done on how sleep deprivation affects the learning of young doctors, which is, after all, the entire purpose of being a resident: to learn how to be a doctor. While ACGME purports to “set standards for U.S. graduate medical education,” their argument to extend work hours is not based on science at all — the neuroscience literature is very clear that sleep deprivation is detrimental to many kinds of learning and cognitive functions. Instead, it relies almost entirely on reports from residency programs, who have a strong financial interest in long work hours for residents. The limited objective research that they cite shows that cutting extended shifts actually improves resident attention without compromising patient safety. 

Ultimately, I tested negative for HIV and hepatitis. There was no lasting damage from the car accident either. I was incredibly lucky. Many of my fellow residents will not be. Exhausted, backs aching, gulping down coffee, we continue to report for 28-hour shifts. And starting in June, we will be joined by the new intern class, who will have graduated medical school just weeks earlier. It doesn’t take a doctor to understand that this isn’t safe for anyone. 

Dr. Josephine Valenzuela is an emergency medicine resident and Committee of Interns and Residents’ regional vice president for Northern California.