As a third year medical student I rotated through a sleep clinic. My job was to administer the Epworth Sleepiness Scale, a tool used to screen patients for sleep disorders. At the end of the day, I took the questionnaire myself and was shocked when I scored worse than many of my patients, one of whom had narcolepsy.
Concerned, I showed my attending my Epworth score. He looked at my questionnaire and chuckled, “You probably don't have sleep apnea. You probably are just a medical student."
Still concerned, when I had time six months later, I signed up for a sleep study. The study revealed a very mild form of apnea that isn’t typically treated. My attending was right; my primary problem was being a sleep deprived, stressed out medical student.
Earlier this month, the Journal of the American Medical Association published a meta-analysis representing over 120,000 medical students from around the globe. They reported that 27 percent of medical students had depression or depressive symptoms and that 11 percent reported suicidal ideation, both of which are higher than the general population. Because these symptoms began during medical school, the authors concluded “it is not just that medical students are prone to depression, but that the school experience may be a causal factor.”
In 2009, a combined analysis of more than 2,000 medical students and residents showed that 21 percent of these medical trainees had symptoms of depression. 5.7 percent of trainees reported suicidal ideation within the last two weeks.
Consider that there are currently 212,000 U.S. medical trainees. If the more conservative 2009 study results generalize to my entire cohort (a statistical leap, I know), some 25,000 of my co-trainees have symptoms of major depression and a shocking 12,000 of my peers have considered suicide in the last two weeks.
Understandably, such evidence that medical trainees are at risk has sparked research into why this is the case. I’ve heard the question framed as “How can so many trainees be so unhappy?” Isn’t medicine the best of all possible professions in this, the best of all possible worlds?
Medical trainees are not depressed or suicidal because they are disgruntled (though for some this may be the case). They are depressed—5.7 percent are suicidal—because they have been pushed beyond their human, physiological limit by chronic stress and sleep deprivation; because in the intensive care unit or on the medical floors they’ve stared disease and death in the face; because despite courageous efforts, they have watched patients’ fragile lives slip away.
Living in this memento mori, trainees can’t help but see their own life slip away as well. As my fellow trainee, Dr. Pranay Sinha, reminded me, “the physical stress of working long hours denudes the resilience necessary to cope with the spiritual and moral distress that is innate in medical practice.”
Current duty hours restrict medical trainees to 80-hour workweeks—that’s the equivalent of two full-time jobs. But in an astonishing reversal of policy, the ACGME (the governing board of graduate medical education) recently announced that they were scrapping a 16-hour shift limit for interns, doctors in their first year of on-the-job training. The new policy would allow programs to compel interns to work as many as 28 consecutive hours.
This policy reversal was based on the FIRST trial, which showed that “less-restrictive duty-hour policies [read: longer shifts] were not associated with an increased rate of death or serious complications [in patients].” Dr. Thomas Nasca, ACGME’s chief executive officer, defended the change: “Just as drivers learn to drive under supervision in real life on the road, residents must prepare in real patient-care settings for the situations they will encounter after graduation.”
The message here is that trainees need to “cowboy up to join the rodeo”, without opening the conversation to what sort of environment trainees are being prepared to work in. If trainees are being prepped to work 28 hours straight, what does this say about the medical community’s understanding of sleep physiology?
Sleep is an essential part of our physiology that has evolved over millions of years. Even one night of sleep deprivation changes brain function so much that machine learning algorithms can distinguish rested from unrested participants with 93 percent accuracy. Other studies reveal that sleep deprivation decreases cognitive performance in every measure tested, and that these decreases accumulate over time. Attempts to pharmacologically mitigate (or “manage” to use the medical term) brain fatigue with stimulants are only partially successful. Such evidence suggests an obvious human element: physical stamina is a limited resource.
Another study, published in The New England Journal of Medicine, reported that medical interns were at a serious risk of motor vehicle accidents, “near misses,” or falling asleep at the wheel after a grueling 24-hour shift. “Extended-duration work shifts...pose safety hazards for interns,” the authors argued and then noted, “medical residency programs…routinely schedule physicians to work more than 24 consecutive hours.”
The main argument for the euphemistic “less-restrictive,” 28-hour shift is that extended shifts promote continuity of care and fewer provider handoffs—having the same doctors with the same acutely ill patient for a longer period of time theoretically improves patient care.
Earlier this year, however, Dr. John Birkmeyer, chief academic officer at the Dartmouth-Hitchcock system, beautifully pointed out in The New England Journal of Medicine that studies like FIRST “effectively debunked” the idea that shorter shifts are worse for patient care. The FIRST trial showed that patients fared no differently when trainees worked 16-hour or 28-hour shifts (or longer). In other words, shorter shifts do not affect patient care, but how could they not affect trainee quality of life?
”Rather than backtrack on the ACGME duty-hour rules,” Birkmeyer suggested, “leaders should focus on developing safe, resilient health systems that do not depend on overworked resident physicians.”
Instead, the ACGME proposal of a 28-hour shift suggests that the lives of medical trainees are an expendable resource, one to be exploited to the point at which patient outcomes suffer.
Reports that medical trainees are depressed and suicidal at astonishingly high rates force us to confront our vulnerability and human-ness. We are a limited resource and our community is suffering.
Please note that the ACGME is accepting public comments on this important issue until 19.Dec. I encourage you to submit an official comment to the ACGME at http://www.acgme.org/What-We-Do/Accreditation/Common-Program-Requirements