Dog-tired doctors pose a health risk

It’s been a hard day’s night, and I’ve been working like a dog. It’s been a hard day’s night, I should be sleeping like a log.» It is hard to imagine that this pithy summary of the issues of long working hours, safety and the restorative effects of sleep on human performance should come from a love song by four mop haired musicians.
However, since the 1960s, scientists have increasingly recognized the risks of long working hours facing inhabitants of the modern 24 hour society. Electric lighting keeps factories, supermarkets and airports operating around the clock. Planes fly across multiple time zones. Large trucks are driven all night. Pursuits ranging from health care to the military are nonstop activities. The Internet never closes.
While we marvel at the convenience of so many modem technologies, the price we pay is exposure to a range of problems including social dislocation and increased risk of catastrophic accidents. The combination of long work hours, short sleep hours and working at night when the human body’s biology is programmed for sleep is a recipe for human error and impaired safety. The Three Mile Island nuclear accident, Chernobyl, the launch failure of the space shuttle Challenger, and the Exxon Valdez oil spill have all, in part, been caused by human error triggered by lack of sleep and excessive work hours.
Although most people are aware of their impaired function after going without one or two nights of sleep, the most common form of «sleep loss» is shortening of sleep hours. Everyone encounters some nights of reduced sleep length but when this persists and there is no or little recovery sleep, problems occur. Recent research has highlighted that shortening sleep to four or even six hours per night over a two week period is associated with increased lapses in attention due to «microsleeps». More worrying is that individuals who have restricted sleep seem to have an inability to monitor their own deterioration in performance, resulting in overconfidence in their ability to undertake tasks. So a sleep restricted person may behave in the same way as a person who has had too much alcohol to drink both underestimating their impairment and thinking they are fit to drive a car or some other responsible task, like complicated medical surgery.
Indeed, the hospital workplace is one setting where the risk of sleep loss has increasingly attracted attention from medical researchers. Professor Charles
Czeisler and his team from Harvard University have recently published a series of landmark papers in The New England Journal of Medicine and other leading medical journals. These papers have provided direct evidence that working extended shifts in the hospital intensive care unit results in more errors, especially medication orders. Shorter split shifts with time allowed for napping resulted in fewer errors. In a nationwide US survey of 2737 interns, the Harvard group found extended shifts were linked to a greater rate of needlestick injuries and near miss or actual driving accidents.
How does this relate to the hospital workplace in Australia? Although, in general, work hour regimes are kinder here than in US hospitals, 15 per cent of all doctors in Australia report working more than 80 hours per week. Problems arise in rural areas or in specialized settings where individuals may be on call all week. We know that even being on call without being called in can impair sleep and often little is done to acutely monitor on call specialist trainee work hours. These trainees are few in number and in high demand. Even more worrying is who monitors the sleep wake schedules of their bosses. Watching a senior hospital specialist fall asleep at a lunchtime meeting often provokes a laugh but perhaps ignores the underlying problem. No patient would consent to surgery if they noticed their doctor’s breath smelt of alcohol. However, how many patients ask their surgeon how much sleep they’ve had lately.
Hospitals are often imbued with a cultural mix of altruism, machismo and denial. Many of us who have worked in hospitals have bored our friends and family with tales of stoical never ending shifts and battling to stay awake in a sleepy fog. The reality is that we cannot kid ourselves that this is safe and any hospital administration that tolerates this situation is at fault. The current shortage of doctors in the health system has resulted in «moonlighting», with some doctors working for two or sometimes three employers. At the moment hospitals in Australia are probably more concerned where their doctors left their last SIM card but they should also be asking where else do you work how many hours do you work and how much sleep do you get?
Health administrators may be held criminally liable for their sleepy doctors in the same way that a transport company may be held criminally liable for fall asleep accidents caused by its drivers. The first step to prevent this is to recognize the risk, use scientifically proven strategies to deal with the problem and finally to recognize that the best treatment is to sleep like a dog.
Professor Ron Grunstein heads the Sleep and Circadian Group at the Woolcock Institute of Medical Research at the University of Sydney. Professor Charles Czeisler is speaking at the Royal Prince Alfred Hospital this morning.
from by ron grunstein