It was 4PM. I snapped awake at the desk, looking around quickly to see if anyone had noticed my moment of weakness.
No one was watching.
Relieved, I continued to dictate the patient’s discharge summary. As words tumbled from my lips, I realized they were not making any kind of sense. I stopped the recording and replayed what I had just said.
A bunch of gibberish.
I tried again, rewinding back further. Still gibberish.
Fully awake now, heart racing, I trashed the whole dictation and started over again, jotting down a quick outline so my brain would not get lost.
My whole body ached from the fatigue. All I wanted was a bed. Nice cool sheets. A fluffy pillow. Maybe a soft blanket or two. Darkness would be nice but was not critical.
Then my pen started to laugh at me.
Was that a dream or a hallucination? After 38 hours of awake, I was no longer sure…
It was the very first hospital shift of my intern year of residency. I had never been up that long at one stretch before.
When people talk about how hard residency was, this is what I remember… the bone aching fatigue. When I was moving, things were better, so when I was on the hospital service I got into the habit of dictating and writing orders while standing up instead of sitting down. I think I got used to the sleep deprivation, if you can imagine.
Resident work hour restrictions went into effect my last year of residency. Rather than coasting to graduation, letting everyone else cover call, I found myself covering intern and second year primary calls overnight at the hospital, filling in their gaps. My class worked much harder than anyone before or after us. We were caught in the middle.
Interestingly, while everyone believes work hour restrictions save lives, what they don’t realize is that it has increased medical errors from more frequent hand offs. When you go off duty, you have to check out your patients to the next physician. It is not possible to discuss in detail every event of the preceding shift, so you give a short summary. It is thought that the more frequent hand offs, increasing those lost details, has caused an increase in medical errors that cancels out the fewer errors from sleep deprivation.
So in the end, it’s a wash.
Personally, I think the longer hours made me tougher, taught me that I could do and survive much more than I ever thought possible. It reinforced my work ethic. It exposed me to a lot more medical knowledge than I would have gotten otherwise. It helped shape me into the person I am now.
Does that mean we should go back to insane work hours?
Sleep deprivation clearly does increase errors, but that isn’t the only source of medical errors. We need to drill down on those. We need to figure out better ways to do patient hand offs. We may need to add a year to family practice residency in order to get the proper exposure, to ensure we are graduating solid physicians.
I love that people are looking at these things more closely now, identifying where errors are coming from, but dang if we don’t move painfully slow on this front. Work hour changes in the U.S. went into effect over a decade ago…. Seems like we should have a better handle on this by now.