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Waking Up to the Problem of Fatigue Among Medical Interns


At 3 a.m., intern Michael Greger, awakened for the fifth time that night, listened as a nurse ticked off a long list of blood test results for one of his patients, then fell back into an exhausted stupor. Later in the morning, when he checked the patient's chart, Greger was horrified: He had failed to realize that one of the blood tests clearly showed the man was in imminent danger of having a fatal arrhythmia, a heart rhythm disturbance. The patient was rushed to intensive care.

* It was 2 a.m., anesthesiology resident Steven K. Howard had been working for more than 16 hours and was facing another hectic, sleepless night in the operating room. After preparing two syringes containing drugs for his next patient, Howard had a vague feeling something was amiss. He checked the syringes and discovered that one contained the wrong drug, a medication that would have triggered a fatal stroke.

* Plastic-surgery resident Risa S. Moriarity had been working for more than 50 hours without sleep when she started to perform complicated colon surgery. Minutes after the nine-hour procedure began, Moriarity briefly nodded off, instruments in her hand. After her repeated attempts to stay awake failed, a sympathetic senior surgeon sent her home.

Although none of these episodes resulted in harm to a patient, they are emblematic of an issue that long has escaped scrutiny: the risk of errors made by medical residents, collectively the most inexperienced, overworked and sleep-deprived of American doctors. A landmark report issued 18 months ago by the Institute of Medicine estimated that as many as 98,000 hospitalized patients die each year as a result of medical errors, many of them preventable and most of them unreported.

But the report, which urged organized medicine to examine the error reduction programs undertaken by other industries, barely mentioned fatigue as a factor in mistakes made by the nation's 100,000 interns and residents.

The reason, according to a member of the panel, is simple: The institute is obligated to consider the most rigorous scientific evidence. And although many experts believe fatigue is a significant factor in medical errors--just as it is in mistakes in aviation, aerospace and other industries--there are only a few studies that indicate a causal relationship.

One often-cited report is an anonymous survey published in 1991 in the Journal of the American Medical Assn. Researchers found that 41% of 145 residents cited fatigue as a cause of their most serious mistake; in nearly one-third of these cases, the patient died as a result of the error. Another report, which appeared in the British journal Nature in 1997, found that staying awake for 24 hours impairs cognitive and motor skills to the same degree as having a blood alcohol level of 0.1%--above the legal limit for driving drunk in most states.

The dearth of rigorous research into the relationship between residents' fatigue and the errors they make may be a reflection of the subject's enormous sensitivity. For years the medical establishment has defended the residency training system, largely unchanged since it was pioneered a century ago at Johns Hopkins Hospital. Many doctors have insisted that the grueling three to seven years of hands-on specialty training after medical school--which, after all, they survived--teaches neophyte physicians to subordinate their needs for sleep and food to the unpredictable and often consuming demands of patient care. These defenders insist that residents, who provide much of the round-the-clock care in the nation's teaching hospitals, learn to transcend fatigue and function effectively.

But safety researchers, sleep experts and a growing number of influential physicians contend that this view represents the triumph of self-delusion over science. They point to numerous studies conducted since 1980 in transportation, at NASA and elsewhere that clearly demonstrate that sleep deprivation causes errors. These studies consistently show that fatigue erodes every aspect of performance: judgment, vigilance, mood, motor coordination, cognitive skills, reaction time and even the ability to recognize error.

In medicine, fatigue is inextricably linked to another well-documented and often overlooked hazard: the night shift. Human performance declines measurably between the hours of midnight and 6 a.m. and most sharply between 3 a.m. and 5 a.m., in accordance with innate circadian rhythms. A disproportionate number of accidents occurs at night, such as car crashes. There is no reason to suspect that the same is not true in medicine, scientists say, and a few studies have suggested this to be the case.

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