Should doctors work 24 hour shifts?BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3522 (Published 26 July 2017) Cite this as: BMJ 2017;358:j3522
- Steven C Stain, chair1,
- Michael Farquhar, consultant in sleep medicine
- 1Department of Surgery Albany Medical College Albany, NY, USA
- 2Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust London, UK
- Correspondence to S C Stain , M Farquhar
Yes— Steven C Stain
The question of whether doctors should work 24 hour shifts has several aspects: are they harmful to patients, are they harmful to trainees, and are there benefits to trainees if they are going to be required to care for patients for 24 hours after completion of training?
In the United States, the question of 24 hour shifts resurfaced with the recent decision of the Accreditation Council for Graduate Medical Education (ACGME) to revise the requirements for all residency and clinical fellowship programmes they accredit.1 Although many changes were to improve the clinical learning environment related to patient safety and physician wellbeing, the modest change of allowing first year residents to increase their maximum limit of hours on duty from 16 hours to 24 hours received the most attention.
Since 2003, the council’s standards for residents’ hours of duty have been based on an 80 hour weekly limit. They have allowed 24 hour shifts (with additional time to transfer patient responsibility) except for interns, who had a 16 hour limit applied in 2011.2 The council’s comprehensive literature review on residents’ work hours and learning environment found that evidence on the effect on patient safety was inconclusive and that resident learning and the shortened work periods under the 2011 standards resulted in workload compression and increased resident stress and potential risk of burnout.3456
In response to these uncertainties, the American College of Surgeons, the ACGME, and the American Board of Surgery funded the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial, a prospective “non-inferiority” study comparing the ACGME 16 hour limits for interns with flexible duty hour policies (up to 24 hour limits per shift).7 The less restrictive duty hour policies (24 hour shifts) were not associated with an increased rate of 30 day mortality or serious complications (9.1% v 9.0%) based on data from 138 691 patients obtained from the American College of Surgeons national surgical quality improvement programme. This is the best evidence we have that 24 hour shifts do not adversely affect outcomes among surgical patients.
Effect on trainees
The effect of 24 hour shifts on trainees is uncertain. It is likely that trainees, especially during the most junior years of training, will be tired at some times during their shifts, but this may help prepare them for their patient care responsibilities as attending physicians. Longer shifts with appropriate supervision (direct or indirect) allow for optimal patient care and the maturation of the trainees’ clinical skills. The commitment to providing continuity of care when necessary is an important part of professionalism .18
Hypothetical discussions of working time limits often ignore the realities of physicians delivering patient care after they complete training. Optimal care immediately after operations may require care by the surgeon who operated on the patient—because he or she has a unique understanding of the relevant anatomy and what has been done. It seems unreasonable to expect a surgeon to work a 12 hour shift and then to have another surgeon come in and take care of any complications or reoperations when necessary. Attending physicians, or at least surgeons, therefore may need to be available for a 24 hour shift to provide the best care to their patients. The best time to learn how to manage fatigue and recognise fitness for duty is under supervision.
No conclusive evidence indicates that working 24 hour shifts negatively affects patient care, and it is important for residents to train in a supervised environment to prepare them for independent practice.
When asked how many hours’ sleep someone should have, Napoleon Bonaparte is said to have replied: “Six for a man, seven for a woman, eight for a fool.”
Sleep is essential. We evolved to be awake by day and asleep at night. Our physical and mental health depends on sleep. Most adults need 7-8 hours of quality sleep each night to allow optimal daytime functioning.
Deprived of sleep, fatigue and its consequences soon appear1: we become exhausted, achy, nauseous, less focused, more forgetful, more readily distracted. We feel more irritable, find it harder to deal with pressure, become less productive, and less able to analyse risk and complex situations or to perform tasks9; it becomes increasingly difficult to think clearly, quickly, and effectively. Risk of harm to ourselves and those around us rises.101112131415 Crucially, our sense of empathy fades.
For most adults awake for 16-18 hours, reaction times become impaired as if at the legal drink-drive limit.16 Effects of sleep deprivation rise rapidly. After 16 hours awake, every cell in your brain and body demands sleep. The longer sleep is denied, the more punishing that becomes.
Social folklore tells us “great people need less sleep.” Napoleon gave the impression that he thrived on much less sleep than an “ordinary” person and that anyone sleeping longer was weaker. The British prime minister Winston Churchill was often awake at night but used long daytime naps to compensate. And another prime minister, Margaret Thatcher claimed that four hours’ sleep was all she needed—probably true during a crisis, but at other times she slept much closer to the typical amount. It suited her to be perceived as being strong, better than those around her, functioning at a superhuman level. As so often with the great and the powerful, appearance and truth are often at odds.
Their stories persist in common misperceptions about sleep: that extraordinary people function safely, effectively—even better—with less sleep than their peers. A few people may genuinely need much less sleep than typical, but probably less than 1% of us. Most adults have a physiological necessity for regular sleep routines giving us at least six, and probably closer to 7-8, hours of sleep every 24 hours.
As doctors, we can be guilty of cultivating the illusion that we are extraordinary heroes routinely delivering outstanding care despite extreme pressures. The reality is that we are normal people—often asked to act in extraordinary ways to meet extraordinary demands, but normal people with normal needs and normal physiology that cannot safely be ignored.
Healthcare systems must be designed accordingly. Our NHS must provide healthcare 24 hours a day, seven days a week, 365 days a year. Our systems must support us as functioning human beings; they must acknowledge, not ignore, the limitations of our physiology and the effect fatigue has on us and on patient care and safety. Healthcare systems must smoothly handover patient care between well rested, optimally functioning teams, not rely on overtired, exhausted individuals to deliver the appearance, but not the substance, of continuity of quality care.
A policy of 24 hour shifts hits a double blow. It forces us to function sleepless for far longer than our brains and bodies expect to—functionally similar to working having drunk a few pints of beer.17 And it means we must work at night, a time of maximum physiological vulnerability,18 already lacking in sleep.
Proud of being masters of physiology, adeptly manipulating patients’ rhythms from illness back into health, we must also recognise physiology’s consequences on ourselves.
There is no shame in being ordinary, in acknowledging we have the same human needs as our patients for comfort, for rest, and for sleep. Without them we cannot function. The shame is in allowing systems to depend on us routinely being extraordinary because ultimately we—and they—will fail.
Should most doctors routinely work 24 hour shifts? No. Instead we must acknowledge sleep deprivation and fatigue have profound effects on us and the care we deliver to our patients, and encourage better strategies to deal with them.1920
Napoleon declared those who prioritised sleep were fools; we must send the opposite message and challenge the foolish thinking that we can routinely cheat our fundamental need for sleep without consequence.
Doctors’ hours in the UK
The European Working Time Directive reduces the working week to an average maximum of 48 hours and mandates 11 hours continuous rest a day and a right to a day off each week
Doctors can work longer hours by opting out of some of the directive’s requirements
Follow Michael Farquhar on Twitter @DrMikeFarquhar
Competing interests: Both authors have read and understood BMJ policy on declaration of interests and declare the following. SCS served as the chair of the ACGME residency review committee for surgery and on the ACGME task force that recommended changes to the ACGME common programme requirements.
Provenance and peer review: Commissioned; not externally peer reviewed.