Marathon 24- to 26-hour doctor shifts may be unsafe for patients: experts
While many countries impose strict limits on shifts for doctors in residency, Canada lags behind
The shifts that doctors in their residency work in Canadian hospitals are some of the longest in the world and may be unsafe for patients, a Marketplace investigation reveals.
Pilots, truck drivers and bus drivers in Canada are not allowed to work for more than 13 or 14 continuous hours. But many of Canada's 12,000 resident doctors may be working almost twice that, between 24 and 26 hours, according to guidelines in several provinces.
Some experts believe this poses a serious risk to patient safety as it can impair judgment, reflexes and decision-making — and can ultimately lead to mistakes.
- For more, watch the Marketplace report, Tired Doctors, this Friday on CBC Television at 8 p.m. (8:30 p.m. NT) or online.
- CBC Forum | How Can Doctors' Shifts Change To Best Serve Patients?
Sleep deprivation, which may occur if you work too long or sleep too little, can have a number of marked effects on the brain.
"We know that when people are awake for 24 hours, their neurobehavioural performance is as impaired as if they were legally drunk," says Dr. Charles Czeisler, a senior physician who specializes in sleep research at Brigham and Women's Hospital in Boston.
Marketplace investigated the effect that long shifts could have on patient safety. Working with the Western University's Brain and Mind Institute, Marketplace conducted sleep-deprivation tests on cognitive functions like decision-making and reaction time.
'There's more risk'
A 2012 report by the Resident Doctors of Canada found that more than 80 per cent of residents surveyed say fatigue compromises the quality of care they give patients.
Czeisler's research found that residents who worked several long shifts a month reported 300 per cent more fatigue-related medical errors that resulted in a patient's death. And those who worked shifts longer than 24 hours made 460 per cent more serious diagnostic mistakes compared to when they worked shorter shifts.
It's a reality that concerns some doctors.
"The longest I've ever been awake working at the hospital would have been close to 30 hours" says cardiologist Dr. Christopher Labos about his time working long shifts as a resident in Montreal. "That's at work, trying to make sure people don't die. Thirty hours."
"There's more risk of making a mistake."
Labos, alongside resident Dr. James Yan and Marketplace's David Common, underwent sleep-deprivation tests at Western.
Quebec takes action
While a resident in Montreal, oncologist Dr. Alain Bestavros says he was afraid that his long shifts might lead to medical errors.
"I remember very clearly being scared and worried about making mistakes," he says. "I remember second-guessing myself constantly."
In 2007, Bestavros challenged the legitimacy of marathon shifts when he worked at McGill University's teaching hospital, arguing long hours violate the Canadian and Quebec Charters of Rights and Freedoms.
"I think most residents had experienced these very prolonged shifts at the edge of sleep deprivation," he says.
In 2011, the province agreed, and Quebec became the first and only province to limit shifts to 16 hours.
Not as simple as shortening hours
The United States, New Zealand, and the European Union have all imposed limits on doctors' shifts, but Canada does not have national guidelines that regulate resident duty hours.
Some countries have changed their policy after overwork and exhaustion led to preventable medical errors. In 1984, the death of 18-year-old Libby Zion in a New York hospital triggered a worldwide re-evaluation of how long doctors should work.
However, in Canada, where duty hours are negotiated at a provincial level and between labour unions at a regional level, many residents report they often work shifts as long as 30 hours.
Simply shortening shifts will not lead to better patient care, says Dr. Kevin Imrie, president of the Royal College of Physicians and Surgeons of Canada and co-chair of a steering committee on resident duty hours.
The steering committee looked at the problem of resident shifts in 2013 and found that strategies, such as managing the risk of fatigue, are a better solution than limiting shift lengths.
The panel found while 26-hour shifts are too long, caps aren't the answer.
"There is a risk if you reduce the shift length and do nothing else, that you can simply make residents work harder, which is also a source of significant fatigue," says Imrie. "A tired doctor is not necessarily an unsafe doctor."
Shortening a doctor's shifts increases the number of times that doctor has to hand a patient's case over to someone else, Imrie says, which can increase the risk of something going wrong.
Right to know?
But better handovers can be managed, argues Czeisler — for example, with checklists.
He also says patients should be told if their doctor hasn't slept.
"No one would argue that a patient doesn't have a right to know if they're going in for an elective surgical procedure that their physician is drunk," he says.
"By that same token, I think that if a physician hasn't slept in the previous 24 hours, a patient has a right to know. They may have been planning for six months to have a back operation or some other elective procedure; they don't have to necessarily have it at that moment."
- Based on a Marketplace investigation by Andreas Wesley, Tyana Grundig, Ghazala Malik and David Common.