Navigating the Health Care System

The pilot who safely ditched the U.S. Airways jet into the Hudson River drew on years of skill, training, and sound judgment in the critical moments before landing.

Chesley "Sully" Sullenberger and his crew reacted calmly while facing potential disaster. The miraculous outcome drew attention to the pilot's skill and courage in an extraordinarily stressful situation.

One variable—limits on pilots' work hours—also played a positive, if hidden, role. To reduce the risk of error caused by fatigue, pilots cannot fly more than 8 straight hours, according to airline industry and Government rules.

Like piloting a jetliner, some medical situations, especially in the hospital, also have life-and-death consequences. You might be surprised to know that, until recently, doctors who train in hospitals, called medical residents, did not have limits on their work hours.

Before limits were put in place, some residents worked more than 100 hours each week. And a resident's day could last 36 hours or longer. Cases came to light showing that doctors who worked these long hours were more likely to make errors—sometimes very serious ones—when taking care of patients.

A weekly 80-hour limit for medical residents was put into effect across the United States in 2003. Unlike the work-hour limit for pilots, the rule for medical residents is voluntary. It also lets residents work up to 30 hours in a row as long as they do not take care of patients after they've worked 24 hours.

Nearly 6 years later, are we safe from the errors an overly tired medical resident might make?

Not likely, says a recent report from the Institute of Medicine (IOM). A year-long review found that residents still aren't getting enough time to sleep and require more protection of the 80-hour limit. The study was funded by my Agency, the Agency for Healthcare Research and Quality (AHRQ).

Specifically, the report found that many hospitals do not follow through on the 80-hour work limits. It also found that people aren't reporting violations of the rules to the agency that that oversees training programs. This is often due to residents' fear that reporting the hospital could hurt their careers.

In its recent report, the IOM described what it would take to protect residents from ongoing or serious fatigue. It said hospitals should allow residents to work only 16 consecutive hours when they are treating patients. After that, they should have an uninterrupted 5-hour sleep period.

Other changes called the IOM called for include:

• Increasing work-hour oversight: More reviews should be conducted to ensure hospitals follow the work-hour rules. Residents and others who complain that the rules aren't being followed should be protected.
• Providing days off: Residents should get a 24-hour break from duty each week and get one 48-hour break each month.
• Giving residents safe transportation after long shifts: AHRQ research has shown that residents who work extra-long shifts are more than twice as likely to have auto accidents.
• Training on better communications during handovers: Many errors happen when a patient's care is taken over by another doctor. If doctors work shorter hours, these handoffs will occur more often. Therefore, residents need better training on how to communicate with the new doctor and others about the patient's care.

I realize that patients can't tell how long their doctors have been awake or if their judgment is affected by fatigue.

What you or a family member can do is to take as much information as you can to the hospital. Bring a complete list of the medicines you are taking. That way, your medical team will have this information even if your doctor forgets to ask.

Don't be surprised if you see new people taking care of you, but don't be afraid to ask who's in charge of your care. As I always advise, ask questions.

For too long, our system of medical training has overlooked the risks that come when residents work extreme hours. That has slowly begun to change, but this change must continue.

I'm Dr. Carolyn Clancy, and that's my advice on how to navigate the health care system.

More Information

Agency for Healthcare Research and Quality
New Report Recommends Strategies to Reduce Medical Resident Fatigue-Related Errors and Improve Training
Press release, December 2, 2008
https://www.ahrq.gov/news/press/pr2008/iomrespr.htm

Agency for Healthcare Research and Quality
Check Your Medicines: Tips for Using Medicines Safely
https://www.ahrq.gov/consumer/checkmeds.htm

Agency for Healthcare Research and Quality
Questions are the Answer: Build Your Question List
https://www.ahrq.gov/questions/qb/

Accreditation Council for Graduate Medical Education
Duty Hours Language
http://www.acgme.org/acWebsite/dutyHours/dh_index.asp

Institute of Medicine
Resident Duty Hours: Enhancing Sleep, Supervision, and Safety
http://www.iom.edu/CMS/3809/48553/60449.aspx