The Institute of Medicine's recommendations to ensure sleepy residents don't make medical mistakes could hurt rad residents' education and be costly, according to some radiologists.

An IOM report published at the end of 2008 suggested making changes to residents' on-duty workload, such as slashing late-night hours, to prevent fatigue-related errors. But in the January edition of the Journal of the American College of Radiology, researchers argue that some of the proposed changes, such as curbing night-shifts to no more than 2 or 3 a week, are "problematic."

The IOM, a respected scientific affairs group currently evaluating the FDA's medical device approval process, got tapped by Congress to find out if the current duty-hour limits set in 2003 by the Accreditation Council for Graduate Medical Education (ACGME), which monitors medical school and residency education, protected patients from the dangers of residents working long hours on little sleep.

The concern is that sleep deprivation could lead to serious, even fatal, medical errors. Although a randomized control study comparing long and shorter shifts mentioned in the December 2008 IOM report failed to turn up a significant difference in error rates, other studies have shown that the grueling long-hour shifts typical of residencies result in more failures of attention and more serious medical errors.

"Studies in residents have been limited," admits David Dinges, Ph.D. Dr. Dinges is a professor of psychology and psychiatry at University of Pennsylvania and an authority on sleep research who was a member of the committee that developed the IOM report. But the "scientific evidence the sleep field has built up over the last 30 years" is immense, he says: sleepy people make more mistakes.

"The overwhelming amount of data from non-medical areas, as well as medical areas, is that there is a risk from inadequate sleep and that needs to be mitigated."

Still, the IOM didn't find much fault with the current ACGME duty-hour guidelines, and didn't recommend federal oversight of the program, something called for by many observers.

Their recommendations, which largely left the ACGME rules untouched and which allow a maximum 80-hour workweek for residents, focused on ensuring residents had blocks of time in which to get adequate sleep and pay off their "sleep debt."

For this to happen, the IOM recommended that residents have at least one day off per week, not one day off per week as averaged out over a whole month, as in the current system. And they said that residents could work the 30-hour maximum shift length (which includes a hefty educational portion) only if there was a protected 5-hour sleep period between 10 p.m. and 8 a.m., and even then the amount of time devoted to direct patient care, as opposed to education, was cut.

Most relevant for radiology, the IOM wants to limit night-shift work, unregulated in the current system, to no more than four nights a week, with a mandatory 48-hour break after three or four nights of consecutive graveyard hauls.

NIGHT-SHIFT WORRIES

And it is these night-shift proposals that worry the authors of the JACR article.

They believe that demanding a two-day break for residents after consecutive night shifts could interrupt their education, and that with IOM recommendations for breaks, radiology residents might miss about 50 percent more educational material than under the current scheduling system.

"Every time you put them on nights [in the proposed system] that's a lot more days they're going to be off, and it also means they'll be away from the conferences," says Martha Maineiro, M.D., lead author of the JACR paper and an associate professor of diagnostic imaging at the Warren Alpert Medical School of Brown University in Providence, R.I. "We don't seem to think that makes any sense."

But Dr. Dinges stresses that night-shift work hits the body hardest, as daytime sleep is more difficult to get, leaving night workers burdened with a grogginess equivalent to jet lag.

"Most industries cap number of nights [someone can work], because you don't adapt to night-shift in a week. You have to live on it all the time to do it. In order to prevent serious build-up, you need recovery sleep," he says.

But Dr. Maineiro says many residents she has spoken with might actually prefer consecutive night shifts, precisely because they find it gets easier with time.

"The residents say the most difficult night shift is the first one or two, and they'd prefer a week of night floats," she says.

THE MONEY ISSUE

But one of the big concerns - and one freely acknowledged by the IOM - is figuring out who will pay for the changes.

In common with most specialties outside of the emergency room, major health centers' radiology departments are staffed with residents at night, Dr. Maineiro says. The cost of replacing them with doctors, or physician assistants, would be great. In the paper, Dr. Mainerio estimates the total costs of making the IOM changes to reach almost $1.7 billion, nearly 9 percent of the whole graduate medical education cost.

SUPERVISION FROM AFAR

IOM's report also called for more direct, on-site supervision of residents by attending physicians. While Dr. Mainiero agrees with the IOM that supervision is critical to prevent mistakes, she believes in radiology it doesn't have to be on-site.

"I think supervision is exceedingly important," she says. But "for radiology we wanted to clarify that supervision with teleradiology should be accepted as equivalent to the standard of having the physician in-house." Radiologists on-call from home or another medical center reading on a computer the slides sent by the resident offers nearly the same level of oversight as having the radiologist check the slides on a computer on-site, she argues.

NO CLOCK-PUNCHING

Another concern brought up in the JACR article hints at something more resistant to quantification, and perhaps closer to the heart of the profession, a worry that insisting on residents "clocking out" at a specific time could create a culture of time-serving or clock-watching hostile to the spirit of medicine.

"If you get residents used to a culture where their job ends at 5 o'clock or 3 o'clock, then you're not teaching them that as part of being a physician you have to put the patients' interest above your own. You have to look after the patient, if it means you stay a little later," Dr. Mainiero says. "[If you're not] adhering to a strict patient mentality, it's not good what you're teaching the next generation about what it means to be a physician," she says.

It could also result in "hand-off" errors, which a report in the New England Medical Journal noted in Dr. Mainiero's article argues are known to occur when a patient transfers out of a resident's or doctor's care at the end of a shift.

The IOM also acknowledges these errors exist, and recommends instituting structured hand-off procedures, as well as training residents in how to better pass along patients.

"Everyone pretty much admits in medicine that hand-overs are a risk, period," says Dr. Dinges. "That may be true, but fix hand-over. Make hand-over better."

NEXT STEPS

But whether any or all of these recommendations get adopted is up to the ACGME, which is still reviewing the IOM suggestions, after a congress was held this summer in which doctors and residents got to comment about the proposed changes.

"We expect in July their new recommendations," says Dr.Mainiero.

Whatever they choose, Dr. Dinges hopes the IOM report "will stimulate an ongoing dialogue, as opposed to entrenching positioning." And that doctors can work together to find out how to ensure that traditions of intensive training to produce the best doctors can be preserved, while also minimizing risks to patients - and the residents themselves - from lack of sleep.

"The evidence is the evidence," says Dr. Dinges. "If you come at the problem from the side where the suggested changes might produce more hand-over...risks and make less well-trained physicians, you can see why there would be an adamant response. But if you approach it from the other side - tired doctors making mistakes is not something I want to hear about."