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Medical interns report long hours, percutaneous injuries at work
Even after mandated duty-hour reductions, many interns continue to work more than 80 hours per week.
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Physicians in their first year of training are subject to working long and grueling hours. Various researchers have closely assessed the consequences associated with an extended workday and sleep deprivation.
In two reports that appeared in the Journal of the American Medical Association, researchers discussed how an intern’s lifestyle could put them — and potentially their patients — at risk.
Working long hours, especially overnight, can lead to injuries among interns. “Interns commonly reported percutaneous injuries, with an increased risk associated with extended work duration and nighttime work,” said Charles A. Czeisler, MD, PhD, of the department of medicine at Brigham and Women’s Hospital and Harvard Medical School, both in Boston.
The most significant contributing factor to injury was fatigue, which was more common among interns who worked an overnight shift than among interns who completed a daytime shift.
Exposures to contaminated fluids from percutaneous injuries are serious hazards associated with postgraduate medical training. Consequences of percutaneous injuries include the transmission of blood-borne pathogens, including hepatitis and human immunodeficiency viruses, according to one report.
Czeisler and colleagues theorized that sleep deprivations possibly contributed to these occupational hazards. To test their hypothesis, they contacted medical students from the National Residency Matching Program to participate in a survey. The monthly survey contained detailed questions about work hours, sleep, work rotation during the month, days off and number of extended-duration work shifts. The survey also asked interns to indicate whether they had experienced an occupational exposure to potentially contaminated blood or other body fluids. A total of 2,737 interns completed the survey.
Participants who reported a hazardous exposure filled out another survey that elicited further details of the incident. Incidents that were not accompanied with these specifications, such as the location and time of exposure, were not included in the analysis.
Of the surveyed interns, 192 completed daily work diaries where they reported their work hours and extended-duration work shifts.
Reporting injuries
During the study interval, the interns reported 1,551 exposures to contaminated body fluid, 1,051 of which were not percutaneous injuries. The majority of the incidents that were not percutaneous were splashes, according to the study.
Czeisler and colleagues identified 498 documented percutaneous injuries: 294 were due to lacerations from sharp instruments and 204 were the result of a needlestick. Although the rate of injury was about 0.03 per intern-month (P<.001), the rates of injuries varied according to residency specialty.
Interns working in obstetrics/gynecology, surgery and pathology reported percutaneous injuries at rates of 0.10, 0.07 and 0.05 per intern-month, respectively. Interns working in psychiatry, internal medicine and pediatrics, on the other hand, experienced injuries at a significantly lower rate, compared with the mean rate.
Fifty-eight percent of interns reported their injuries to the occupational health department. Interns in obstetrics/gynecology were most likely to report injuries compared with the mean rate. Interns in internal medicine were least likely to report such incidences.
About 64% were a result of lapses in concentration, the interns indicated in the surveys. Other common reasons for injuries were fatigue, an exposed sharp instrument and unexpected patient movement, according to the participants.
Extended-work hazards
The researchers performed a case-crossover analysis to assess the relationship between percutaneous injuries and work duration.
Extended-work percutaneous injuries followed overnight work and occurred after a mean of 29.1 consecutive hours of work (95% CI, 27.8-30.4). Percutaneous injuries that did not take place following an overnight shift occurred after a mean of 6.1 consecutive hours at work (95% CI, 5.4-6.9).
“Extended-work percutaneous injuries were significantly more likely to be associated with fatigue as a contributing factor [44%],” Czeisler said.
Next, the researchers compared overnight injuries with daytime injuries. Interns were working an average of 10 consecutive hours before reporting a daytime injury vs. 17.5 consecutive hours preceding an overnight injury. The risk of percutaneous injury was twice as likely to occur overnight than during the day (OR=2.04; 95% CI, 1.98-2.11). Fatigue was more commonly a contributing factor to injury for interns who had worked an overnight shift vs. those who worked during the day (P<.001).
Mandating reductions
In another study, Christopher P. Landrigan, MD, MPH, one of Czeisler’s colleagues at Brigham and Women’s Hospital and Harvard Medical School, found that, although the Accreditation Council for Graduate Medical Education reduced intern work hours in 2003, interns have not complied with the new requirements.
The ACGME mandated that each trainee be limited to a maximum of 30 consecutive work hours, with a maximum of 80 weekly work hours, averaged over four weeks. The ACGME required that each intern have an average of one day off per seven days worked.
Landrigan and colleagues decided to assess interns’ compliance with the ACGME regulations. They began collecting work-hour and sleep data from medical trainees through the Harvard Work Hours, Health and Safety program. They created a survey to determine whether first-year interns were complying with the ACGME’s work-hour requirements.
The 1,278 interns who participated in the study provided monthly data during their intern year. Survey items asked interns to describe hours spent working or studying outside of the hospital, classroom or workplace; hours of sleep at the hospital, classroom or workplace; and hours of sleep outside the hospital, classroom or workplace.
Other survey items asked interns to report number of days off; numbers of extended shifts, defined as at least 24 hours of consecutive work; the average length of an extended shift; and the average hours of sleep during an extended shift.
A subset of participants completed daily work diaries to supplement the survey data. The work hours reported in the diaries closely matched the survey data (P<.001), Landrigan said.
Marginal improvements
In 2004, one year after the ACGME released its duty-hour regulations, about 84% of the interns participating in the study reported hours that did not comply with the standards for at least one month. Throughout the year, however, monthly rates of noncompliance steadily decreased.
“Our results are notably different from those of the ACGME, which found in its national survey of residents that only 3.3% were noncompliant with the 80-hour rule,” Landrigan said.
Of the 707 residency programs represented in the survey, interns from 85% reported violations. There were 346 hospitals represented in the survey: Interns reported errors from 91%.
New York State and Puerto Rico have laws enforcing resident work limits, Landrigan said. As a result, both New York and Puerto Rico reported fewer violations than hospitals from other states or commonwealths, though rates were still high: 88% vs. 92% (P=.02). For all interns, work hours decreased from an average of 70.7 hours per week to 66.6 hours (P<.001).
After the implementation of the ACGME regulations, interns reported increases in sleep from 5.91 hours to 6.27 hours per night (P<.001). Sleep during overnight shift, however, decreased from 2.69 hours to 2.57 hours (P<.001), according to the survey data. – by Rebekah Cintolo
For more information:
- Ayas NT, Barger LK, Cade BE, et al. Extended work duration and the risk of self-reported percutaneous injuries in interns. JAMA. 2006;296:1055-1062.
- Landrigan CP, Barger LK, Cade BE, et al. Interns’ compliance with Accreditation Council for Graduate Medical Education work-hour limits. JAMA. 2006;296:1063-1070.