Ontario lags in shortening residents’ shifts
MDS asked to defy sleep cycles by working up to 24 hours in a row; Quebec’s cap is 16
MONTREAL— How long has the bleary-eyed medical resident treating you at the hospital been working?
Ontario has laws to ensure the trucker hurtling along beside you on Highway 401 has been driving for no more than 13 hours, but the frontline doctor-in-training most likely to be prescribing your cocktails of drugs, sleuthing your mystery symptoms or slicing you open can work for up to 24 hours at a stretch before taking mandatory time off.
In medical parlance, it is known as “call duty.” When duty calls, medical tradition holds that doctors sacrifice their families, leisure time and, in some cases, personal safety to treat patients. Like all traditions, it may soon be a thing of the past.
Thank the Fédération des médecins résidents du Québec, the union that represents the province’s medical residents. One of its members filed a complaint in 2007 that being forced to work 24-hour shifts violated his Charter rights “to life, liberty and security of the person” as well as similar rights under the Quebec Charter.
An arbitrator ruled in the student’s favour in 2011 and gave the province a year to overhaul the scheduling and systems that have been used to train the province’s doctors.
New rules putting a 16-hour cap on residents’ shifts came into effect on July 1 this year. So far, the big change is the resentment, frustration and the rash of new fault lines that have emerged in Quebec hospitals.
The province is now the lab rat for institutions across Canada eyeing similar changes. One Health Canada project set to end in next March is looking at how to create a “panCanadian consensus” on duty hours for residents. The Canadian Medical Association and the national association of medical residents and internists have endorsed the changes, which many now say are inevitable.
The problems may also be impossible to avoid.
“There’s some try and miss that we are experiencing at this time,” said Dr. Charles Dussault, president of the FMRQ. “But we aren’t experiencing any problems in terms of patient care, because that is for sure doing better.”
Others are not so sure. The shortened shifts have given rise to a dangerous game of broken telephone where sometimes vital information can slip through the hands of residents as they pass patients over to a replacement at the end of a shift.
“I’m hoping that patients will get better care, but I don’t think we can show that yet,” said Dr. Thomas Maniatis, the head of the internal
“We’re never going to be able to engineer a human that doesn’t need to sleep in a 24-hour period.” DR. CHRISTOPHER MCCOY MAYO CLINIC STUDY AUTHOR
medicine training program at McGill University. “My hope is that we reassure people by showing that they get at least equivalent care.”
The wave of reforms to control the hours that a medical resident can work in a single shift started with a tragic ripple — the death of young Libby Zion in the New York Hospital on Oct. 5, 1984.
Admitted with a fever and body spasms the night before, her care as well as the care of 40 other patients on the ward, fell to two residents. Both were deep into a 36-hour shift.
She was prescribed the painkiller and sedative meperidine. When that drug mixed with the phenelzine, an antidepressant prescribed by her family doctor, Zion’s temperature spiked to107 degrees and she suffered a cardiac arrest. Her death launched a crusade by her father, a lawyer and journalist, which led to a grand jury hearing where murder charges were put aside but a stinging criticism of residents’ working hours stuck. In 1989, New York State mandated a maximum 80-hour work week for residents. In 2003, the standard went nationwide. Other countries have followed suit. New Zealand caps the work week for medical residents at 72 hours with maximum daily shifts of16 hours, Britain and France won’t let them work more than 48 hours a week, with respective 13- and 10-hour work days and Denmark limits shifts to 16 hours with no more than 37 hours worked over a seven-day period. But Canada remains one of the few western nations yet to adopt the stricter rules. Even those provinces that normally schedule 12hour shifts, like Alberta, can end up with residents working on call and logging much longer hours.
The idea behind the marathon shifts is for residents to experience the full stress of caring for the ill and injured in the critical early hours of treatment.
Proponents say residents come out of it better prepared for the unpredictability of the real world of medicine. Some consider it a right of passage.
In Quebec, the new rules have exposed a generational divide.
Most of the resistance has come from oldschool physicians who think residents have it too easy, said Dussault, a fourth-year cardiology resident at the Université de Sherbrooke.
“At some point, they all did 72-hour (shifts) and felt it was perfectly fine. They cut down from 72 to 36, saying that 72 was crazy. Then they went from 36 to 24 and now most people say that 36 was way too much,” Dussault said.
“And I do believe that 10 years from now we will say that 24 hours was completely ludicrous to accept in 2012.”
Quebec’s residents haven’t reported a life of ease since the new shift rules came into effect.
“What we’re realizing is that there are other problems that surface,” said Dr. François Caron, a fourth-year internal medicine resident at Université de Montréal, who is conducting a study to gauge the success of transition.
“There are many residents who find that their lives are more difficult now than before.”
To ensure both shorter shifts and exposure to real-live patients, residents’ lives are now consumed by the commute to and from the hospital.
Aone-month trial of16-hour shifts conducted at Minnesota’s Mayo Clinic in 2009 foreshadowed Quebec’s problems. Participants emerged feeling less prepared to hand off patients at quitting time. Those working nights were missing important teaching sessions. They complained they were coming and going from the hospital too frequently, often with fewer than 10 hours between shifts.
Despite the problems, the hospital instituted 16-hour shifts in 2010. The bugs are still being worked out, but Dr. Christopher McCoy, who conducted the 2009 study, said the hospital’s focus has been on building better systems to communicate patient information between doctors rather than on asking doctors to defy sleep cycles.
“The reality is we can engineer . . . better ways to make sure information doesn’t get dropped, whereas we’re never going to be able to engineer a human that doesn’t need to sleep in a 24-hour period,” said the instructor of internal medicine at the Mayo Clinic.