Doctors at Risk


      Hospitals can be dangerous places. It's estimated up to 440,000 Americans a year die from preventable hospital errors, the third leading cause of death in the U.S.

      That risk can be exacerbated by doctors who are tired and more prone to mistakes.

      So why are some in the medical community pushing hard to work doctors on longer, more brutal shifts?

      There is a controversial study going on right now at 63 hospitals, including the University of Pennsylvania, Johns Hopkins and Yale University. The test subjects are hundreds of thousands of patients who have no idea they're in a study, and thousands of doctors who have little choice but to take part.

      Dr. Michael Carome: It's clearly unethical research. It's among the most unethical research I've ever seen, in fact.

      Dr. Michael Carome is a medical ethicist with the watchdog group, Public Citizen. He's talking about the controversial study, iCOMPARE. Funded with millions of your tax dollars, it's testing the endurance of young physicians to see, quite literally, do more patients die when their doctors work longer shifts?

      Carome: There is substantial evidence that residents who are sleep deprived, particularly first-year residents, make more medical errors and those medical errors can lead to harms and even deaths to patients.

      If it seems like a no-brainer, Carome says it is. He should know. He himself attended medical school and completed a residency.

      Sharyl Attkisson: So right now, there's no limit?

      Carome: There is a limit and the most stringent limit is for first-year residents, often called interns fresh out of medical school, and for those residents there is a maximum of 16 consecutive hours that they're allowed to work and that limit was imposed by the accreditation body in 2011.

      Yet in iCOMPARE, residents can be assigned to shifts that break the normal rules and far exceed the 16-hour limit. They may work up to 28 hours straight.

      Attkisson: So are the patients of the sleep-deprived residents being told, 'You're being cared for by somebody who isn't following the normal protocol?'

      Carome: No, they are not.

      The most egregious problem, Carome says, is that icompare violates basic tenets of human research: informed consent rules requiring that test subjects be told about and choose whether to take part in any research.

      Carome: There are actually two groups of subjects in this study. There's the patients of the residents and there's the residents themselves, and informed consent, which again is a fundamental ethical requirement for research like this, isn't being obtained for either of those groups. Now the residents, they know they're in the research because they're being told, but they don't have a choice. They're told, but it's not consent. They're forced to participate in the research. If they don't like being in the research, they can quit the training program and that would be very damaging to their career, so it's very coercive to them.

      Dr. Robert Klitzman is on the other side of this debate. He's a bioethicist at Columbia University Mailman School of Public Health.

      Dr. Robert Klitzman: There's a tension. On the one hand, we want to have doctors who are awake, but we don't want to have so many doctors coming and going and coming and going that there's gonna be a breakdown in care.

      According to Klitzman, patients benefit from doctors working longer shifts. Fewer handoffs mean continuity in care. He says it's not necessary to tell patients they're in the study, and being seen by doctors working outside the normal rules, because there's little risk.

      Klitzman: We want science to go forward that can help people and help their lives. But if sometimes to do that science, if you had to get informed consent from every single person and the study is minimal risk, that there's no more risk than there would be if you weren't in the study basically, that we say, 'You know what? In these cases, if we asked for informed consent, we're not gonna be able to do the study'.

      In other words, iCompare researchers assume sleepy doctors aren't more dangerous, so there's no reason to tell patients they're in a study to see if that's true.

      Carome says that's faulty circular reasoning and that unsuspecting patients at 63 hospitals are being put at "increased risks of medical errors and death".

      The issue of sleepy doctors has long been recognized. Current work hour limits were prompted by the case of teenager Libby Zion. She died at a New York hospital in 1984, under the questionable care of exhausted residents who routinely worked 36-hour shifts.

      And then there's the case of 15-year old Lewis Blackman, who had minimally invasive surgery at a South Carolina hospital. In this web video, his mother says numerous overtired residents and interns missed signs that medicine was eating a hole in her son's intestines after surgery. Lewis bled to death in the hospital.

      Helen Haskell: And he said, 'We lost him'. That made no sense to me. It didn't fit into anything, anything that we had understood. Five minutes before this happened they were still telling us he was fine.

      But even with modern limits on their hours, 80 hours a week and 16 hours straight, young doctors push the bounds of endurance. After a resident in Mexico was criticized for getting caught on camera napping at a hospital desk last year, others rushed to her defense. They posted images of themselves sleeping on the job during punishing shifts. Pictures like this one of Caro Leyva Santoyo, who's training in Mexico and spoke with us via Skype.

      Caro Leyva Santoyo: So it's pretty bad if you haven't sleep. You haven't eat. You haven't rest. How did you imagine my brain is going to work treating a patient like in the emergency room?

      Dr. Carome: There is substantial evidence in literature that tired residents are more likely to have motor vehicle accidents, are more likely to injure themselves while caring for patients, poking themselves with a needle that was maybe used to draw blood, and that can lead to blood-born infections like HIV, hepatitis being transmitted from a patient to the resident.

      Psychiatry resident David Harari and a colleague at the University of Washington, one site where iCOMPARE is underway, wrote this editorial in December. "Conducting this research without the informed consent of residents and patients violates the basic ethical principle of respect for personsAdequate sleep is a fundamental physiological need. No amount of caffeine, prescription stimulantsor 'alertness management strategies' can adequately compensate for acute and chronic sleep deprivation".

      Attkisson: Do hospitals save money if they keep doctors on the longer schedules? What's their motivation?

      Dr. Carome: Residents are the cheapest labor for these hospitals, and if you cut back on their hours, then you have to make that up somewhere to still deliver the same medical care and that obviously would be more expensive. So I think, unfortunately, financial cost and greed are one of the motivators here.

      iCOMPARE's lead researcher, David Asch of the University of Pennsylvania, declined our interview requests. The University has said in the past that, "patient safety is always our top priority" and "the study was designed and vetted by regulatory bodies, research review boards and established ethics panels".

      Even without knowing how this study will turn out, Klitzman thinks there's already enough evidence to favor longer shifts for doctors with fewer handoffs.

      Dr. Klitzman: If you were to ask people in a surgery, 'Do you want to have one doctor be the one who sees you from beginning or end, or doctors coming and going, each turning over the knife to the next one?', I think most patients would say they prefer to have one doctor.

      Not if he's on hour 28, says Carome.

      Attkisson: Some doctors, don't they wear those hours as a badge of honor? Sort of like, 'I did that when I was a resident. What's the big deal? I was fine.'

      Dr. Carome: We used to have pilots fly airplanes without sleep restrictions and that was deemed to be unacceptable, because we know that tired pilots are more likely to have to make mistakes that could lead to catastrophic crashes. The fact that medicine for years, maybe 100 or more years, has allowed doctors who are particularly trained to work almost unlimited hours, that doesn't mean that it's acceptable. Doctors are not physiologically different than other human beings. They're just like pilots. They're just like truck drivers and for some reason, you know, senior doctors think they're impervious to the effects of sleep deprivation and that's simply not true.

      Months ago, Public Citizen called for the study to be suspended immediately and asked for an investigation by the federal ethics body that oversees such matters, the Office for Human Research Protections, but it has taken no action. The study ends next month.