Residency Overwork and Changing Paradigms of Service

In this issue, Green [1] reviews key issues in residency overwork, including the effect of overwork on patients, on the residents themselves, and on the hospitals that sponsor the residents' training. He concludes that residency overwork is both prevalent and harmful and that the most persuasive argument against long hours is the negative effect they have on the professional and personal growth of residents at a critical time in their development.

Green reviews several studies that either support or reject the thesis that overwork harms patients. These studies include indirect measures of performance among sleep-deprived and rested residents and self-reported survey results attributing important clinical mistakes to fatigue [2, 3]. Green points out that, conflicting conclusions notwithstanding, intuition suggests that an exhausted physician does not function as effectively as a rested colleague. I agree. Most of us can probably identify many substantial mistakes we have made while caring for patients that resulted from inordinate fatigue. Mistakes of greatest concern, such as a preventable death or a permanent disability, are not likely to be shown by analytical studies. As with the relation between chloramphenicol and aplastic anemia, in which the risk for the disorder with any given dose of the drug is low, uncommon events like these are usually recognized by anecdote.

The issue of whether sleep deprivation harms patients may be moot. Patients trust their physicians and expect physicians to treat them effectively and safely. As with airline pilots, the public can understand and accept …