Medical Interns Working Long Hours at Risk of Injury

Medical interns who work overtime and constantly are fatigued are at an increased risk for job-related injuries such as needlesticks and cuts, according to two studies in the Sept. 6 issue of the Journal of the American Medical Association (JAMA).

Exposure of the skin to contaminated fluids (percutaneous injuries or PIs) and lacerations are hazards interns face while doing their training. This potentially could result in the transmission of blood-borne pathogens, including hepatitis and human immunodeficiency viruses, and have significant occupational health implications, according to researchers.

Najib T. Ayas, M.D., M.P.H., of Brigham and Women's Hospital and Harvard Medical School, and colleagues examined the contributing factors for PIs in interns and assessed their relationship to extended-duration work.

From a total of 17,003 monthly surveys, 498 PIs were reported. Of these, 294 were due to lacerations from a sharp instrument (such as a scalpel), and 204 were due to a needlestick. Rates of injuries varied significantly, depending on type of residency. Interns in surgery and obstetrics/gynecology residency programs had the greatest risk because they perform more invasive procedures than other specialties, according to the report.

Lack of Concentration a Common Factor

The most commonly reported contributing factor to injury was a lapse in concentration (63.8 percent of the incidents), followed by fatigue (31.0 percent of the incidents). Percutaneous injuries were more frequent during extended work compared with non-extended work.

Extended work injuries occurred after an average of 29.1 consecutive work hours; non-extended work injuries occurred after an average of 6.1 consecutive work hours. The rate of PI was twice as high during the evening than during the day.

"The association of these injuries with extended work duration is likely due to the adverse cognitive effects of the sleep deprivation associated with such extended work, consistent with experimental data," the authors wrote.

"Given the potentially serious consequences of such injuries, implementation of safety measures designed to reduce the risk of these occupational injuries should be undertaken. The impact of comprehensive fatigue management programs on the risk of these occupational exposures should be evaluated," the researchers concluded.

Non-Compliance with Work-Hour Limits

A related study reported in the same issue of JAMA demonstrates that more than 80 percent of medical interns surveyed in 2003 and 2004 indicated they were working hours in excess of what currently is mandated.

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented work hour limits for all physicians-in-training (residents) in the United States. Each trainee is limited to a maximum of 30 consecutive work hours, a maximum of 80 weekly work hours, averaged over 4 weeks with 1 day in 7 (averaged over 4 weeks) free of all duties. These limits were developed in response to national concern with the long work hours of residents.

The study found that 67.4 percent of interns worked shifts greater than 30 consecutive hours. Averaged over 4 weeks, 43.0 percent reported working more than 80 hours weekly, and 43.7 percent reported not having 1 day in 7 off work duties.

Researchers of the study conclude that there could be several reasons why so many interns are not compliant with the mandated hours.

"First, the ACGME duty hour standards were unaccompanied by financial and technical support. Programs may not have the resources or expertise to redesign their schedules to the extent required. In addition, house officers are typically unwilling to depart precipitously at the scheduled change of shift when an emergent patient care situation demands their continued presence. Such situations are common in high intensity settings, yet most scheduling systems do not account for these commonplace emergencies," they write.

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