Medical residents at McGill University Health Centre (MUHC) in Montreal will no longer have to work 24-hour shifts after an arbitrator ruled their collective agreement violated both the Canadian Charter of Rights and Freedoms and the Quebec Charter of Human Rights and Freedoms.
The grievance was filed in March 2009 by Alain Bestawros, former president of the Association of Residents at McGill, who claimed his health, safety and physical integrity were at risk during on call duty at the hospital — so he sought to have the shift reduced to 16 hours.
Bestawros claimed the longer shifts provided fragmented opportunities to sleep and he was slower physically and cognitively towards the end of the shift. The exhausting conditions meant he sometimes had trouble taking notes, became irritable, committed errors and hesitated to use techniques for fear of applying them incorrectly, he said.
Other residents spoke of problems such as headaches, nausea, leg pain, low blood pressure, diminished concentration, difficulty remembering common knowledge and fatigue driving home after work.
“It is clear to me that a condition of employment exposing a doctor to greater risk of physical or mental injury for himself, higher risks of errors, incorrect diagnoses and even causing injury to individuals when his mission is to take care of them is an unfair, unreasonable condition of employment,” said Jean-Pierre Lussier, arbitrator at Quebec’s Conseilconsultatif du travail et de la main-d’oeuvre.
And the MUHC agrees, according to Eva Sidorowicz, director of professional services at the centre.
“We do believe that there is an issue and that we need to look at different ways of organizing our residents, she said. “The evidence is quite strong that long periods of sleep deprivation are not ideal.”
For that reason, it’s likely this kind of enforcement will spread to other parts of Canada, she said.
“A lot of other provinces are looking at what’s happening in Quebec with greater interest,” said Charles Dussault, president of the Fédération des médecinsrésidents du Québec in Montreal. “We do expect some other provinces to go in this direction at some point.”
The decreasing of shift hours has been an evolution that began years ago when 72 hours was allowed, he said.
“Medical culture is anchored in profound traditionalism so we need to fight even harder, because it’s not founded on rational arguments.”
Not getting enough sleep can have significant ramifications on physical and psychological functions, said Roger Godbout, professor of psychiatry at the University of Montreal and head of the sleep laboratory and clinic at Rivière-des-Prairies hospital.
“You cannot compress sleep, like you cannot compress your daytime,” he said. “There was a point where we didn’t take sleep seriously. Now we know all of this, there’s no way it should go on.”
After a certain threshold, about 14 to 15 hours, the probability of falling asleep increases, said Godbout. And if a person has a bad night’s sleep, it can lead to irritability, impulsivity, difficulty planning and a lack of concentration, memory and discernment. It also becomes difficult to exercise sound judgment.
Going 24 hours without sleep leads to a weakening of faculties equivalent to 10 mg of alcohol per 100 mL of blood, according to Charles Czeisler, a professor at Harvard Medicine School in Boston, who spoke at the arbitration.
Studies have shown after a 24-hour shift there are 36 per cent more major errors than a 16-hour shift, he said, and 5.6 times as many diagnostic errors.
Canada’s limits on shift length differ from other countries, according to Czeisler. In New Zealand, there is a limit of 16 hours for residents; in Europe, they cannot work longer than 13 hours; and in the United States, there is no legal limit but residents can work no more than two 30-hour shifts and 80 hours per week.
Even a person who works night shifts regularly and gets a regular amount of sleep during the day is going to be challenged by our circadian rhythm, which has our biology slowing down over the midnight hours, said Cam Mustard, president of the Institute for Work and Health in Toronto.
“Human performance is less optimal during the night if we’re asked to be wakeful and attentive and it also declines if we’re expected to work for a shift, because it seems to show up at about the ninth or 10th hour. People’s concentration begins to decline, their alertness begins to decline.
“So, by and large, do we give enough attention to this risk of decline in human performance across occupations when we think about how many hours people are working? Probably not, frankly.”
Challenges to breaking the 24-hour cycle
However, several residents at the arbitration spoke out against reduced hours, saying errors often happen during
sign-overs — the transfer of information between work teams — so if there are additional sign-overs, there will be a higher probability of more errors of omission.
A surgeon should also get used to working long hours and a reduction in residents’ call duty would reduce work hours and, therefore, experience, said others.
But it is only speculation a 16-hour shift would have a negative impact on training, said the arbitrator, and pilot projects show residents can still accumulate the same number of hours.
“The evidence did not convince me… that working a maximum of 16 hours in a row would be less effective than working 24 straight hours.”
The quality of training and safety of patients is also the union’s main objective, said Dussault. And in conceiving 16-hour models, the same amount of training hours would result.
For the past year-and-a-half, the internal medicine department at MUHC has been transforming how resident shifts are organized, said Sidorowicz. The residents do not work more than 16 hours and there is a day team along with a night float system that has residents doing a series of nights instead.
But the main challenge is continuity of care for patients, she said.
“You have to make sure when you set up the system that there is enough of an interface between the day shift and the night shift, so a proper hand-off can occur.”
That is one of the reasons MUHC has filed a disagreement with the arbitrator’s decision, requesting an extension of the six-month deadline it was given to change the residents’ schedules.
“The other concern is to make sure that pedagogically we have rotations that remain sound,” said Sidorowicz, which means making sure any resident doing nights also learns as much as his colleagues and has the ability to interact with them.
Changing the culture is a whole other issue. People get used to working a certain way, she said.
“You have to change people’s mindsets.”