American College of Physicians: Internal Medicine — Doctors for Adults ®


Despite new work hour rules, residents need more rest

Training programs try everything from seminars to free taxi services to help housestaff cope with lack of sleep

From the December ACP Observer, copyright 2004 by the American College of Physicians.

By Yasmine Iqbal

One morning when she was still a third-year pediatric resident, Judith Owens, MD, was driving home after her last night as a resident on call. She was bone tired, but that was normal—after all, allnighters are a hallmark of medical training.

But then disaster struck. As she drove through an intersection, she plowed into a car that had run a stop sign. Although no one was hurt and the other driver was clearly at fault, Dr. Owens felt she bore some responsibility.

"A normally alert driver could have avoided that accident," she said, realizing that she was anything but "normally alert" after a night on call.

While the accident was the first time Dr. Owens considered the correlation between sleep deprivation and unsafe driving, it certainly wasn't the last. Instead, the incident sparked a research career into sleep deprivation, with Dr. Owens spending the last several years studying how fatigue impairs residents' ability to function. She now chairs an American Academy of Sleep Medicine task force that focuses on sleep deprivation among residents.

Strategic napping can help you stay awake during the remainder of a long shift—if naps are taken at the right time and don't last too long.

Other researchers are likewise demonstrating how critical sleep is to a resident's performance. Two recent studies, for instance, found that residents working traditional shifts of 24 hours or more make substantially more errors than those who work fewer hours at a stretch and are thereby better rested.

New work hour rules issued last year by the Accreditation Council for Graduate Medical Education (ACGME) were meant to help protect residents against fatigue. But some experts say those rules need to be tweaked—and the tough-it-out culture of medicine needs to be changed—before sleep deprivation stops being a hazard to young physicians and patients alike. In the meantime, training programs across the country are implementing new techniques and requirements to keep residents either in bed or on their toes.

A rite of passage

Just about every physician associates residency with lack of sleep.

James Swiencicki, ACP Associate, chief resident at MetroHealth Medical Center in Cleveland, remembers falling asleep while writing progress notes. Alan W. Dow, ACP Member, a former chief resident and now a hospitalist at Virginia Commonwealth University Medical College in Richmond, Va., found that fatigue made it "harder to be a good listener and have quiet time with your patients."

And Christine Yeh, ACP Associate, a third-year resident at Barnes-Jewish Hospital in St. Louis, pointed out that lack of sleep can likewise cause problems outside the hospital.

"It really does affect your relationships," she said. "You're more impatient and easily irritated after a night on call."

Sleep deprivation—defined as getting less than four hours of uninterrupted sleep—has been associated with chronic health problems, depression and pregnancy complications. But it is its effect on patient care that is getting new scrutiny.

Two studies published in the Oct. 28, 2004, New England Journal of Medicine (NEJM) found that first-year residents working more than 80 hours a week made 36% more serious medical errors, had more attention lapses and were more fatigued than residents who worked 65 hours a week. The residents on shorter shifts were able to sleep almost six more hours a week.

Helping residents avoid mistakes was a big reason why ACGME issued new work hour rules in 2003. Those rules limited resident workweeks to 80 hours, averaged over four weeks, and daily shifts to no more than 24 hours.

But the new rules allow shifts to be extended by six hours, while programs can apply to extend workweek limits. (See "Work hour rules rile educators-and residents" in the October 2003 ACP Observer.) And, said Dr. Owens, "there's nothing to suggest that human beings can function well on an 80-hour workweek. That number isn't based on any real data."

In light of the NEJM studies, "continuing efforts to further refine the standards are needed," the ACGME said in a news release. In the meantime, physicians say that even if work hours were curtailed, the culture of medicine has made sleep deprivation an accepted part of medical training, akin to a rite of passage.

"There can be a social stigma attached to sleep deprivation," said Alon Avidan, MD, MPH, director of the sleep disorders clinic at the University of Michigan Medical Center in Ann Arbor. "The culture of medicine requires residents to be alert and awake at all hours of the day."

And residents themselves contribute to the problem by spending their limited downtime doing other things besides sleeping. According to Vineet Arora, Chair-Elect of ACP's Council of Associates and a former chief resident at the University of Chicago, "There's a saying among post-call residents: 'The hospital has already taken one day from you, so don't let them take two.' " After spending so many hours at the hospital, she said, residents "want to attend to their personal lives," not catch up on the sleep they sorely need.

New solutions

To protect both residents and patients, many hospitals have designed interventions to help residents leave the hospital to get some sleep or sleep more when they're on call. The University of Chicago, for instance, has installed bedside lamps in all call rooms, allowing residents to stay in bed while they read their pagers. Those rooms have also been equipped with computers so residents can quickly get back to bed after they check lab results or other data.

"The changes were a big upgrade, and welcomed," said Dr. Arora, who studied sleep deprivation among residents at the University of Chicago. The hospital has also asked nurses to use alphanumeric pages when paging residents on call and to save all nonurgent messages for the morning.

To help residents get home to bed at the end of their shifts, chief residents at Chicago's Loyola University Medical Center keep tabs on post-call residents, offering help if they're running behind, said Brian J. Hertz, ACP Associate, a third-year resident. The hospital has also cancelled clinics on post-call days.

Several training programs, including those at the University of Chicago and Cleveland's Case Western Reserve University, offer free post-call taxi services to tired residents. At Case Western, internal medicine residents have used the service more than 340 times since it was launched two years ago. But, Dr. Owens pointed out, not all residents can tell when they're too tired to drive.

"I don't know if I would have taken a ride service on the day of my accident," she said. "After all, I had made the drive many times before."

To help residents detect when they're impaired by fatigue, Virginia Commonwealth University has created a lecture series that addresses residents' problems with sleep deprivation that is mandatory for all internal medicine housestaff, said Edmond Wickham, MD, a former chief resident. Faculty also discusses fatigue issues with residents one-on-one during evaluations, and the hospital is using more housestaff, including 10 hospitalists, to help share duties with residents.

And residents at Case Western must complete the Sleep, Alertness and Fatigue Education in Residency (SAFER) program, developed by the American Academy of Sleep Medicine in 2003. The program includes a one-hour slideshow and covers the science of sleep, sleep misconceptions, good sleep habits and effective ways to stay awake. (Information on the program, which is being used by more than 400 hospitals, is online.

"I think SAFER best addressed the problem of the culture of medical training," said Ena Andrews, MD, a pediatric neurology fellow at the University of Michigan Medical Center who attended a SAFER presentation put on by Dr. Avidan. "Seeing that the sleep patterns of some residents mimic that of narcoleptics really drove home the point of the severity of the problem."

At the same time, experts urge residents to find healthy ways to both stay awake and go to sleep. Here are some tips they offer to avoid sleep deprivation:

  • Make sleep a priority. Most adults need seven to nine hours of sleep a night to function optimally. But many residents think they can adapt to less sleep, which just isn't true. Similarly, you can't "pay back" a sleep debt, said Dr. Avidan. "It's not like owing money to the bank. The effects of sleep deprivation are cumulative, and they get worse over time."

    Experts recommend preparing for a long shift ahead by getting enough sleep the night before. Also, practice healthy sleep habits, such as adopting a pre-sleep routine and avoiding heavy meals or strenuous exercise within three hours before bedtime. (More sleep tips are available online.

  • Learn to recognize the signs of fatigue. According to the SAFER program, performance starts to decline after about 15 to 16 hours of continued wakefulness. You are also less alert between 6 a.m. and 11 a.m. after being up all night. Red flags include irritability, trouble focusing, and checking and re-checking work.

  • Give yourself time to recover after call and adapt to new shifts. The SAFER program claims that it takes two nights of extended sleep to restore baseline alertness and recover from on-call sleep loss. It also takes at least a week for circadian rhythms to adjust after switching from a day to a night shift.

  • Shift forward. It's usually easier to stay up later rather than get up earlier, Dr. Owens said. If you have to change shifts, try moving forward in the day, from afternoon to night, for example.

  • Nap strategically. Many residents are reluctant to nap. Dr. Yeh of St. Louis' Barnes-Jewish Hospital recalled interns who wouldn't even sit down after a night on call for fear of falling asleep. But naps can be effective fatigue-fighters, as long as they're taken at the right time and don't last too long.

    According to Dr. Avidan, napping strategies should include "prophylactic" naps before work. If possible, schedule sleep to take advantage of those times in the circadian cycle when you tend to feel the most sleepy. For most people, that means between 3 p.m. and 4 p.m. and in the very early morning, after 3 a.m.—optimal times for a short nap.

    If you can't hit those windows of opportunities, experts recommend napping whenever possible, as some sleep is better than none at all. It's best to nap in a quiet environment and for no more than 30 minutes to avoid entering a deep sleep. If you need to recover from sleep inertia—a brief period of grogginess that can last between 15 and 30 minutes—a small cup of coffee may help.

  • Use caffeine wisely. "Caffeine is the universal elixir," said Dr. Arora. But it may have diuretic effects, and it has a half-life of seven hours. Experts recommend moderate, strategic consumption, while a study in the May 2004 issue of Sleep claimed that frequent, low doses of caffeine (about two ounces of coffee) may be more effective for staying alert than larger, less frequent doses.

    A small cup of coffee might help you recover from a nap or to stay awake for the drive home. But drinking large amounts during the day can stop you from getting to sleep later. Obviously, stimulants such as nicotine and alcohol won't induce sleep.

  • Be aware of light. Bright light can cue the brain to stay awake, so get as much light exposure as possible to stay alert. Conversely, Dr. Owens suggested, wearing dark glasses can help you avoid being stimulated by light during the drive home.

  • Don't drive while drowsy. Getting a ride is the best solution, but if that's not possible, take a nap first or drink coffee. Pull over and take a nap if necessary.

  • Get educated. The ACGME requires hospitals to provide education on sleep deprivation and fatigue. Online programs are convenient, but Dr. Avidan said he believes information is most effective when presented by a sleep expert, who can also serve as a counselor.

    "Many residents are embarrassed to discuss these issues openly," he said.

  • Devise your own tricks to stay alert. Dr. Dow found it helpful to run up and down flights of stairs, while Dr. Swiencicki swore by a shower after a long night. Dr. Yeh said she's revived by a cold drink, not a hot cup of coffee, while Dr. Hertz just tries to keep moving to stay awake.

But none of these strategies can replace your need for sleep. Residents, said Virginia Commonwealth's Dr. Wickham, must take care of themselves before their patients. "And don't be afraid to ask for help if you're stretched beyond what you can do."

Yasmine Iqbal is a Philadelphia-area freelance writer specializing in health care.


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