Library of Academic Literature on Sleep and Fatigue

This area is reserved as a library of selected references to the academic literature related to work hours issues.

BEST PRACTICES

Articles describing Best Practices can be found at Hours Watch.

EFFECTS OF SLEEP LOSS

Barger L, Cade B, Ayas N, Cronin J, Rosner B, Speizer F, Czeisler C. Extended Work Shifts and the Risk of Motor Vehicle Crashes among Interns. N Engl J Med 2005;352(2):125-134.

• Corroborating earlier studies, this paper demonstrates that the odds of reporting a motor vehicle crash or near crash was increased for residents after an extended shift compared to shifts that were not extended. More importantly, it demonstrates that this effect is seen for residents who work within the ACGME guidelines, which allow for shifts of over 24 hours, leading to the conclusion that the current guidelines still puts residents at risk.

Parshuram C, Dhanani S, Kirsh J, Cox P. Fellowship training, workload, fatigue and physical stress: a prospective observational study. CMAJ 2004;170(6):965-70.

• Physiologic measures of stress (ketonuria, dehydration, arrhythmia and heart abnormalities) were detected in 11 senior fellows at the Hospital for Sick Children in Toronto. The study suggests that even within currently accepted Ontario work hour guidelines physical stress and sleep deprivation are common.

Papp K, Stoller E, Sage P, Aikens J, Owens J, Avidan A, et al. The effects of sleep loss and fatigue on resident-physicians: a multi-institutional, mixed-method study. Acad Med 2004;79(5):394-406.

• 84% of residents who completed the Epworth Sleep Scale scored on a level for which clinical intervention for sleep disorder is indicated. Most residents indicated that sleep loss and fatigue had major impacts on personal life and ability to perform work. Resident perceptions of sleep loss and fatigue are highlighted, including the negative effects of fatigue on professionalism.

Van Dongen H, Maislin G, Mullington J, Dinges D. The cumulative cost of additional wakefulness: dose-response effects on neurobehavioral functions and sleep physiology from chronic sleep restriction and total sleep deprivation. Sleep 2003;26(2):117-26.

• Chronic sleep restriction of 6 hrs or less per night produced cognitive performance deficits equal to 2 days of total sleep restriction. Subjective sleepiness ratings indicated that subjects were unaware of increasing cognitive deficit, meaning that subjects often did not realize that their performance was impaired.

Baldwin DC Jr , Daugherty S, Tsai R, Scotti MJ Jr. A national survey of residents' self-reported work hours: thinking beyond specialty. Acad Med 2003;78(11):1154-63.

• This national survey conducted in 1999 correlated work hours with a variety of measures. Average work hours for PGY1 residents was 83, versus 76.2 for PGY2. Total work hours significantly correlated with perceived levels of stress, total sleep hours, satisfaction with learning, inadequate supervision, working while ill, observations of self and others working in an "impaired condition," and perceptions of humiliation and belittlement. Residents working more than 80 hours a week were more likely to be in a personal accident or injury, a serious conflict with other staff, and make a serious medical error.

Howard S, Gaba D, Rosekind M, Zarcone V. The risks and implications of excessive daytime sleepiness in resident physicians. Acad Med 2002;77(10):1019-25.

• The baseline daytime sleepiness level of participating anesthesiology residents approached the levels seen in patients with narcolepsy or sleep apnea, with post-call levels exceeding this level. Extended sleep returned these levels to the normal range. Baseline sleepiness did not differ from post-call levels, suggesting that these residents were working in a chronically sleep-deprived state. And, subjective measures showed that residents were often unaware of the level of their sleepiness.

Dawson D, Reid K. Fatigue, alcohol and performance impairment. Nature 1997;388(6639):235.

• The often-cited study showing that performance declines after 24 hours of sustained wakefulness to a level roughly equivalent to that of alcohol intoxication with a blood level of 0.1%.

Lockley SW, Cronin JW, Evans EE, et al. Effect of reducing interns` weekly work hours on sleep and attentional failures. N Engl J Med 2004;351(18):1829-37.

• This study showed that reducing work hours for interns resulted in increased hours of sleep per week, longer periods of sleep before each working hour, and a reduced level of attentional failures during on-call nights.

WORK HOURS AND PATIENT CARE

Howard D, Silber J, Jobes D. Do regulations limiting residents' work hours affect patient mortality? J Gen Intern Med 2004;19(1):1-7.

• No significant difference was found in the decline of in-hospital patient mortality from congestive heart failure, acute myocardial infarction, or pneumonia in teaching versus non-teaching hospitals before and after the Bell Regulations.
• AMSA editorial: These results may be confounded by the fact that the Bell Regulations were not widely enforced until well after the measurements taken in this study (1991).

Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns` work hours on serious medical errors in intensive care units. N Engl J Med 2004;351(18):1838-48.

• This ground breaking article validates AMSA's argument that reducing work hours will lead to fewer medical errors. This study found that interns made substantially more serious medical errors when working frequent shifts of 24 hours or more compared to interns working shorter shifts.

STUDENT WORK HOURS

Chen J, Kamath R, Lam A, Litrovnik B, Leight K, Miller S, et al. How will changes in resident work hours affect medical students? Curr Surg 2003;60(3):268-70.

• An examination of the effects of RWH regulations on medical students, calling for greater clarification of the role of medical students in the clinical setting.

REVIEWS

Steinbrook R. The debate over residents' work hours. N Engl J Med 2002;347(16):1296-302.

• An in-depth history and overview over the resident work hour debate, presenting both rationales for reform and perceived drawbacks.

Friedman W. Resident duty hours in American neurosurgery. Neurosurgery 2004;54(4):925-31; discussion 931-3.

• A thorough and comprehensive review of the resident work hours issue

Buysse D, Barzansky B, Dinges D, Hogan E, Hunt C, Owens J, et al. Sleep, fatigue, and medical training: setting an agenda for optimal learning and patient care. Sleep 2003;26(2):218-25.

• An extremely thorough conference (October 28-29, 2001) report on the current state of knowledge regarding sleep and fatigue and their effects on medical training. It provides a wealth of information on the issue from historical, scientific, academic, occupational, and stakeholder perspectives, and includes recommended future goals.
• The reference list is itself a library of references to pertinent academic literature, although limited to articles published prior to 2003.

EDITORIALS

Wylie, C. Sleep, Science, and Policy Change. N Engl J Med 2005;352(2):196-197.

• This author, who has conducted important research on the effects of extended shifts on truck drivers, calls for improved enforcement of work hours guidelines, based on the results of the Barger et al. paper in the same issue.

Charap M. Reducing resident work hours: unproven assumptions and unforeseen outcomes. Ann Intern Med 2004;140(10):814-5.

• A critical view of RWH regulations, touching on lost patient contact resulting in reduced clinical competence, potential development of unprofessional attitudes, loss of continuity of care, and loss of community in the medical setting.

Hill J. Sleep deprivation. Lancet 2004;363(9413):996.

• In this editorial, the author argues that sleep deprivation, in addition to endangering patient safety, has a negative impact on professionalism, provoking resentment towards patients and the medical system. Working while impaired (typically construed as alcohol or drug induced impairment) is a breach of ethics and professional duty; the author puts forth the question: "does medical training [itself] produce impairment" via sleep deprivation?

Drazen J. Awake and informed. N Engl J Med 2004;351(18):1884.

• This author supports reforming the medical system to a more team-oriented approach which lets residents get more sleep, along with calling for improved systems for patient transfers.

Mukherjee S. A precarious exchange. N Engl J Med 2004;351(18):1822-4.

• This editorial proposes that a change in the culture of residency training is required to incorporate work hour regulations into a safer and more comprehensive system of providing safe and high quality patient care.

Ofri D. Residency regulations--resisting our reflexes. N Engl J Med 2004;351(18):1824-6.

• This author argues that energies should be focused on improving the medical system instead of reflexively challenging the effects and implications of resident work hour regulation.

Skeff K, Ezeji-Okoye S, Pompei P, Rockson S. Benefits of resident work hours regulation. Ann Intern Med 2004;140(10):816-7.

• This editorial examines the benefits of resident work hours regulation on the public, on trainees, and on the system of medical education.

Glines M. The effect of work hour regulations on personal development during residency. Ann Intern Med 2004;140(10):818-9.

• A resident's perspective on work hour regulations and the importance of personal development and fulfillment during a medical career