"Work-related sleep loss and fatigue in medical training has become a source of increasing concern," according to background information in the article. One study found that interns got 5.8 hours less sleep, had 50 percent more attentional mistakes, and made 22 percent more serious errors on critical care units while working a traditional schedule compared with a schedule with less hours. Also, self-reported lifetime rates of motor vehicle crashes and near-miss crashes among residents are 3 and 2.5 times those of nonresident drivers, respectively.
J. Todd Arnedt, Ph.D., from the University of Michigan, Ann Arbor, and colleagues compared post-call neurobehavioral performance of 34 medical residents (18 women, 16 men) after their rotations to examine the effect of extended work hours. The residents were tested after light call rotation (four-week rotations averaging 44 hours per week), light call with alcohol, heavy call (an average of 90 hours per week, every fourth or fifth night, 80 hours after July 2003), and heavy call with placebo. In the light call with alcohol condition, participants' blood alcohol concentrations were raised to 0.05 grams percent. Average age of residents was 28.7 years.
The researchers found that performance impairment during a heavy call rotation was comparable to impairment associated with a .04 to .05 grams percent blood alcohol concentration during a light call rotation. Compared with light call, heavy call reaction times were 7 percent slower and lane variability and speed variability during the simulated driving test were 27 percent and 71 percent greater, respectively. Speed variability was 29 percent greater in heavy call with placebo than light call with alcohol, and there were similar errors and reaction times.
"These findings have important clinical implications. Residents must be aware of post-call performance impairment and the potential risk to personal and patient safety. There should be sleep loss, fatigue and countermeasure education in residency programs. Because sleepy residents may have limited ability to recognize the degree to which they are impaired, residency programs should consider these risks when designing work schedules and develop risk management strategies for residents, such as considering alternative call schedules or providing post-call napping quarters. Additional studies should examine the impact of these operational and educational interventions on resident driving safety and on patient care and safety," the authors conclude.
(JAMA. 2005; 294: 1025 – 1033. Available pre-embargo to media at www.jamamedia.org.)
Editor's Note: This study was supported by a grant from American Sleep Medicine Foundation (formerly the Sleep Medicine Education and Research Foundation) from the American Academy of Sleep Medicine.
Editorial: Work Hours and Reducing Fatigue-Related Risk - Good Research vs. Good Policy
In an accompanying editorial, Drew Dawson, Ph.D., from the University of South Australia, Adelaide, South Australia, and Phyllis Zee, M.D., Ph.D., from the Feinberg School of Medicine, Northwestern University, Chicago, write, "While there is little doubt that physicians-in-training work long hours and experience chronic sleep restriction over many years, the consequences remain unclear."
"Although the authors [Arnedt et al] acknowledge that these laboratory tests of performance have not been validated against medical tasks, the indirect implication is that residents working 80- to 90-hour weeks are at an equivalent or greater risk compared with an intoxicated physician. This is, without doubt, a notable finding and one that should concern those responsible for patient safety and medical training."
"Despite the appeal of restricting working hours, it is important to consider potential negative ramifications," the editorialists write. "In some scenarios, limiting working hours may increase risk to patients and physicians. For example, restricted working hours may lead to restricted access to health care practitioners through a reduction in the labor supply, insufficient clinical preparation for the 'real world,' increased sleep restriction in senior physicians, or increases in error rates due to work intensification."
They conclude by saying, "Failure to consider the broader issue carries the considerable hazard that well-intentioned policies to reduce fatigue-related risk may not lead to overall improvements in patient safety." (JAMA. 2005; 294: 1104 – 1106. Available pre-embargo to media at www.jamamedia.org.)
Journal
JAMA