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Attention, vigilance, driving skills suffer as much from
long work hours & overnight shifts as from blood alcohol
level of 0.04%
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ANN ARBOR, MI - The long hours and overnight shifts that
are a rite of passage for young doctors may leave them
so sleep-deprived that they function as poorly as if
they’d had a few cocktails, a new study finds.
In findings published in this week’s issue of the
Journal of the American Medical Association, 34 young
pediatric residents showed similar impairments in
vigilance, attention, and driving skills on standardized
tests after they had been on duty overnight in the
hospital and worked a month of 90-hour weeks, compared
with when they had consumed three to four alcoholic
drinks after a month of 44-hour weeks with no overnight
duties.
The study involved medical residents from Brown
University Medical School and was led by a sleep
researcher from the University of Michigan Health
System. Most subjects were tested before new national
requirements limited resident work hours to an average
80-hour work week and maximum 24-hour work day. The team
monitored participants’ sleep habits during the study
using sleep diaries and an automatic wrist-watch
activity monitor, which verified that the residents on
heavy work shifts got significantly less sleep per night
on average than those with lighter schedules.
They also asked the residents to rate their performance
and effort on the tests. Ratings of impaired performance
were higher following the month of heavy work shifts
compared to the light work shifts and residents rated
their effort as higher after heavy work shifts compared
to the light work shifts with alcohol.
“This adds to the growing evidence that sleep
deprivation among medical residents significantly
impairs their ability to perform, although it is
important to note that we did not assess performance on
specific medical tasks,” says J. Todd Arnedt, Ph.D. a
sleep psychologist who is a Clinical Assistant Professor
of Psychiatry and Neurology at the U-M Medical School.
“The regulations in place that limit the number of hours
residents can work each week on average are a good
initial step, but the solution to the problem is not
likely as simple as well-intentioned policies aimed at
reducing work hours, which can themselves have negative
ramifications. Our study, like others before it, does
raise concerns about the performance of sleep deprived
physicians-in-training and suggests that strategies
aimed at reducing fatigue-related impairments are likely
necessary.”
Arnedt and his colleagues are the first to study medical
residents using the sleep deprivation and alcohol
comparison model, which has been used in other
populations including truck drivers. Both sleep
deprivation and alcohol consumption impair a person’s
reaction time, attention, judgment, control and driving
ability.
The residents were tested four times, in two separate
sessions. Two of the tests were done after they had
worked a month of light duty without overnight shifts;
the tests were done before and after they consumed three
to four alcoholic drinks. In the second session, they
were tested on the day after an overnight shift that
came at the end of a month of 90-hour work weeks that
included overnight work every fourth or fifth night.
During this session, they were tested before and after
drinking a non-alcoholic placebo beverage. The main
comparison of interest were the tests conducted after
they had drunk either the alcohol or the placebo.
In a Harvard University study published earlier this
year, the authors found that first-year residents
(called interns) were more likely to have an automobile
crash or near-miss while driving after an extended work
shift. Arnedt and his colleagues found that skills on a
driving simulator deteriorated in residents who were
tested after an overnight shift in the hospital and at
the end of a month of heavy night work. The findings
from these two studies suggest that the personal safety
of residents who drive home after working all night may
be at risk.
The new U-M/Brown study compared residents who were
working days in office-based clinics for about 44 hours
a week with those who were working up to 90-hour weeks
of day shifts in the hospital’s wards or intensive care
units, and also had to be in the hospital and awake
overnight once every four or five nights to care for
patients. (In hospital jargon, a resident who has just
completed a period of such intense duty is said to be
“post-call.”)
Depending on the type of medical or surgical care they
decide to specialize in, young doctors can spend
anywhere from three to twelve years in residency and
fellowship training. The first year, called the
internship, is considered the most intense and also
features more rotation between different sub-specialties
and hospital wards.
Arnedt hopes that this growing body of research on the
effects of sleep deprivation among residents helps to
highlight the consequences of inadequate sleep in
medical training. In 2003, the Accreditation Council for
Graduate Medical Education imposed an 80-hour weekly
work-hour limit, a 24-hour limit on continuous duty
time, in-house call duty no more than once every three
nights, and one day in seven free from all patient care
and educational obligations, all averaged over four
weeks.
“We need to continue to find simple, practical, and
effective strategies that hospitals and senior doctors
can take to reduce sleep deprivation among residents,”
says Arnedt, who hopes to study such strategies in
future. “We also need to continue to study this issue in
other types of residents.” Arnedt is a member of the the
U-M Sleep Disorders Center, and the U-M Depression
Center Sleep & Chronophysiology Laboratory.
For now, though, the new JAMA paper quantifies the issue
further, with clear results that contrast with some
previous studies whose methodologies did not allow for
clear interpretation.
For example: The reaction time of residents who had just
finished a month of heavy work schedules was 7 percent
slower and they committed 40 percent more errors than
when they were on a month of light schedules, On a
driving simulator, they had more difficulty maintaining
a consistent lane position and a constant speed during
the heavy work compared to the lighter work schedule.
Speed variability on the driving test was also 29
percent higher following the heavy-schedule compared to
the light schedule after drinking alcohol, but there
were no other performance differences between these two
conditions.
In other words, after a month of 90-hour weeks with
overnight shifts every fourth or fifth night, residents
performed about the same as when they had a BAC of 0.04
percent after a month of 44-hour weeks of daytime
shifts.
The sleep monitoring performed for the study used a
wrist device called an actigraph, which records the
wearer’s level of movement and allows researchers to
download data into a computer to assess how many hours a
person was inactive, which is used as a proxy measure of
sleep.
In the 24 hours leading up to the test days, residents
on a light schedule slept an average of 6 hours and 37
minutes, compared with about 3 hours for the residents
on a heavy schedule. Residents’ post-call ratings of
sleepiness during the heavy call month were also higher
than their ratings during the light call month, even
after they had consumed alcohol on the light call
rotation. Residents were not allowed to nap on the test
day or to use caffeine after noon time. Both the
light-duty and post-call tests were conducted at 3 p.m.
The researchers asked the residents to rate their
performance on the driving, attention and vigilance
tests, from poor to very good.
They then correlated those self-ratings with the
residents’ actual performance. In general, the residents
who had just completed heavy work schedules could judge
their own performance, but only modestly.
In addition to Arnedt, who moved from Brown to U-M in
2004, the study’s authors include his two sleep-research
colleagues from Brown: Judith Owens, M.D., MPH and Mary
Carskadon, Ph.D. Research assistants Megan Crouch and
Jessica Stahl are co-authors. The study was funded by a
grant from the American Academy of Sleep Medicine.
The original news release can be found
here at the University of Michigan Health System
Website.
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