Resident overnight call — an idea past its time?

Williamson and Feyer's study sparked intense discussion in the media as well as among medical professionals. The authors compared the relative effects of sleep deprivation and alcohol on the ability of 39 individuals (37 men and 2 women) to execute computerized performance tests. After 17 to 19 hours without sleep, subjects' test results were equivalent to or worse than those of people with a blood alcohol concentration of 0.05%. Specifically, the authors found that skills with low cognitive demand, such as simple reaction time, were affected by sleep deprivation much more than higher cognitive skills, such as logical reasoning and memory.

Although some people experience adequate sleep, work schedules and lifestyle demands increasingly require people to extend their waking period for longer than 18 hours. This change in activity effectively shortens their sleeping period, and doing so repeatedly over days, weeks, or even months results in a state of chronic partial sleep deprivation, which may present serious risks and compromise safe performance.¹

One limitation of this study is the lack of randomization. Another limitation is the baseline alcohol consumption of the participants, which was high: 35 (90%) reported consuming alcohol on at least a weekly basis, and 18 (46%) reported drinking at least 4 drinks per occasion. Because of the high baseline alcohol consumption of these men and women enrolled in the study, it is unclear how these results would be generalized to a population that does not regularly consume as much alcohol as this study population.

During medical training, chronic partial sleep deprivation occurs with repeated overnight call. As early as 1983, medical educators questioned the justification for night call in light of the potentially severe adverse effects of sleep deprivation.² In 1988, after the well-publicized Libby Zion case, New York became the first state to implement regulatory measures limiting house staff work hours.³ A minor paradigm shift in medical education occurred as residency programs across the country came under pressure to reduce the number of on-call nights for their residents. Residency programs experimented with such systems as night floating. Studies looked at the relationship between resident physicians' sleep deprivation and patient/parent satisfaction,⁴ physician alertness,⁵ number of laboratory tests ordered, and lengths of patient stay.⁶ Interestingly, a study examining the effects of sleep deprivation on surgical residents found no significant change in incidence of complications when residents were sleep deprived.⁷ In contrast, emergency medicine residents self-reported being in a higher number of motor vehicle crashes and nearcrashes while driving home after a night shift compared with other shifts.⁸

In the study by Williamson and Feyer, sleep deprivation did not affect higher cognitive functioning, but a study by Nelson and colleagues looking specifically at the performance of residents when sleep deprived found that alertness and concentration were significantly impaired after a 32-hour on-call shift.⁹

Why does overnight call continue to be a major component of residency training? It is absurd to expect a resident to be receptive to the educational process when deprived of adequate sleep. Ironically, the concept of overnight call was constructed originally for educational purposes, with the idea that many illnesses presented or evolved during nighttime hours. But the workload in hospitals has increased because of pressure to treat more patients with shorter lengths of stay in the hospital. Residents are a relatively inexpensive workforce, and they are an economic benefit to the hospital and its operation. Therefore, resident physicians have 2 conflicting roles: physician-in-training and worker in the business of hospital care.

Perhaps the medical profession itself is guilty of perpetuating the practice of overnight call as a sort of “rite of passage.” But overwhelming data now exist to denounce working while sleep deprived. We urgently need the commitment of faculty, residency directors, and governing organizations to make a change. It is time to implement policy and develop creative curricular solutions.