Steven Howard, MD, an anesthesiologist on the faculty of Stanford University School of Medicine, recently gave the Bookatz Lecture at Baylor University Medical Center (BUMC) surgery grand rounds. His presentation addressed the issue of sleep deprivation and its impact on physician performance. Although Dr. Howard's research, and his lecture, focused principally on surgical and anesthesiology trainees, his findings and conclusions are clearly applicable to all physicians.
Doctors of my vintage can clearly recollect “the good old days” when residents frequently took call every other night and those on call every third night were considered “wimps” or “weaklings,” who had the misfortune of missing so many interesting cases. We also recollect being dead on our feet, sleeping through many conferences, and sometimes falling asleep in the midst of important clinical tasks. Some of us fell asleep while driving home, with tragic consequences. Gradually, the call schedule was modified to permit more reasonable time for sleep and also to provide physicians in training with some opportunity for downtime away from the hospital and the medical profession.
Efforts to shorten duty hours and to provide days off between call shifts have intensified, in part, because of several unfortunate and disastrous errors attributed to sleepy trainees and also because of the greater emphasis now placed on patient safety. Overwhelming evidence shows, and it makes common sense, that sleep-deprived individuals, whether they be physicians, airline pilots, or truck drivers, do not perform their jobs optimally. However, although residency duty hours have progressively declined, and this is good, the quantity of information physicians-in-training must learn continues to increase. How can a resident learn all the facts and techniques he or she requires to become a competent physician and simultaneously spend fewer and fewer hours at the hospital? This is a challenge with which all educators and trainees now struggle, and this difficult conundrum remains far from being adequately resolved.
BUMC internal medicine residents are on call every fifth night when assigned to general medicine/ward rotations and every fourth night during their coronary care unit rotations. They generally have no night or weekend call during elective and sub-specialty rotations. Residents do not work more than 80 hours in any given week. After 24 hours in the hospital, the residents must be off duty for at least 19 hours. Today, similar maximum duty hour limits apply to virtually all residency and fellowship programs, including all of those here at BUMC.
Although the recent and current focus has been directed at physicians in training, it is virtually inevitable that similar discussions and debates will eventually include junior and senior attending physicians practicing in hospitals, those at medical schools, and private practitioners. There is no doubt that many of our colleagues are also overworked and chronically sleep deprived. Legislating work hours and minimal sleep time for senior established physicians may be difficult or impossible, but it is hoped that heightened awareness of these problems will nonetheless lead to improved working conditions for physicians in general.