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Journal of ASPR - Summer 2013 - Regulated work hours, something physicians lack…
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What do pilots, truck drivers, & maritime workers have in common?

Regulated work hours, something physicians lack…

By Miranda Grace, DASPR, Physician Recruiter, Lewistown Hospital, Lewistown, PA

Four friends meet for dinner at a restaurant: A pilot, a truck driver, a maritime worker, and a physician. They talk about their day, enjoy a meal and then head to their homes to get their eight hours of sleep in before getting up for their 7 a.m. shifts…except for the physician. He sticks around for a few more hours to listen to the live music, even though he also has a 7 a.m. shift, and he’s been on call for the last 24 hours. Should we be worried about how much sleep he’s had?

Dr. Jose AcostaOf course! Today, pilots, truck drivers, and maritime workers all have regulated work hours, something physicians seem to lack. Studies show that 24 hours of wakefulness produces impairment equivalent to a blood-alcohol level of 0.1%!1 Add the potential to this scenario that there was alcohol consumption during the evening, and the impairment from sleep deprivation is compounded. Sleep deprivation is a problem among residents, fellows, and practicing physicians. It can have negative effects on health and mood, and if not handled in a timely manner through shared call and/or shift work, sleep deprivation may also infringe on physician retention. Dr. Jose Acosta, Sleep Medicine physician at Lewistown Hospital, urges a cultural change among physicians everywhere, “Sleep deprivation is a problem that needs to be addressed for both physicians in training and those already in practice. We must ensure that one day adequate sleep is as readily expected of physicians as hand washing.”

History of regulated work hours
On the evening of March 4, 1984, Libby Zion, 18 (daughter of Sidney Zion, a former lawyer and New York Times journalist), was taken to New York Hospital with a fever and unexplained spasms. After being admitted for observation, several residents examined Libby in order to diagnose and treat her effectively. Although several attempts were made with a number of medications, Libby’s symptoms got progressively worse. The first year resident on Libby’s case was overwhelmed with her workload and alone after the second-year resident had left to catch some sleep. Distracted and unsure of what to do, she ordered restraints and a sedative. Later that same morning, Libby’s temperature spiked. She suffered a cardiac arrest and died.2

Devastated by his daughter’s sudden and mysterious death, and determined to seek justice, Sidney Zion decided to use the circumstances surrounding the case to spur reform among physicians in training. Zion persuaded the Manhattan district attorney to convene a grand jury to consider murder charges against the physicians involved. A malpractice case finally went to trial in 1994. In a New York Times article, A Life-Changing Case for Doctors in Training, Dr. Barron Lerner recalled the days following the trial, “This came as no surprise to us in the trenches. We knew what it was like to stay up for 36 hours straight, first as medical students and later as residents. It was in a word, insanity. Deprived of sleep, we roamed the wards, dreaming of when we could finally leave, dozing off on rounds, screaming at patients and colleagues and praying we would not make any grievous mistakes…I felt sorry for the competent and well-meaning doctors he pilloried, but was thrilled that change was occurring.”3 Ultimately the physicians were not indicted; however, the case did spark an impassioned debate surrounding work hours and other factors that lead to sleep deprivation among providers.

In 2003, the Accreditation Council for Graduate Medical Education (ACMGE) made mandatory that no physician in training work more than 80 hours per week or 24 hours in a row. Also, the frequency of call was limited to every third night with a rest period of 10 hours between calls.4 Unfortunately, this recommendation does not account for the many external factors that contribute to sleep deprivation among residents and fellows — including, but not limited to, moonlighting for supplemental income. And while attending and/or practicing physicians may have more clinical experience than those in training, their work hours are not regulated, nor are they exempt from the effects of sleep deprivation.

The human sleep requirement
We all need sleep. So much so, that without it we are at risk for many physical and mental impairments. Physical consequences for lack of sleep include increased blood pressure, CHF, stroke, obesity, and more. As recruitment and retention professionals, we need to be aware of the physical strain our physicians are under when suffering from sleep deprivation. In time, these issues could lead to a decline in productivity, increased call offs, and potentially early retirement and/or medical leave.

A lack of sleep among physicians also decreases empathy for patients, interrupts cognitive and behavioral dexterity, and shows a marked decline in attention. In addition, sleep loss gives rise to anger, frustration, depression, and confusion, explaining the many poor relationships among physicians and staff, patients, even family. “These mental impairments caused by a lack of sleep can certainly affect a physician’s family and marriage,” said Dr. Acosta. “After working any number of hours at the hospital, a physician can go to their children’s recital, for example, and fall asleep — unintentionally causing a rift between themselves and their family. In addition, the more frequently physicians are on call, the more likely their spouses’ sleep patterns are disrupted which may cause them to sleep in separate rooms. Over time, this may not be good for the physician’s marriage.”

A cause for concern also occurs when those who are chronically sleep deprived underestimate their impediments. A 2009 article, Physicians and Sleep Deprivation, noted, “Although physicians may believe that they adjust to a restricted sleep schedule, the data indicate that this does not occur…In addition, sleep loss not only affects performance, it can contribute to false memories.”1 Dr. Acosta added, “We need to change the attitude about long hours of work [among physicians]. Instead of bragging about working 100 hours in a week’s time, we should chastise our colleagues as dangers to our patients and themselves.”

Chronic sleep loss, a condition experienced by many physicians, occurs when obtaining two to three hours less sleep per night regularly than what’s ideal for that individual. There is no substitute for a lack of sleep, and sadly, caffeine and other energy supplements just don’t cut it. However, the recommendations that follow could help curb the limited hours of sleep physicians are getting in practice and/or manage the effects of sleep loss.

  1. Recognize sleep deprivation as a serious problem.
  2. Understand that a lack of sleep impinges on patient safety and physicians’ physical and mental health.
  3. Spur a cultural change in your organization regarding long work hours among providers.
  4. Encourage shared call among a number of providers so that sleep is less fragmented.
  5. When possible, allow for naps to help compensate for a loss of sleep. If napping before work, ask physicians to limit sleep time to 30 minutes to account for “sleep inertia”.1
  6. Understand that two nights of unrestricted sleep are imperative to reduce the likelihood of sleep debt and impaired performance. 1
  7. Urge physicians to avoid beginning work in “sleep debt.” When this is not possible, exposing oneself to bright blue-spectrum light before work can help accelerate wakefulness. 1
  8. If caffeine must be consumed, encourage consumption 30 minutes before the expected decline in alertness, i.e. 3-5 am/pm. 1
  9. Encourage social interaction among fellow physicians and staff. 1
  10. Allow for snacking, exercising, and singing, when possible, as this can help sustain alertness. 1
  11. Offer education for physicians on the importance of sleep and how to achieve restful sleep, even during the day*.
    1. Limit activities in bed.
    2. Exercise.
    3. Do not stay in bed fully awake.
    4. Do not watch the clock.
    5. Do not use bed as a place to solve problems.
    6. Go to bed when tired.
    7. Use earplugs.*
    8. Darken the room to increase melatonin production.*
    9. Use eye shades to block out light.*
    10. Ensure that the environment is cool.*
  12. Offer education for physicians’ family members about the importance of sleep and the disturbances that can occur at home (during the day) from phone calls, the television, the vacuum, and more.
  13. Always be respectful of physicians’ sleep and ask others to do the same.

Among physicians, the desire to avoid call is cited as the most common reason for early retirement. If we take the necessary steps to curb sleep deprivation among our medical staff, we may be able to keep them significantly longer. Ultimately, we need to recognize sleep deprivation as a problem. With extended work hours and sleep fragmentation from call, stress, and/or primary sleep disorders from training, physicians may be putting themselves and our patients at risk. The ACGME’s recommendation is just a start. A cultural change must occur, first in individual organizations then nationwide. Long hours are discouraged in and among pilots, truck drivers, and maritime workers, so why not physicians?

Vorona, Robert Daniel, Ian Alps Chen, and J. Catesby Ware. “Physicians And Sleep Deprivation.” Sleep Medicine Clinics 4, no. 4 (2009): 527-540.
Lerner, Barron. “A Case That Shook Medicine; How One Man’s Rage Over His Daughter’s Death Sped Reform of Doctor Training.” The Washington Post, November 28, 2006. (accessed May 8, 2013).
Lerner, Barron. “A Life-Changing Case for Doctors in Training.” The New York Times, March 3, 2009. (accessed May 8, 2013).
Hawkins, Finn, Joseph Murphy, and William Dunn. “Is My Doctor Impaired, or Just Sleep Deprived?” Chest Journal 135, no. 5 (2009): 1194-1197.

Journal of ASPR - Summer 2013

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