ON CALL: ISSUES IN GRADUATE MEDICAL EDUCATION Sleep Loss and Fatigue in Residency Training A Reappraisal Sigrid Veasey, MD Raymond Rosen, PhD Barbara Barzansky, PhD Ilene Rosen, MD Judith Owens, MD, MPH L ONG WORK HOURS ARE A TIME- honored tradition in most resi- dency programs. Demanding schedules are often said to be neces- sary for learning and development of professionalism. The use of resident physicians to provide relatively inex- pensive coverage has also become an important economical factor for teach- ing hospitals within the United States. Recent studies of the negative effects of sleep loss and fatigue, however, call this model into question. Any consideration of the impact of sleep loss and fatigue on medical train- ing and patient care should be based on relevant data. In this article, we con- centrate on 3 questions. First, is the quality of patient care jeopardized when residents are deprived of sleep? Sec- ond, is the well-being of residents at risk when they have not had adequate sleep? Third, what strategies are effective for overcoming the negative effects of sleep loss? We answer these questions by summarizing data on the effects of sleepiness and fatigue on cognitive function, the impact of sleep loss on residents’ performance and health, and the effectiveness of countermeasures for sleep loss. REGULATION OF SLEEP AND ALERTNESS Sleep and wakefulness are highly regu- lated states of brain activity and behavioral responsiveness, governed by a balance of homeostatic drive for sleep, circadian influences on alert- ness, and a composite interaction of external and internal stimuli. 1 Optimal neurobehavioral performance requires activation of the circadian wakefulness circuitry and maintenance of sleep homeostasis. 2 When healthy adults receive an average of less than 5 hours of sleep per night, the homeostatic drive to sleep rises sharply, as evi- denced by an increased propensity to sleep, 3 and cognitive performance begins to decline. 4 Thus, sleepiness and fatigue are the result of funda- mental biological processes. Sleepiness is commonplace among house staff; 10% of residents perceive sleepiness as an almost daily occurrence for them- selves. 5 This raises concern whether increased sleepiness and fatigue impair cognitive and performance skills of residents. EFFECTS OF SLEEP LOSS ON COGNITIVE PERFORMANCE Effects of sleep loss on performance have been documented in sleep labo- ratory studies of healthy young adults. Some of this research has direct impli- cations for interpreting the results obtained in studies of sleep loss effects in residents and medical students. The studies performed in sleep laborato- ries have identified both important con- founders and neurobehavioral assays most sensitive to the effects of sleep loss. One important observation to con- sider when interpreting studies of sleep loss in residents is that the severity of neurobehavioral impairment may be similar in both short-term sleep loss (re- cent 24-hour complete sleep loss) and chronic partial sleep restriction (6 hours of sleep per night on average for at least 1 week). 6-12 One study found that performance testing of vigilance (responsiveness to simple repeated Author Affiliations: University of Pennsylvania School of Medicine, Philadelphia (Drs Veasey and I. Rosen); University of Medicine and Dentistry of New Jersey– Robert Wood Johnson Medical School, New Bruns- wick (Dr R. Rosen); American Medical Association, Chi- cago, Ill (Dr Barzansky); and Brown University School of Medicine, Providence, RI (Dr Owens). Corresponding Author and Reprints: Sigrid Veasey, MD, Center for Sleep and Respiratory Neurobiology, University of Pennsylvania, 972 Maloney Bldg, 3600 Spruce St, Philadelphia, PA 19106 (e-mail: veasey @mail.med.upenn.edu). On Call Section Editors: Joseph K. Lim, MD, and Ste- phen J. Lurie, MD, PhD; Associate Editors: Ethan M. Basch, MD, R. Sonia Batra, MD, MPH, Natalie Holt, MD, Alison J. Huang, MPhil, MD, Nina Kim, MD, Vin- cent Lo Re, MD, Dena E. Rifkin, MD, and Mrugesh- kumar K. Shah, MD, MPH. Reduced sleep time is commonplace for many interns and residents. Recent studies, however, suggest that sleep loss and fatigue result in significant neurobehavioral impairments in healthy young adults. We reviewed stud- ies addressing the effects of sleep loss on cognition, performance, and health in surgical and nonsurgical residents. We describe the effectiveness of coun- termeasures for sleepiness, including recent work-hour restrictions. A more complete understanding of the issues of sleep loss during residency train- ing can inform innovative strategies to minimize the effects of sleepiness and fatigue on patient care and resident safety. JAMA. 2002;288:1116-1124 www.jama.com 1116 JAMA, September 4, 2002—Vol 288, No. 9 (Reprinted) ©2002 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 11/24/2021