Sleep Deprivation and Physician Performance: Why Should I Care?

Abstract

Fatigue is a timely topic—for society as well as health care. In health care, most of the discussion of fatigue has focused on work hours. Surveys conducted over the past 20 years have shown that interns work more hours than residents, and surgical subspecialists tend to put in the most hours. The range is 35 to 120 hours a week, with an average of 60 to 90 work hours a week. Most survey respondents believe that long hours negatively impact patient care and safety. Curtailing resident work hours has had both advocates and critics. On the one hand, most agree that long hours offer a valuable educational experience: residents can see the evolution of disease, retain continuity of patient care, and have adequate time to learn the profession. Rigorous schedules can also build confidence and prepare young physicians for the demands of practice. The arduous training schedule is also seen as a rite of passage and most importantly saves money for teaching hospitals. On the other hand, scientific evidence has shown that fatigue affects performance (Table ​(Table11). Brief moments of sleep may intrude into wakefulness, so that the physician actually sleeps during patient care. In addition, fatigue may cause physicians to injure themselves—either at the hospital or on the drive home—and may expose the hospital or educational entity to litigation. Lack of sleep also affects mood: negative moods—such as anger, hostility, depression, confusion, tension, and sadness—increase, while positive moods such as vigor and happiness decrease. Such negative moods are bound to affect the quality of patient care. Table 1 The effects of fatigue on performance The Accreditation Council for Graduate Medical Education now limits resident work hours to 80 per week—10% more if the program gets a dispensation. In comparison, residents in the United Kingdom work about 50 hours a week. As with any complex system, it is likely that changing the scheduling of residents will have unintended and unforeseen consequences, both good and bad. Someone has to pick up the slack since patients will continue to be ill, and those who do so may be less tolerant of sleep deprivation. In the future, regulations may be developed for all physicians and not just those in training. Yet limitations on work hours may never be enough. In its large national surveys, the National Sleep Foundation found that we are a society of chronic undersleepers. Because of the many competing interests in our 24/7 world, a physician working 20 hours a week may still come to work fatigued. A culture change is required: it should be unacceptable to come to work impaired from any cause. Fatigue has also become an issue in relation to patient safety. The Institute of Medicine report To Err Is Human revealed that medical errors cause 44,000 to 98,000 deaths a year. While caveats exist in the interpretation of the data, the number is irrefutably large: in fact, it is equivalent to a jumbo jet crashing daily. It is hard to know fatigue's role in these errors. However, since fatigue affects performance and decision-making processes, it is a likely contributor. Fatigue has already been shown to be a contributing factor in non—health care accidents, including the explosion of the Space Shuttle Challenger and the nuclear meltdowns at Three Mile Island and Chernobyl (both of which occurred during the circadian low point between 3:00 and 5:00 AM). Fatigue was found to be the probable cause of the grounding of the Exxon Valdez. Each year, more automobile crashes are related to drowsy driving than to driving while under the influence of alcohol. In June 2003, New Jersey state lawmakers passed Maggie's Law, which allows a sleep-deprived driver to be convicted of vehicular homicide. Thus, compared with the safety culture in transporta-tion industries, health care is still in its infancy when evaluating safety and errors. In this article, I review sleep physiology, discuss some relevant studies on sleep in a health care environment, and present recommendations to help counter the effects of fatigue.