COMMENTARY

Legislating Sleep Is Difficult: Resident Work Hours Do Not Affect Surgical Outcomes

Aaron B. Holley, MD

Disclosures

April 21, 2016

When I entered internal medicine residency in 2001, we averaged well over 100 hours in the hospital per week. Shifts routinely lasted close to 40 hours.

In response to several high-profile lawsuits alleging medical errors due to acute sleep deprivation (ASD), in 2003 the Accreditation Council for Graduate Medical Education (ACGME) began to enforce work-hour restrictions. Our residency program director and chief resident had to chase us out of the hospital. Leaving without completing our work was akin to abandoning our patients and colleagues. We didn't like it.

There's no shortage of opinions on whether work-hour restrictions are helpful. In the February 25 issue of the New England Journal of Medicine, Bilimoria and colleagues[1] published their investigation of the effect that work-hour changes have on surgical outcomes and resident quality of life.

The investigators compared standard with "flexible" ACGME work-hour policies (see Table 2 in the manuscript for details). Both policies limited work hours to 80 per week, but the "flexible" residents had no limits on individual shift duration or time off between shifts. There were some minor differences in resident perceptions of quality of life and patient care, but work-hour policy did not affect patient outcomes.

So how does a sleep doctor reconcile this data with what he or she already knows? In a laboratory setting, sleep deprivation consistently degrades attention, cognitive function, and reaction time,[2] but there are individual differences in vulnerability.[3,4] It may be that a surgical residency self-selects for those who tolerate sleep debt, so extended periods of wake time have little effect on performance. Or maybe the benefits from continuity of care outweigh any errors in judgement due to inadequate total sleep time.

Finally, having chronic sleep deprivation prior to acute sleep deprivation exacerbates the effects of ASD.[5] Perhaps limiting total work to 80 hours per week allows enough restorative sleep between shifts to mitigate the effects of ASD during longer shifts. Many questions remain unanswered.

The bottom line is that legislating sleep via work-hour restrictions is a difficult business. It's a reasonable endeavor, given what we know about sleep deprivation, and because patients and the public are concerned about the effect ASD has on their care.[6] The ACGME has consistently mandated tougher requirements, but it's not clear where the optimum point on the risk/benefit spectrum lies.

What schedule allows residents to get enough sleep without affecting education or continuity of care? When individual susceptibility to sleep deprivation is added to the mix, you're left with a very messy picture. More studies like this one are welcome.

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