Sleeping on the Job – A Program Director’s Take on IOM Recommendations




Health and Healthcare CategoryI’ve been thinking about sleeping a lot lately. Not in the sense of curling up under the blankets for hours on end, but in the sense of thinking about the topic of sleeping. As the program director of an internal medicine residency program, one of my jobs is to make sure that my residents are rested enough to provide appropriate patient care. I was under the impression that they were. But recently, the Institute of Medicine (IOM) came to the conclusion that many residents are still sleep-deprived, posing a threat to the safety of patients under their care across the United States. Based on this conclusion, the IOM made the bold recommendation that after 16 hours of continuous work, residents must be allowed an uninterrupted five hour block of time for sleep, preferably between the hours of 10pm and 8am.

DoctorsOn the surface, this seems reasonable. When it became apparent that I was going to need a cesarean section after 12 hours of labor with my third child, I had serious misgivings about the fatigue of my physician, who had been awake with me the entire time, not to mention the twelve hours prior. I’m happy to report that all went well, but the fact that my physician had been in practice for over twenty years and could probably do c-sections in his sleep (and maybe even had) probably played largely into his success.

But what about residents? Fresh out of medical school and eager to please, these young physicians are often scheduled to be “on call” for up to thirty hours at a time. And studies have shown that with only 24 hours of sleeplessness, brain performance is equivalent to that of someone with a blood alcohol level of 0.10%. So in theory, at any given moment in the United States, there could be an inexperienced physician writing orders for life-altering medications with all the acumen of the town drunk.

This assumes that the resident has been awake continuously for that 30-hour shift, however. It’s important to note that even though residents are scheduled to be “on call” for extended periods of time, most nights they actually do get some sleep. So the question becomes: how much is enough? The National Sleep Foundation states that adults need seven to nine hours of sleep per night. How did the IOM come up with the idea that five would be just fine? Why not just say you can’t work longer than 16 hours, period? And who’s to say that given five interrupted hours residents will actually sleep?

I agree with the spirit of the IOM’s recommendations. Patients shouldn’t be subjected to inexperienced, overtired physicians. But I can’t help but wonder if the IOM’s new recommendations fall short of the goal that they are trying to achieve.

  • Greg

    As a psychologist somewhat familiar with the sleep deprivation research, it strikes me that only persons who are inured to this system of training would even remotely consider defending the sleep-deprivation training model. It reminds me of people who used to defend old-fashioned military training, involving extensive use of live ammo and bombs with green recruits, that resulted in a small but reliable percentage of fatalities and PTSD among the troops — the “well, in real combat it’ll be worse” school of thought.

    There is no valid training or logistical reason for subjecting residents to extended periods of severe sleep deprivation. From a learning perspective, if you really want people to perform complex tasks super well under potential future conditions of severe sleep deprivation or stress, you train and rehearse them extensively when they’re at their most alert. After they’ve developed extensive practice and so can do these things fairly automatically, it’ll more easily generalize to high-stress, low-sleep situations than if they mostly learned things while only halfway alert from the outset.

    As a patient, you bet I’d sue a hospital and the supervisors of any resident who was shown to be sleep deprived when they took out the wrong organ or otherwise messed up my or a loved one’s care. It’s irresponsible, outmoded, and frankly, kind of a narcissistic model of training (the “we are teaching them to be gods like us” model). It should change.

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T. A. McNamee, MD

T. A. McNamee, MD, is an associate professor and internal medicine residency program director at Sanford School of Medicine of the University of South Dakota.
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