The path to becoming a physician in the United States is not easy. After earning a bachelor’s degree — during which most amass large number of hours in community service, clinical work and research — medical students undergo an additional four years of medical school before entering residency. This is a post-graduate training period of 3-7 years that provides in-depth training in a specific field such as general surgery, internal medicine and pediatrics in preparation for independent practice. Residency is often regarded as the most grueling and transformative period along this path due to new responsibilities of patient care, continuous study for rigorous exams and demanding work schedules. The Accreditation Council for Graduate Medical Education (ACGME) mandates an 80 hour per week cap averaged over a four-week period.
History of Residency Duty Hours
Believe it or not, 80-hour work week caps in residency are considered progressive. Starting in the early 20th century, physicians resided in the hospital for “on-call” shifts and often worked over 90 hours a week. This workload consisted of 36 hours shifts separated by 12 hours or less of rest. In 1984, the death of 18-year-old Libby Zion in an emergency room in New York City catalyzed the reform for resident duty hours. A grand jury concluded her death was due to inadequate care provided by overworked and under-supervised medical residents. As a result, the Bell Commission was formed to review these issues and recommended the reduction of duty hours in New York resident physicians. Still, it was not until 2003 that the ACGME mandated nationwide 80-hour average requirements for all specialties.
Resident Physician Performance and Sleep Deprivation
Over twenty years have passed since the ACGME resident duty hour cap, with little momentum for further reform. The dangers of insufficient sleep are well known within the sleep care community — which include decreased decision-making capacity, executive functioning and motor ability. One study found that residents experienced low-grade systemic inflammation and impaired HPA-axis function based on elevated c-reactive protein and greater impulsivity, slower cognitive processing and impaired executive function after a 26 hour shift due to acute-on-chronic sleep deprivation. Additionally, arthroscopy simulator performance was significantly worse amongst trained orthopedic resident surgeons after a 24-hour shift.
Resident physicians are chronically sleep deprived, with studies showing an average of 6.2 hours a night with significant variations in sleep schedules. In addition, resident physicians only obtain an average of 1.6 hours of cumulative sleep when working 24-hour on call shifts. Unsurprisingly, nearly half of resident physicians reporting burnout during training.
What’s next?
Despite mandated residency programs wellness for by the ACGME, little has been done to combat the sleep deprivation experienced by residents due to their extreme work hours and shift lengths, with some shifts lasting up to 28 hours. While some residency programs are transitioning from 24-hour calls to a night shift float system, it is not enough to combat the moral injury experienced by residents in which sleep deprivation plays a central part.
Overhauling the current residency work schedule is a nuanced endeavor complicated by medical billing structures, physician shortages leading to small resident workforces in hospitals and concerns of medical errors associated with increased patient turnover among providers. However, given nearly 40% of physicians are planning on leaving the workforce in two years, the medical community should strive to reduce physician burnout among residents for their professional betterment and patient safety.
Rebbecca Brena, BS, RPSGT,
was introduced to the sleep field after obtaining her BS from the University of Arizona in neuroscience and cognitive science and molecular and cellular biology as a CPSGT. She earned her RPSGT while conducting sleep and critical care research at the University of California, San Diego. She decided to pursue medical school after witnessing health disparities among her low-income patients who struggled to access care for their sleep disorders. Now she is a third-year medical student at the David Geffen School of Medicine at UCLA with a passion for sleep and health equity.