Falling Back to Sleep

November 05, 2017

Hi everyone:

I embraced last night’s extra hour of sleep. 

Since I was a resident, I’ve cherished sleep, not surprising after three years of 36-hour shifts: in at 6A one day, out at 6P the next.  Call after call, I trudged home across the Schuylkill, disheveled, unshaven, and unwashed.  A bite to eat and off to sleep.  Few of us questioned the sleeplessness.  Instead, we proudly fought fatigue and viewed it as the price to pay to become physicians, a hallowed tradition bestowed by our forebears.  We rarely considered better ways to train.

I’ve come to have mixed feelings about overnight call.  Outcome studies suggest no obvious harm or benefit, which is why the ACGME relaxed its rules for interns this year.  I can see the value of call in the ICU, where critical illness unfolds in real time, without respecting the clock.  To learn to manage DKA and septic shock, you have to stand by the bedside until the crisis abates.  In addition, as attendings we’re sometimes forced to push through fatigue, so at some point you have to learn how to overcome exhaustion.

But we'd be foolish to ignore sleep deprivation’s toll, both physically and emotionally.  Overnight call is especially challenging for interns, probably because of the enormous workload and effort needed to gain new skills.  In some ways, overnight call is tougher than it was during my residency.  Shifts were longer back then—36 hours as opposed to 28—but I slept more, 3-4 hours a night on average.  Paradoxically, the demand to leave by 28 hours can introduce work compression, which can make it harder to sleep, even when you try.

I believe our residency is approaching the sweet spot.  With your input, we've eliminated overnight call when it lacked an educational or clinical rationale, while continuing it in the MICU for interns and, on select rotations, for residents. We continue to work to promote sleep on call whenever possible, for example by simplifying note writing expectations so sleep isn’t sacrificed on the altar of documentation.

Even without overnight call, residency is exhausting.  When we eliminate 28-hour call, we introduce night shifts, which destabilize our clocks and circadian rhythms.  80-hour work weeks are mentally and physically taxing, even when we go home to sleep.  For these reasons, we have to watch out for dangerous fatigue and, because it’s hard to recognize sleep deprivation, we need to monitor each other carefully.  We need to call the Chiefs immediately when fatigue prevents us from working safely and effectively.  If you haven’t done so yet, please review the attached PowerPoint, prepared by Dr. Rosemarie Fisher, which highlights what we all should know about sleep, fatigue, and medical training.

We will likely debate the pros and cons of overnight call for years to come.  The forthcoming results of iCOMPARE may shed light on this subject, but they’re unlikely to be transformative.  Pending further data, I invite you to join the discussion and help us find the best ways to optimize patient care, education, and sleep.

Tell me what you think,

Mark

PS Congratulations to our Chief Resident, Danielle, and her husband, Michael, who were married last night in Boston. Best wishes for a happy, healthy, wonderful life together!

M

Submitted by Mark David Siegel on November 05, 2017