Sleep deprivation in resident physicians, work hour limitations, and related outcomes: a systematic review of the literature

Improving the Resident Educational Experience in a Level IV Neonatal/Infant Intensive Care Unit

Supplemental Digital Content is available in the text.

The neonatal/infant intensive care unit (N/IICU) at the Children’s Hospital of Philadelphia is a 98-bed, level IV unit through which second-year pediatric residents rotate monthly. We developed a quality improvement project to improve the resident educational experience using goal setting. Primary objectives were to increase resident educational goal identification to 65% and goal achievement to 85% by June 2017. Secondary objectives were to (1) increase in-person feedback from fellows and/or attendings to 90% by June 2017 and (2) sustain improvements through June 2018.

The impact of nurses' and physicians' shift change on obstetrical outcomes

PURPOSE

To evaluate the effect around nurses' shift change and on-call physicians' shift change on obstetrical outcomes.

METHODS

A retrospective study of women who had an attempt of labor in a single-medical center, January 2006-December 2017. Obstetrical outcomes were compared between the time around nurses' shift change (6:00-8:00, 14:00-16:00, and 22:00-00:00) to the rest of the day, and between the time around on-call physicians' shift change (6:00-8:00, 14:00-16:00) to the rest of the day.

RESULTS

32,861 women were included, 7826 deliveries occurred during nurses' shift-change, and 25,035 deliveries occurred during the rest of the day. The groups had similar general and obstetrical characteristics, with no statistical difference in cesarean delivery rate (10% vs. 9.8%, P = 0.45) (Table 1). Nurses' shift change had no measurable effect on obstetrical outcomes, including induction of labor, preterm labor, 5-min-Apgar score and cord pH value, except PPH which was less likely to occur during nurses' shift change period (3.8% vs. 4.4%, P = 0.045) (Table 2). From 32,861 deliveries, 5155 deliveries occurred during on-call physicians' shift-change, and 27,706 deliveries occurred during the rest of the day. Induction\augmentation of labor and epidural analgesia were less likely to happen during on-call physicians' shift change (34.4% vs. 38%, P < 0.0001, 59.6% vs. 61.8%, P = 0.003, respectively) (Table 3). The two groups had similar obstetrical outcomes, without statistical difference in cesarean delivery rate (10% vs. 9.8%, P = 0.63) (Table 4). Table 1 General and obstetric characteristics of women giving birth during the time of nurses shift change versus during the rest of the day Variable Change of nurses shifts (n = 7826) All other hours of the day (n = 25,035) P value Maternal age, y 30.3 ± 5.1 30.2 ± 5.2 0.09 Gestational age at birth (weeks) 39.7 ± 1.09 39.8 ± 1.10 0.55 Nulliparity 2077 (35%) 7067 (37%) 0.01 Induction\augmentation of labor 2905 (37) 9368 (38) 0.62 Epidural analgesia 4746 (61) 15,396 (62) 0.16 Neonatal birth weight, g 3340 ± 422 3330 ± 423 0.06 Data is presented as mean ± S.D or N (%) Table 2 Maternal and neonatal adverse outcomes of women giving birth during the time of nurses shift change versus during the rest of the day Variable (%) Change of nurses shifts (n = 7826) All other hours of the day (n = 25,035) P value Vacuum assisted delivery 615 (7.9) 2002 (8.0) 0.69 Cesarean delivery 788 (10) 2443 (9.8) 0.45 Postpartum hemorrhage 294 (3.8) 1089 (4.4) 0.045 Third- and fourth-degree perineal laceration 106 (1.4) 372 (1.5%) 0.51 5-min Apgar score < 7 39 (0.5) 139 (0.6) 0.65 Umbilical pH < 7.2 170 (23) 580 (23) 0.96 Prolonged second stage 190 (2.5) 559 (2.2) 0.22 Maternal and fetal composite adverse outcome* 1309 (16.7%) 4219 (16.9%) 1.00 Data is presented as N (%) *Maternal and fetal composite adverse outcome was defined as the presence of any of the following: vacuum delivery, CD, prolonged second stage, postpartum hemorrhage, third and fourth degree perineal laceration, 5-min Apgar score < 7 and umbilical cord pH < 7.2 Table 3 General and obstetric characteristics of women giving birth during the time of the on-call physicians shift change versus during the rest of the day Variable Change of physicians shifts (n = 5155) All other hours of the day (n = 27,706) P value Maternal age, years 30.3 ± 5.1 30.2 ± 5.2 0.38 Gestational age at birth (weeks) 39.8 ± 1.09 39.8 ± 1.10 0.95 Nulliparity (%) 1303 (33.4) 7841 (37)  < 0.0001 Induction\augmentation of labor (%) 1769 (34.3) 10,504 (38)  < 0.0001 Epidural analgesia (%) 3067 (59.6) 17,075 (61.8) 0.003 Neonatal birth weight (gr) 3345 ± 416 3330 ± 424 0.019 Data is presented as mean ± S.D or N (%) Table 4 Maternal and neonatal adverse outcomes of women giving birth during the time of physicians on-call shift change versus during the rest of the day Variable (%) Change of physicians shifts (n = 5155) All other hours of the day (n = 27,706) P value Vacuum assisted delivery 397 (7.7) 2220 (8.0) 0.45 Cesarean delivery 517 (10.0) 2714 (9.8) 0.63 Postpartum hemorrhage 209 (4.1) 1174 (4.3) 0.54 Third- and fourth-degree perineal laceration 67 (1.3) 411 (1.5) 0.31 5-min Apgar score < 7 22 (0.5) 156 (0.6) 0.30 Umbilical pH < 7.2 94 (20.3) 656 (23.3) 0.15 Prolonged second stage 127 (2.5%) 622 (2.3%) 0.36 Maternal and fetal composite adverse outcome* 852 (16.5%) 4676 (16.9%) 1.00 Data is presented as N (%) *Maternal and fetal composite adverse outcome was defined as the presence of any of the following: vacuum delivery, CD, prolonged second stage, postpartum hemorrhage, third and fourth degree perineal laceration, 5-min Apgar score < 7 and umbilical cord pH < 7.2 CONCLUSION: Nurses' shift change and on-call physicians' shift change does not appear to be associated with an increase in adverse maternal or neonatal outcomes.

Long weekend sleep is linked to stronger academic performance in male but not female pharmacy students

Poor sleep hygiene portends loss of physical and mental stamina. Therefore, maintaining a regular sleep/wake schedule on both weekdays and weekends is highly recommended. However, this advice runs contrary to the habits of university students who sleep late on weekends. Pharmacy students at Duquesne University sit for frequent examinations, typically commencing at 7:30 AM, and they complain about mental fatigue. Here, we tested the central hypothesis that longer sleep durations on both weekdays and weekends are linked to stronger academic performance in men and women. Students in their first professional year were administered three surveys to collect data on sleep habits and factors that might influence sleep, such as roommates, long commute times, and sleep interruptions. Grade point averages (GPAs) were collected from the Dean's office, with individual permissions from the students. Longer weekend-but not weekday-sleep durations were significantly correlated with higher cumulative GPAs in men and not in women. Women achieved slightly higher cumulative GPAs than men. Students who fell asleep within 15 min of going to bed had higher professional-phase GPAs than those who fell asleep after an hour or more. Our observations cannot establish causal links, but, given the body of prior evidence on the salutary properties of sleep, men may reap more benefit from recovery sleep on weekends. Rather than recommending that students force themselves awake early on weekends in an attempt to maintain a consistent sleep routine, the real-life habits of students should also be given consideration.

Night shift work in resident physicians: does it affect mood states and cognitive levels?

BACKGROUND

The effects of night shift work on health status have been widely studied. Night workers seem to smoke more, eat badly and show a low propensity to physical activity. Night work can be associated with an increase in cardiovascular and gastrointestinal disorders, alterations in immune response, diabetes, aging, hormonal imbalance, and premature death; alteration of circadian rhythm is also regarded as a risk factor for breast cancer and neuropsychiatric disorders. Moreover, several studies have highlighted the effects of sleep deprivation on clinical performance, quality of care and personal safety of healthcare personnel. No studies have investigated the effects of night work on Italian resident physicians and compared its effect across specialties. This study aims to assess the prevalence of sleep disorders, possible cognitive impairment and mood states, in relation to night shift work among resident physicians.

METHODS

80 resident physicians, attending the postgraduate training into an Hospital located in the South of Italy, were divided into 4 areas (medical, surgical, services and anaesthesia). They were recruited from July 2017 to June 2018 and participated to a survey consisting of 4 questionnaires to investigate the presence of sleep deprivation and sleep quality (Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index), their cognitive status (Mini Mental State examination) and mood profiles (Profile of Mood States, POMS). Analysis of variance was used for comparison of questionnaires scores across specialties.

RESULTS

Authors reported no sleep deprivation, no sleep disorders and their outcomes, no changes in intellectual efficiency and no cognitive impairment in this population, neither in the areas performing night shifts nor in those involving only day shifts. Mood states measured by POMS showed a borderline level of Anger-Hostility (A) value among the residents of the medical area and services, and an increase slightly beyond the physiological levels of the T-score 50 of Fatigue-Inertia (F) always in the same groups. An increase in the Vigour-Activity (V) value beyond T-score 50 levels was also observed among residents of all the areas considered.

CONCLUSIONS

Emotional involvement could be attributed to the gap between high professional demand and lack of experience and knowledge among trainees. Tutors should help their students in order to identify earlier changes in the mood. Improvement in the organization of the trainee's activity could reduce the emotional overload.

Self and Other in Medical Education: Initial Emotional Intelligence Trend Analysis Widens the Lens Around Empathy and Burnout

Context

Integral to emotional intelligence (EI), empathy is frequently studied in medical students. While important, given the implications for patient safety and physician well-being, traits such as self-regard may also affect physician efficacy. Emotional intelligence offers a holistic framework from which to study empathy, allowing it to be explored with coexisting traits and offering opportunities to identify related risk factors.

Objective

To identify trends in osteopathic medical student EI to help mitigate burnout, with specific attention to empathy and self-regard.

Methods

Eight hundred eighty-five students at Western University of Health Sciences College of Osteopathic Medicine of the Pacific from classes 2014-2016 were offered the Emotional Quotient Inventory 2.0 (EQ-i) at the start of school, completion of their second year, and at graduation. Participants completed all 3 inventories, yielding a response rate of 16.3%. Repeated measurement analysis of variance analyses were conducted using SAS software for Windows version 9.3.

Results

A total of 144 students participated. The total EI score shifted from mean (SD) 100.2 (12.4) at baseline to 96.1 (12.8) midway to 96.8 (13.3) at graduation (P=.0161) with significant decreases between baseline and midway (P<.001) and baseline and final administrations (P<.001). Empathy declined from 103 (13.1) to 99.9 (12.7) to 99.6 (12.6) (P=.0481) with significant decreases between baseline and midway (P<.001) and baseline and final administrations (P<.001). Self-regard declined from 98.6 (14.1) to 95.8 (15.1) to 95.5 (14.7) (P=.135) with significant decreases between baseline and midway (P=.0021) and baseline and final administrations (P<.001).

Conclusion

This study's findings support further investigation of potential roles played by EI, empathy, and self-regard in physician burnout.

Poor Sleep Hygiene is Associated with Decreased Discrimination and Inattention on Continuous Performance Task in Doctor of Physical Therapy Students: A Cross-sectional Study

Introduction

Reduced sleep quality impairs learning, memory formation, attention, and executive function ability. Poor sleep quality or sleep hygiene has been shown to impair academic performance of undergraduate and medical students. The purpose of this study was to examine the association between sleep quality, sleep hygiene, and cognitive performance in Doctor of Physical Therapy (DPT) students.

Methods

Fifty DPT students at the University of Kansas Medical Center completed the Pittsburgh Sleep Quality Index (PSQI) and the Sleep Hygiene Index (SHI). Cognitive performance was assessed using the Continuous Performance Test (CPT) which is a test of sustained attention and the Trail-Making Task (TMT) to assess executive functioning. An actigraph was worn for one week to objectively characterize sleep outcomes. Spearman's correlations were performed to assess the association between self-report sleep quality, sleep hygiene, and outcomes on the cognitive tasks. Post-hoc Mann-Whitney and Kruskal-Wallis tests were conducted to examine group differences between sleep outcomes and cognitive performance for demographic variable categories.

Results

Twenty-three students (46%) reported poor sleep quality, and 27 participants (54%) had objectively-reported poor sleep quality. There was a significant positive correlation between SHI and Detectability (r_s= 0.297, p= 0.036) and Omissions (r_s=.343, p=0.015). There were group differences between sex and number of pets on the CPT outcomes, and there was a significant group difference between the number of drinks/week categories on the SHI.

Discussion and Conclusions

About half of the participants were identified as having poor sleep quality. Poorer sleep hygiene was associated with poorer discrimination and inattention, which could potentially impact the students' academic and clinical performance as well as their health and wellbeing. Also, certain demographic variables may modulate the results.

Encountering Patient Suicide During Psychiatric Training: An Integrative, Systematic Review

BACKGROUND/AIM

Patient suicide is an adversity that can be considered an "occupational hazard." It has been identified as one of the most stressful adverse events during psychiatric training. The aim of this study was to systematically review the literature assessing the impact of patient suicide on trainees.

METHODS

We conducted a systematic review on the MEDLINE, Science Direct, Scopus, and Web of Science databases. Studies that reported prevalence of patient suicide, quantitative or qualitative assessment of psychological and professional impacts, coping strategies, and support or educational and postvention programs were deemed eligible for inclusion.

RESULTS

Of the 1994 articles identified, 22 were included. The literature on the topic was scarce, and the quality of the studies was moderate. No article dealt with nonpsychiatric residents. During their training, 46.4% of psychiatric trainees encountered at least one patient suicide. The traumatic impact was significantly more intense in trainees compared to senior physicians. A negative impact on their professional practice was reported by 17% to 39% of trainees. Formal institutional support for the affected trainees was described as having major shortcomings, and informal support from peers and families was reported as the most helpful response. However, 52% of impacted trainees considered encountering patient suicide a useful and beneficial experience.

CONCLUSION

The frequent posttraumatic symptoms and the negative professional consequences following patient suicide are worrying phenomena that highlight the need to improve suicide prevention and postvention programs during psychiatric training. Identifying trainees with personal vulnerability factors should be a major concern during the postvention process.

Sleep among primary care physicians-Association with overtime, night duties and strategies to counteract poor sleep quality

Physicians belong to the risk group for sleep disorders as a result of work related stress, excessive working time, large amount of on-call duties and shift work. Poor sleep quality of healthcare providers threatens not only their safety, but also the safety of their patients. This study examines if there are any differences in how working either long hours or at night duties relates to self-reported sleep time, sleep quality and daytime sleepiness in primary care physicians. We analyzed data from a survey research of 807 participants. Respondents were divided into four groups based on their reported work hours per week and number of nights on duty per month. Overtime was associated with shorter sleep time and worse subjective sleep quality even when compared with that of participants who work on night duties. All investigated groups of participants reported short sleep latencies which suggests that sleep debt is a common problem in this population. Surprisingly in the case of poor sleep quality participants rarely used recommended methods like regular physical activity or specialist advice. The most frequently reported answer was that they do nothing to improve sleep and every third participants uses hypnotics to do that. These results suggest that primary care physicians despite being at high risk for sleep disorders due to working overtime and at night, pay less attention to their sleep quality and do not use recommended strategies to improve it.

Automatic Work-Hours Recorder for Medical Staff (Staff Hours): Mobile App Development

Background

There are numerous mobile apps for tracking work hours, but only a few of them record work hours automatically instead of relying on manual logging. No apps have been customized for medical staff, whose work schedules are highly complicated as they have both regular hours and on-call duties.

Objective

The specific aims of this study were to (1) identify the Staff Hours app users’ GPS-defined work hours, (2) examine the overtime work hours from the app-recorded total work hours and the participants’ self-reported scheduled work hours, and (3) compare these app-recorded total work hours among different occupations.

Methods

We developed an app, Staff Hours, to automatically calculate a user’s work hours via GPS background data. Users can enter their scheduled hours, including regular hours and on-call duties. The app automatically generates overtime reports by comparing the app-recorded total work hours with the user-defined scheduled hours. A total of 183 volunteers (60 females and 123 males; mean age 32.98 years, SD 6.74) were included in this study. Most of the participants (162/183, 88.5%) were medical staff, and their positions were resident physicians (n=89), visiting staff (n=38), medical students (n=10), registered nurses (n=25), and non–health care professionals (non-HCPs; n=21).

Results

The total work hours (mean 55.69 hours, SD 21.34) of the 183 participants were significantly higher than their scheduled work hours (mean 50.67 hours, SD 21.44; P=.01). Medical staff had significantly longer total work hours (mean 57.01 hours, SD 21.20) than non-HCPs (mean 45.48 hours, SD 20.08; P=.02). Residents (mean 60.38 hours, SD 18.67) had significantly longer work hours than visiting staff (mean 51.42 hours, SD 20.33; P=.03) and non-HCPs (mean 45.48 hours, SD 20.08; P=.004).

Conclusions

Staff Hours is the first automatic GPS location–based app designed for medical staff to track work hours and calculate overtime. For medical staff, this app could keep complete and accurate records of work hours in real time, reduce bias, and allow for better complying with labor regulations.

Cardiac Autonomic Modulation during on-Call Duty under Working Hours Restriction

Background: Medical residency is a time of high stress and long working hours, which increase the risk of cardiovascular disease. This study aimed to investigate the autonomic modulation of resident physicians throughout the on-call duty cycle. Methods: Spectral analysis of heart rate variability (HRV) was used to compute cardiac parasympathetic modulation (high-frequency power, HF) and cardiac sympathetic modulation (normalized low-frequency power, LF%, and the ratio of LF and HF, LF/HF) of 18 residents for a consecutive 4-day cycle. Results: Male residents show reduced cardiac sympathetic modulation (i.e., higher LF/HF and LF%) than the female interns. Medical residents’ cardiac parasympathetic modulation (i.e., HF) significantly increased on the first and the second post-call day compared with the pre-call day. In contrast, LF% was significantly decreased on the first and the second post-call day compared with the pre-call day. Similarly, LF/HF was significantly decreased on the second post-call day compared with the pre-call day. LF/HF significantly decreased on the first post-call day and on the second post-call day from on-call duty. Conclusion: The guideline that limits workweeks to 80 h and shifts to 28 h resulted in reduced sympathetic modulation and increased parasympathetic modulation during the two days following on-call duty.

Working hours, common mental disorder and suicidal ideation among junior doctors in Australia: a cross-sectional survey

OBJECTIVE

Despite concern regarding high rates of mental illness and suicide amongst the medical profession, the link between working hours and doctors' mental health remains unclear. This study examines the relationship between average weekly working hours and junior doctors' (JDs') mental health in Australia.

DESIGN AND PARTICIPANTS

A randomly selected sample of 42 942 Australian doctors were invited to take part in an anonymous Beyondblue National Mental Health Survey in 2013, of whom 12 252 doctors provided valid data (response rate approximately 27%). The sample of interest comprised 2706 full-time graduate medical trainees in various specialties, at either intern, prevocational or vocational training stage. Consultants and retired doctors were excluded.

OUTCOME MEASURES

Main outcomes of interest were caseness of common mental disorder (CMD) (assessed using a cut-off of 4 as a threshold on total General Health Questionnaire-28 score), presence of suicidal ideation (SI) (assessed with a single item) and average weekly working hours. Logistic regression modelling was used to account for the impact of age, gender, stage of training, location of work, specialty, marital status and whether JDs had trained outside Australia.

RESULTS

JDs reported working an average of 50.1 hours per week (SD=13.4). JDs who worked over 55 hours a week were more than twice as likely to report CMD (adjusted OR=2.05; 95% CI 1.62 to 2.59, p<0.001) and SI (adjusted OR=2.00; 95% CI 1.42 to 2.81, p<0.001) compared to those working 40-44 hours per week.

CONCLUSIONS

Our results show that around one in four JDs are currently working hours that are associated with a doubling of their risk of common mental health problems and SI. These findings suggest that management of working hours represents an important focus for workplaces to improve the mental health of medical trainees.

Mental Fatigue Evaluation of Surgical Teams during a Regular Workday in a High-Volume Tertiary Healthcare Center

INTRODUCTION

Considering the complex set of manual and psychological tasks a surgeon has to perform during the day, it is very important to assess the surgeon's fatigability, reaction time, attention, and memory.

OBJECTIVE

Here, we wanted to determine the mental fatigue status of surgeons and how their abilities are affected through a regular workday.

METHODS

We included 3 senior urologists and 6 urology residents. In a set period of time, we assessed their fatigue through self-assessed fatigue, Samn-Perelli score, and Karolinska sleepiness scale score. Further, reaction time, attention, and memory correlated with the number of the operations in the day, and total number of operations in that day were assessed.

RESULTS

As the number of tasks increases, and as the surgeons advance to the end of the workday, they become more fatigued, reaction time ultimately increases, and attention and memory become slightly altered.

CONCLUSIONS

Complications resulting from the fatigue of surgeons could be serious. Their performance status and skills decrease as they perform more tasks or advance through the day.

Neurobehavioural complications of sleep deprivation: Shedding light on the emerging role of neuroactive steroids

Sleep deprivation (SD) is associated with a broad spectrum of cognitive and behavioural complications, including emotional lability and enhanced stress reactivity, as well as deficits in executive functions, decision making and impulse control. These impairments, which have profound negative consequences on the health and productivity of many individuals, reflect alterations of the prefrontal cortex (PFC) and its connectivity with subcortical regions. However, the molecular underpinnings of these alterations remain elusive. Our group and others have begun examining how the neurobehavioural outcomes of SD may be influenced by neuroactive steroids, a family of molecules deeply implicated in sleep regulation and the stress response. These studies have revealed that, similar to other stressors, acute SD leads to increased synthesis of the neurosteroid allopregnanolone in the PFC. Whereas this up-regulation is likely aimed at counterbalancing the detrimental impact of oxidative stress induced by SD, the increase in prefrontal allopregnanolone levels contributes to deficits in sensorimotor gating and impulse control, signalling a functional impairment of PFC. This scenario suggests that the synthesis of neuroactive steroids during acute SD may be enacted as a neuroprotective response in the PFC; however, such compensation may in turn set off neurobehavioural complications by interfering with the corticolimbic connections responsible for executive functions and emotional regulation.

The effect of off-hour delivery on severe maternal morbidity: a population-based cohort study

BACKGROUND

Severe maternal morbidity is an indicator for quality of maternal care. Recently, there has been growing interest in identifying which provision factors affect the quality of maternity care. The extent to off-hour delivery on SMM rates contributes to individual or provision factor in Korea has not been studied. This study aimed to determine the relationship between off-hour delivery and SMM during childbirth hospitalization.

METHODS

This is a population-based retrospective cohort study. Data were extracted from the Korean National Health Insurance Service-National Sample Cohort for 90 072 cases of delivery in Korea between 2003 and 2013. The main outcome was SMM which was determined using the Center for Disease Control and Prevention's algorithm. A generalized estimating equation model with log link was performed for the relationship with SMM and day/time of delivery adjusted covariates.

RESULTS

Of the 90 072 delivery cases, 2085 (2.31%) had SMM. Women who were on weekdays at night time or on weekend delivery had a higher risk of SMM compared with those who were on weekdays at daytime (RR 1.26, 95% CI 1.10-1.46, and RR 1.58, 95% CI 1.30-1.93, respectively).

CONCLUSION

Weekday at night time or weekend delivery was related to the risk of SMM. Policymakers should provide financial support and systematically allocate adequate human resources and labour facilities in vulnerable areas, as well as during weekends and night times to improve the quality of intrapartum and postpartum maternity care.

Frequency, Timing, and Types of Medication Ordering Errors Made by Residents in the Electronic Medical Records Era

OBJECTIVES

To describe associations between resident level of training, timing of medication orders, and the types of inpatient medication ordering errors made by internal medicine residents.

METHODS

This study reviewed all inpatient medication orders placed by internal medicine residents at a tertiary care academic medical center from July 2011 to June 2015. Medication order errors were measured by pharmacists' reporting of an error via the electronic medical record during real-time surveillance of orders. Multivariable regression models were constructed to assess associations between resident training level (postgraduate year [PGY]), medication order timing (time of day and month of year), and rates of medication ordering errors.

RESULTS

Of 1,772,462 medication orders placed by 335 residents, 68,545 (3.9%) triggered a pharmacist intervention in the electronic medical record. Overall and for each PGY level, renal dose monitoring/adjustment was the most common order error (40%). Ordering errors were less frequent during the night and transition periods versus daytime (adjusted odds ratio [aOR] 0.93, 95% confidence interval [CI] 0.91-0.96, and aOR 0.93, 95% CI 0.90-0.95, respectively). Errors were more common in July and August compared with other months (aOR 1.05, 95% CI 1.01-1.09). Compared with PGY2 residents, both PGY1 (aOR 1.06, 95% CI 1.03-1.10), and PGY3 residents (aOR 1.07, 95% CI, 1.03-1.10) were more likely to make medication ordering errors. Throughout the course of the academic year, the odds of a medication ordering error decreased by 16% (aOR 0.84, 95% CI 0.80-0.89).

CONCLUSIONS

Despite electronic medical records, medication ordering errors by trainees remain common. Additional supervision and resident education regarding medication orders may be necessary.

Life satisfaction in Norwegian medical doctors: a 15-year longitudinal study of work-related predictors

BACKGROUND

Despite many recent studies on burn-out and dissatisfaction among American medical doctors, less is known about doctors in the Scandinavian public health service. The aims of this study were to analyse long-term work-related predictors of life satisfaction among established doctors in Norway and to identify predictors in a subgroup of doctors who reported a decline in life satisfaction.

METHODS

Two nationwide cohorts of doctors (n = 1052), who graduated medical school 6 years apart, were surveyed at graduation from medical school (T1, 1993/94 and 1999), and 4 (T2), 10 (T3), and 15 (T4) years later. Work-related predictors of life satisfaction (three items) obtained at T2 to T4 were analysed. Individual and lifestyle confounders were controlled for using mixed-models repeated-measures analyses, and logistic regression analyses were applied to identify predictors of the decrease in life satisfaction.

RESULTS

Ninety per cent (947/1052) responded at least once, and 42% (450/1052) responded at all four times. Work-related predictors of higher life satisfaction in the adjusted model were work-home stress (β = - 0.20, 95% confidence interval [CI] = - 0.25 to - 0.16, p < 0.001), perceived job demands (β = - 0.10, CI = - 0.15 to - 0.05, p < 0.001), and colleague support (β = 0.05, CI = 0.04 to 0.07, p < 0.001). The new adjusted individual predictors that we identified included female gender, reality weakness trait, and problematic drinking behaviour. Neuroticism trait and low colleague support predicted a decrease in life satisfaction.

CONCLUSIONS

Work-home stress, perceived job demands, and colleague support were the most important predictors of life satisfaction related to doctors' work. When personality traits were controlled for, female doctors were more satisfied with their life than male doctors. These findings suggest that improving work-related factors with targeted interventions, including a supportive work environment, may increase life satisfaction among doctors.

Resident Physicians are at Increased Risk for Dangerous Driving after Extended-duration Work Shifts: A Systematic Review

BACKGROUND

Resident physicians often work longer than 24 consecutive hours with little or no sleep. A systematic review of the literature was conducted to investigate the risk of resident physician motor vehicle collisions (MVC), and dangerous driving, after extended-duration work shifts (EDWS).

MATERIAL AND METHODS

A keyword search was performed for original research articles evaluating any aspect of driving safety following EDWS for the resident physician population. Two authors independently reviewed articles for inclusion. Subsequent independent data abstraction and quality appraisal were carried out. Five articles met the study inclusion criteria.

RESULTS

The quality of the evidence was low to very low. Results were not pooled due to study heterogeneity. Residents reported between 2.3 to 3.8 hours of sleep during EDWS. Three survey-based studies identified an increased risk of MVCs and falling asleep at the wheel after EDWS. One study associated weekly cumulative sleep hours lost with the risk of falling asleep while driving. Both driving simulation and survey studies linked EDWS with MVCs. Notably, a driving simulation study found an increase in crash frequency in male residents post-EDWS. Additionally, a survey reported that the risk of an MVC post-EDWS increased by 16.2% per shift worked in a month.

CONCLUSION

The period following EDWS is associated with an increased risk of potentially life-threatening driving safety risks for resident physicians. These observations warrant careful consideration. They suggest that there is a need for greater awareness and action in order to avoid the occupational and public health risks of driving after EDWS.

Sleep quality and daytime sleepiness among Polish anaesthesiologists and intensivists

PURPOSE

We aimed to investigate sleep quality (SQ), daytime sleepiness (DS), and their relation with subject- and work-related factors among Polish anaesthesiologists.

METHODS

The study group comprised 786 anaesthesiologists. The Sleep Quality Scale (SQS) was applied in order to assess SQ, while excessive DS was evaluated using the Epworth Sleepiness Scale (ESS).

RESULTS

The median score on the SQS was 31 (IQR 27-35) points. The median score on the ESS was 17 (IQR 13-20) points, with mild-to-moderate excessive DS found in 260 (33.1%) and severe excessive DS among 478 (60.8%) of those surveyed. Worse SQ was found in females; smokers; those who suffered from any chronic diseases; those who were receiving medication interfering with sleeping habits; those who were unsatisfied with their sleep; those who had a greater number of night shifts; and those who had a lower number of non-working days. A detrimental sleepiness pattern was determined by one's advanced age, the presence of any chronic diseases and lower satisfaction with one's sleep quantity.

CONCLUSION

Poor SQ and excessive DS are frequently occurring phenomena. Since sleep disturbances are also related to the nature of their profession, the problem could be reduced by introducing organisational changes at work.

Prevalence of sleep disturbances in Chinese healthcare professionals: a systematic review and meta-analysis

OBJECTIVE

The current review is a systematic, quantitative meta-analysis aimed at examining the pooled prevalence of sleep disturbances in Chinese healthcare professionals. Furthermore, we explore the possible causes of the inconsistencies in the current estimates.

METHODS

Systematic searches of databases were conducted for literature published on English (EMBASE, PubMed and Web of Science) and Chinese (Chinese National Knowledge Infrastructure, Wan Fang database and Chinese Science & Technology journal database) databases until 25 May 2018. Statistical analyses were performed using SPSS and R software, the prevalence of sleep disturbances was pooled using random-effects model.

RESULTS

A total of 52 studies with 31,749 participants were included. The pooled prevalence of sleep disturbances among Chinese healthcare professionals is 39.2% (95% CI: 36.0%-42.7%). Higher sleep disturbance rates are associated with being female, lower cut-off of Pittsburgh Sleep Quality Index (PSQI), later survey year, bigger sample size, the standardized assessment tool, being a nurse, and shift work. Sample size and cut-off of PSQI were significant moderators for heterogeneity.

CONCLUSION

Sleep disturbances are common in Chinese healthcare professionals, and their prevalence is much higher than the general population. Further research is needed to identify effective strategies for preventing and treating sleep disturbances among healthcare professionals.

Association between night-time surgery and occurrence of intraoperative adverse events and postoperative pulmonary complications

BACKGROUND

The aim of this post hoc analysis of a large cohort study was to evaluate the association between night-time surgery and the occurrence of intraoperative adverse events (AEs) and postoperative pulmonary complications (PPCs).

METHODS

LAS VEGAS (Local Assessment of Ventilatory Management During General Anesthesia for Surgery) was a prospective international 1-week study that enrolled adult patients undergoing surgical procedures with general anaesthesia and mechanical ventilation in 146 hospitals across 29 countries. Surgeries were defined as occurring during 'daytime' when induction of anaesthesia was between 8:00 AM and 7:59 PM, and as 'night-time' when induction was between 8:00 PM and 7:59 AM.

RESULTS

Of 9861 included patients, 555 (5.6%) underwent surgery during night-time. The proportion of patients who developed intraoperative AEs was higher during night-time surgery in unmatched (43.6% vs 34.1%; P<0.001) and propensity-matched analyses (43.7% vs 36.8%; P=0.029). PPCs also occurred more often in patients who underwent night-time surgery (14% vs 10%; P=0.004) in an unmatched cohort analysis, although not in a propensity-matched analysis (13.8% vs 11.8%; P=0.39). In a multivariable regression model, including patient characteristics and types of surgery and anaesthesia, night-time surgery was independently associated with a higher incidence of intraoperative AEs (odds ratio: 1.44; 95% confidence interval: 1.09-1.90; P=0.01), but not with a higher incidence of PPCs (odds ratio: 1.32; 95% confidence interval: 0.89-1.90; P=0.15).

CONCLUSIONS

Intraoperative adverse events and postoperative pulmonary complications occurred more often in patients undergoing night-time surgery. Imbalances in patients' clinical characteristics, types of surgery, and intraoperative management at night-time partially explained the higher incidence of postoperative pulmonary complications, but not the higher incidence of adverse events.

CLINICAL TRIAL REGISTRATION

NCT01601223.

Factors That Contribute to Excessive Sleepiness in Midwives Practicing in the United States

INTRODUCTION

Excessive daytime sleepiness is defined as difficulty maintaining wakefulness and alertness during normal waking hours. Excessive daytime sleepiness can lead to clinical errors in health care workers and is associated with dangerous driving. Little is known about the level of daytime sleepiness in midwives in the United States. The purposes of this study, conducted by the American College of Nurse-Midwives (ACNM) Sleep and Safety Taskforce, were first to identify the sleepiness level of US certified nurse-midwives (CNMs) and certified midwives (CMs) by calculating Epworth Sleepiness Scale scores for CNM/CMs in full-scope practice, and then to determine factors that significantly contribute to elevated Epworth Sleepiness Scale scores (>10).

METHODS

Participants in this descriptive, correlational survey study were active ACNM members in full-scope midwifery practice. Descriptive statistics, bivariate analysis, and logistic regression were used for data analysis. Surveys were emailed to all active members of ACNM (N = 4358).

RESULTS

A total of 753 (17.3%) survey responses were returned, of which 639 (14.7%) were eligible for analysis. Within this group, 639 (84.9%) self-identified as being in full-scope midwifery practice, and one-fourth (n = 164; 25.7%) had elevated Epworth Sleepiness Scale scores. Duration of work shifts was the only variable found to significantly contribute to differences in Epworth Sleepiness Scale scores, with midwives working shifts longer than 12 hours having higher rates of excessive daytime sleepiness compared with midwives who worked shifts of 12 hours or less.

DISCUSSION

Midwives, midwifery services, and maternity care centers can work together to ensure that clinicians obtain adequate sleep. Reducing excessive sleepiness will contribute to increased safety for midwives, women, newborns, and the general public.

Improving the working environment for the delivery of safe surgical care in the UK: a qualitative cross-sectional analysis

OBJECTIVES

The aim of this study was to identify current problems and potential solutions to improve the working environment for the delivery of safe surgical care in the UK.

DESIGN

Prospective, questionnaire-based cross-sectional study.

SETTING/PARTICIPANTS

Following validation, an electronic questionnaire was distributed to postgraduate local education and training board distribution lists, the Royal College of Surgeons of Edinburgh (RCSEd) mailing lists and trainee organisations. This consisted of a single open-ended question inviting five open-ended responses. Throughout the 13-week study period, the survey was also published on a number of social media platforms.

RESULTS

A total of 505 responders completed the survey, of which 35% were consultants, 30% foundation doctors, 17% specialty trainees, 11% specialty doctors, 5% core trainees and <1% surgical nurse practitioners. A total of 2238 free-text answers detailed specific actions to improve the working environment. These responses were individually coded and then grouped into nine categories (staff resources, non-staff resources, support, working conditions, communication and team work, systems improvement, patient centred, training and education, and miscellaneous).

CONCLUSIONS

The results of this study have identified a number of key areas that, if addressed, may improve the environment for the delivery of safer surgical care. Common themes that emerged across all grades included: increased front-line staff; a return to a 'firm' structure to improve team continuity; greater senior support; and improved hospital facilities to help staff rest and recuperate. While unlimited funding remains unrealistic, many of the suggestions could be implemented in a cost-neutral fashion and include insightful ideas for remodelling or restructuring the workforce to improve the efficiency of the surgical team. The findings of this study formed the basis of a set of recommendations published by the RCSEd as a discussion paper.

Adapting Maslow's Hierarchy of Needs as a Framework for Resident Wellness

ISSUE

Burnout in graduate medical education is pervasive and has a deleterious impact on career satisfaction, personal well-being, and patient outcomes. Interventions in residency programs have often addressed isolated contributors to burnout; however, a more comprehensive framework for conceptualizing wellness is needed.

EVIDENCE

In this article the authors propose Maslow's hierarchy of human needs (physiologic, safety, love/belonging, esteem, and self-actualization) as a potential framework for addressing wellness initiatives. There are numerous contributors to burnout among physician-trainees, and programs to combat burnout must be equally multifaceted. A holistic approach, considering both the trainees personal and professional needs, is recommended. Maslow's Needs can be adapted to create such a framework in graduate medical education. The authors review current evidence to support this model.

IMPLICATIONS

This work surveys current interventions to mitigate burnout and organizes them into a scaffold that can be used by residency programs interested in a complete framework to supporting wellness.

Physician Parents Attending Work Despite Own Sick Children: A Qualitative Study on Caregiver Presenteeism Among Norwegian Hospital Physicians

BACKGROUND

Studies have shown that physicians manifest a clear duty to work, even in the face of personal risk, and despite their own symptoms of ill health; this is termed presenteeism. We lack knowledge on their willingness to attend work when their children are sick or in times of concern for their unborn; this is termed caregiver presenteeism. To gain a comprehensive knowledge on the occurrence of presenteeism among physicians, it is important to include caregiver presenteeism.

OBJECTIVE

The aim of this study is to explore the perception and experience with caregiver presenteeism among hospital physicians who are parents or pregnant and to explore its foundations and its consequences.

METHODS

Secondary thematic analysis of semi-structured interviews of hospital physicians (N = 18).

RESULTS

Positive and negative dimensions associated with (1) situations with severe pregnancy symptoms or responsibility for sick children; (2) the perceived impact on their work commitments, personal health, and adequate care for own children; (3) accompanying moderators in the organisational structure and professional culture; and (4) proposed approaches to resolve caregiver and work responsibilities simultaneously contributing to caregiver presenteeism.

CONCLUSIONS

The study underlines the impact of factors in organisational structure, professional culture, and the personal sphere affecting caregiver presenteeism. It appears that targeting factors contributing to attendance pressure in physicians, including those who are pregnant, is particularly important. This includes changing attitudes towards caregiver responsibilities among physician colleagues, department leaders, and physicians themselves, as well as simple cost-efficient organisational interventions in staffing, routines of absence, and work adjustment.

Sleep: its importance and the effects of deprivation on surgeons and other healthcare professionals

As clinicians, we sometimes fail to look after ourselves properly and do not regularly eat healthy foods or drink enough. Sleep is another factor that we often neglect. A lack of it can compromise our personal health and performance at work, and the "sleep debt" that results when this is chronic can take far longer to recover from than one might think. Now that junior doctors work more shift rotas and senior colleagues have onerous on-call responsibilities, we all need to be aware of the effects of sleep deprivation, which can lower the mood and motivation, weaken leadership, and result in more clinical errors. In this review we consider what might constitute enough sleep, the consequences of inadequate sleep, and how these might be addressed for surgeons.

Impact of CAre-related Regret Upon Sleep (ICARUS) cohort study: protocol of a 3-year multicentre, international, prospective cohort study of novice healthcare professionals

INTRODUCTION

Healthcare professionals are particularly at risk of developing numerous physical and psychological health problems. The experiences of emotional burden associated with providing healthcare, notably care-related regret, have been associated with these health problems, but only using cross-sectional data so far. Evidence of a causal impact of regret has not been assessed. The Impact of CAre-related Regret Upon Sleep (ICARUS) study is the first prospective and international cohort study established to examine how newly practising healthcare professionals adapt to their challenging job by assessing the impact of care-related regret on sleep and job quitting.

METHOD AND ANALYSIS

The ICARUS cohort study will include newly practising healthcare professionals working in acute care hospitals and clinics recruited between May 2017 and November 2019. Data collection, which will begin as soon as the participant starts working with patients, will consist of a 1-year weekly assessment using a secure web survey. Follow-up data will be collected at 6, 12, 18 and 24 months after the end of the first year. We will collect detailed information on the experience of care-related regret (ie, highest regret intensity, accumulation of regrets and coping strategies related to regrets), sleep problems and job quitting. Moreover, quality of life, health status and burnout will be assessed during the follow-up. Several confounders factors, including sociodemographic characteristics, personality, night shifts and work environment characteristics, will be assessed.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Committee of Geneva Canton, Switzerland (CCER2016-02041), the Ethics Committee of London South Bank University (HSCSEP/17/06) and the University Research Ethics Committee of Bedfordshire (UREC106). Other study centres deemed local ethical approval unnecessary since the main ethics committee (Geneva) had already accepted the project. Results will be published in relevant scientific journals and be disseminated in international conferences. Fully anonymised data and questionnaires will be freely accessible to everyone (scientists and general public).

Caffeine to optimize cognitive function for military mission-readiness: a systematic review and recommendations for the field

Context

In 2001 the Institute of Medicine (IOM) released a report on the use of caffeine during sustained military operations in which recommendations for research and practice were made.

Objective

This systematic review serves as an update on the current quality of the evidence and addresses gaps in the current literature surrounding the effects of caffeinated foods and beverages on cognitive functioning in healthy adult populations exposed to military-like moderators.

Data Sources

PubMed, CINAHL, Embase, PsycInfo, and the Cochrane Library were searched.

Study Selection

Peer-reviewed randomized controlled trials published in the English language since 1998 were eligible.

Data Extraction

Twenty-five trials were included and assessed for methodological quality, and descriptive data were extracted according to each military-like moderator identified.

Data Synthesis

Moderators included sleep deprivation (n = 17), physical or mental exertion (n = 4), sleep deprivation combined with a sustained military operation (n = 3), and physical exertion combined with low ambient temperature (n = 1).

Conclusions

The effects of caffeine supplementation on cognitive functioning in sleep-deprived subjects included improvements in attention and vigilance, complex reaction time, and problem solving and reasoning in the trials reviewed. These findings are consistent with the conclusions reached in the 2001 IOM report. This review contributes to the field by addressing gaps outlined in the IOM report.

Shorter Versus Longer Shift Durations to Mitigate Fatigue and Fatigue-Related Risks in Emergency Medical Services Personnel and Related Shift Workers: A Systematic Review

BACKGROUND

This study comprehensively reviewed the literature on the impact of shorter versus longer shifts on critical and important outcomes for Emergency Medical Services (EMS) personnel and related shift worker groups.

METHODS

Six databases (e.g., PubMed/MEDLINE) were searched, including one website. This search was guided by a research question developed by an expert panel a priori and registered with the PROSPERO database of systematic reviews (2016:CRD42016040099). The critical outcomes of interest were patient safety and personnel safety. The important outcomes of interest were personnel performance, acute fatigue, sleep and sleep quality, retention/turnover, long-term health, burnout/stress, and cost to system. Screeners worked independently and full-text articles were assessed for relevance. Data abstracted from the retained literature were categorized as favorable, unfavorable, mixed/inconclusive, or no impact toward the shorter shift duration. This research characterized the evidence as very low, low, moderate, or high quality according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology.

RESULTS

The searched yielded n = 21,674 records. Of the 480 full-text articles reviewed, 100 reported comparisons of outcomes of interest by shift duration. We identified 24 different shift duration comparisons, most commonly 8 hours versus 12 hours. No one study reported findings for all 9 outcomes. Two studies reported findings linked to both critical outcomes of patient and personnel safety, 34 reported findings for one of two critical outcomes, and 64 did not report findings for critical outcomes. Fifteen studies were grouped to compare shifts <24 hours versus shifts ≥24 hours. None of the findings for the critical outcomes of patient and personnel safety were categorized as unfavorable toward shorter duration shifts (<24 hours). Nine studies were favorable toward shifts <24 hours for at least one of the 7 important outcomes, while findings from one study were categorized as unfavorable. Evidence quality was low or very low.

CONCLUSIONS

The quality of existing evidence on the impact of shift duration on fatigue and fatigue-related risks is low or very low. Despite these limitations, this systematic review suggests that for outcomes considered critical or important to EMS personnel, shifts <24 hours in duration are more favorable than shifts ≥24 hours.

The Media Response to the ACGME's 2017 Relaxed Resident Duty-Hour Restrictions

PURPOSE

In March 2017, the ACGME relaxed resident duty-hour restrictions to allow first-year residents to work 24-hour shifts, affecting the internship experience of incoming radiology residents. The aim of this study was to assess the media response to this duty-hour change, comparing news articles with favorable and unfavorable views.

METHODS

Google News was used to identify 36 relevant unique news articles published over a 4-week period after the announcement. Articles' stance was categorized as favorable, unfavorable, or neutral. Additional article characteristics were explored.

RESULTS

Article sources were 58% national, 22% local, and 20% medical news. Article stance was most commonly unfavorable for national news sources (48%), compared with neutral for local (62%) and medical (72%) news sources. Most common reasons for unfavorable stance were sleep deprivation (n = 11), medical errors (n = 11), residents' health (n = 9), risk for car accidents (n = 9), a patriarchal hazing system (n = 6), and work-life balance (n = 5). Most common reasons for favorable stance were impact on resident education (n = 7) and continuity of care (n = 7). Supporting data were cited by 38% of unfavorable and 100% of favorable articles. Unfavorable articles most commonly quoted physicians affiliated with resident advocacy groups; favorable articles most commonly quoted physicians affiliated with the ACGME.

CONCLUSIONS

The relaxed duty-hour restrictions received an overall unfavorable media response, particularly in nonmedical news sources, driven by concerns regarding sleep-deprived doctors. Favorable articles ubiquitously cited data supporting the safety of relaxed duty hour restrictions. Further research is warranted to better understand the impact of relaxed resident duty-hour limits on sleep deprivation, residents' health and education, and the quality of patient care.

Influence of Shift Duration on Cognitive Performance of Emergency Physicians: A Prospective Cross-Sectional Study

STUDY OBJECTIVE

The relationship between tiredness and medical errors is now commonly accepted. The main objective of this study is to evaluate the cognitive performance of emergency physicians after a night shift of 14 hours (H14) and after a work shift of 24 hours (H24) and to compare it with tests performed after a rest night at home (H0).

METHODS

Forty emergency physicians (19 staff physicians and 21 residents) were randomly evaluated at H0, H14, and H24. Four cognitive abilities (processing speed, working memory capacity, perceptual reasoning, and cognitive flexibility) were tested according to the Wechsler Adult Intelligence Scale and the Wisconsin Card Sorting Test.

RESULTS

No cognitive ability was significantly altered after H14 compared with H0. Three of 4 cognitive abilities were impaired at H24 compared with H0: processing speed (11.2 [SD 2.7] versus 12.4 [SD 3.2]; mean difference=-1.2 [95% confidence interval -1.9 to -0.5]), working memory capacity (10.1 [SD 2.9] versus 11.6 [SD 3.0]; mean difference=-1.5 [95% confidence interval -2.2 to -0.8]), and perceptual reasoning (8.4 [SD 2.7] versus 10.6 [SD 2.8]; mean difference=-2.2 [95% confidence interval -3.4 to -1.0]). Cognitive abilities were not different between residents and staff physicians (except for perceptual reasoning) and were not affected by the amount of sleep during the night shift.

CONCLUSION

The cognitive abilities of emergency physicians were significantly altered after a 24-hour shift, whereas they were not significantly different from the rested condition after a 14-hour night shift. Limiting 24-hour shift work for emergency physicians should be considered and further evaluated.

Incorporation of a Physical Education and Nutrition Program Into Neurosurgery: A Proof of Concept Pilot Program

BACKGROUND

Balancing the demands of a busy medical career with personal wellness can be daunting, and there is little education on these principles available to physicians in training.

OBJECTIVE

To implement a voluntary wellness initiative in our neurosurgery department to promote healthy lifestyle choices. This report details the baseline data collected as part of this quality improvement initiative.

METHODS

The wellness initiative was implemented in July 2015 and available to all faculty and resident physicians in the Department of Neurological Surgery in collaboration with the Medical University of South Carolina Wellness Center. All participants were provided a Fitbit Surge HR wrist monitor (Fitbit, Boston, Massachusetts) and underwent baseline physical and psychological testing.

RESULTS

Six faculty physicians and 9 residents participated. Overall physical fitness levels varied widely between subjects. Health screening demonstrated abnormalities in 80% of participants (elevated systolic blood pressure in 60%, elevated diastolic in 47%, elevated serum low-density lipoprotein in 53%). Body composition analysis demonstrated body weight higher than ideal in 69% (47% overweight; 13% obese). Recommended average body fat mass reduction was 25.4 pounds. Seventy-nine percent reported below-average quality of life compared with the average healthy adult. All subjects reported wanting more time for personal health.

CONCLUSION

Baseline health and psychological screenings in our department demonstrated alarmingly prevalent, previously undiagnosed abnormalities on cardiovascular and body weight screenings. Obstacles to leading a healthier lifestyle have been identified and solutions have been incorporated into the program. This quality improvement initiative may serve as a template for other programs seeking to improve physician physical and mental well-being.

ABBREVIATIONS

BMI, body mass indexESS, Epworth Sleepiness ScaleHR, heart rate.

New common program requirements for the resident physician workforce and the omission of strategic napping: A missed opportunity

OBJECTIVES

Napping has known benefits for fatigue mitigation and improved alertness. However the Accreditation Council for Graduate Medical Education (ACGME) New Common Program Requirements recently removed the 16 h work limit for PGY1 residents and removed any suggestions of napping.

METHODS

We utilized a cross-sectional study design to administer a 44-item questionnaire in June 2016 to 858 residents and fellows at one large urban academic medical center. We assessed: 1) resident physician sentiment of work environment supportiveness for napping at work; and 2) agreement with 2011 ACGME guidelines on workweek hour limitations and strategic napping recommendations.

RESULTS

While 89% of residents reported access to an on-call room at work, only 20% felt their work environment supported a culture of napping while at work. Over 76% expressed agreement with the 2011 ACGME work-hour restrictions.

CONCLUSIONS

Strategies to support napping and well-being within the resident physician workforce and organizational setting are warranted.

Contextual Factors and Mental Distress as Possible Predictors of Hazardous Drinking in Norwegian Medical Doctors: A 15-Year Longitudinal, Nationwide Study

BACKGROUND

We have previously identified long-term individual predictors of hazardous drinking in doctors, but longitudinal studies on contextual factors (work and life stress) and mental distress being independently linked to hazardous drinking over the first 15 years of a medical career are lacking.

METHODS

Two nationwide cohorts of Norwegian doctors (n = 1,052) from all 4 Norwegian universities were surveyed in their final year of medical school (1993/1994 and 1999) (T1), and 4 (T2), 10 (T3), and 15 (T4) years later. Hazardous drinking was measured using a validated 9-item version of the Alcohol Use Disorder Identification Test. Work-related and other predictors were analysed using generalized estimating equations.

RESULTS

Ninety percent (947/1,052) responded at least once, and 42% (450/1,052) responded at all 4 time points. Hazardous drinking was reported by 16% at T1, 14% at T2 and T3, and 15% at T4. Life events (p = 0.009) and mental distress (p = 0.002) were adjusted predictors of hazardous drinking, in addition to male gender, no religious activity, drinking to cope with tension, and low conscientiousness.

CONCLUSIONS

Doctors' work-related stress was not linked to hazardous drinking, but life events, mental distress, and drinking to cope were. Prevention should target mental distress and drinking to cope with tension.

Trouble Sleeping Associated With Lower Work Performance and Greater Health Care Costs: Longitudinal Data From Kansas State Employee Wellness Program

OBJECTIVE

To examine the relationships between employees' trouble sleeping and absenteeism, work performance, and health care expenditures over a 2-year period.

METHODS

Utilizing the Kansas State employee wellness program (EWP) data set from 2008 to 2009, multinomial logistic regression analyses were conducted with trouble sleeping as the predictor and absenteeism, work performance, and health care costs as the outcomes.

RESULTS

EWP participants (N = 11,698 in 2008; 5636 followed up in 2009) who had higher levels of sleep disturbance were more likely to be absent from work (all P < 0.0005), have lower work performance ratings (all P < 0.0005), and have higher health care costs (P < 0.0005). Longitudinally, more trouble sleeping was significantly related to negative changes in all outcomes.

CONCLUSIONS

Employees' trouble sleeping, even at a subclinical level, negatively impacts on work attendance, work performance, and health care costs.

No Variation in Patient Care Outcomes After Implementation of Resident Shift Work Duty Hour Limitations and a Hospitalist Model System

This study examines whether implementing a resident shift work schedule (RSWS) alone or combined with a hospitalist-led model system (HMS/RSWS) affects patient care outcomes or costs at a pediatric tertiary care teaching hospital. A retrospective sample compared pre- and postintervention groups for the most common primary discharge diagnoses, including asthma and cellulitis (RSWS intervention) and inflammatory bowel disease and diabetic ketoacidosis (HMS/RSWS intervention). Outcome variables included length of stay, number of subspecialty consultations, and hospitalization charges. For the RSWS intervention, the preintervention (n = 107) and postintervention (n = 92) groups showed no difference in any of the outcome variables. For the HMS/RSWS intervention, the preintervention (n = 98) and postintervention (n = 69) groups did not differ in demographics or length of stay. However, subspecialty consultations increased significantly during postintervention from 0.83 to 1.52 consults/hospitalization ( P < .01) without significantly increasing hospitalization charges. Neither the RSWS nor HMS/RSWS intervention affected patient care outcomes at a pediatric tertiary care teaching hospital.

Resident fatigue in otolaryngology residents: a Web based survey

IMPORTANCE

Resident fatigue has become a point of emphasis in medical education and its effects on otolaryngology residents and their patients require further study.

OBJECTIVE

The purpose of our study was to evaluate the prevalence and nature of fatigue in otolaryngology residents, evaluate various quality of life measures, and investigate associations of increased fatigue with resident safety.

STUDY DESIGN

Anonymous survey.

SETTING

Internet based.

PARTICIPANTS

United States allopathic otolaryngology residents.

INTERVENTION

None.

MAIN OUTCOME(S) AND MEASURES

The survey topics included demographics, residency structure, sleep habits and perceived stress. Responses were correlated with a concurrent Epworth Sleep Scale questionnaire to evaluate effects of fatigue on resident training and quality of life.

RESULTS

190 residents responded to the survey with 178 completing the Epworth Sleep Scale questionnaire. Results revealed a mean Epworth Sleep Scale score of 9.9±5.1 with a median of 10.0 indicating a significant number of otolaryngology residents are excessively sleepy. Statistically significant correlations between Epworth Sleep Scale and sex, region, hours of sleep, and work hours were found. Residents taking in-house call had significantly fewer hours of sleep compared to home call (p=0.01). Residents on "head and neck" (typically consisting of a large proportion of head and neck oncologic surgery) rotations tended to have higher Epworth Sleep Scale and had significantly fewer hours of sleep (p=.003) and greater work hours (p<.001). Additionally, residents who reported no needle stick type incidents or near motor vehicle accidents had significantly lower mean Epworth Sleep Scale scores. Only 37.6% of respondents approve of the most recent Accreditation Council for Graduate Medical Education work hour restrictions and 14% reported averaging greater than 80hours of work/week.

CONCLUSION AND RELEVANCE

A substantial number of otolaryngology residents are excessively sleepy. Our data suggest that the effects of fatigue play a role in resident well-being and resident safety.

The Importance of Exercise in the Well-Rounded Physician: Dialogue for the Inclusion of a Physical Fitness Program in Neurosurgery Resident Training

Exercise, diet, and personal fitness programs are essentially lacking in modern graduate medical education. In the context of long hours and alternating shift and sleep cycles, the lack of exercise and poor dietary choices may have negative consequences on physician physical and mental health. This opinion piece aims to generate important dialogue regarding the scope of the problem, the literature supporting the health benefits of exercise, potential solutions to enhancing diet and exercise among resident trainees, and possible pitfalls to the adoption of exercise programs within graduate medical education.

Improving surgeon wellness: The second victim syndrome and quality of care

Improving quality of care logically involves optimizing the duty-readiness and well-being of the healthcare provider. Medical errors and poor outcomes adversely impact the involved providers, especially surgeons, as well as the patients and their families. Unfortunately our current system does little to support these "second victims" who experience various degrees of emotional and psychological stresses including confusion, loss of confidence, and debilitating anxiety. These factors contribute to the alarmingly high rates of professional "burnout," substance abuse, and suicide of healthcare providers as well as increase the likelihood of subsequent medical errors. Mindful efforts to improve the healthcare culture and develop personal support systems can help surgeons become more resilient, provide higher quality patient care, and have longer productive professional lives. Institutional support systems are also necessary to assist "second victims" to recover from the impact of an adverse patient event.

Sex-related effects of sleep deprivation on depressive- and anxiety-like behaviors in mice

Anxiety and depressive symptoms are generated after paradoxical sleep deprivation (PSD). However, it is not clear whether PSD produces differential effects between females and males. The aim of this study was to assess the effect of PSD on anxiety- and depressive-like behaviors between sexes. Male and female BALB/c mice were divided in three groups: the control group, the 48-h PSD group and the 96-h PSD group. Immediately after PSD protocols, the forced swimming and open field test were applied. Sucrose consumption test was used to evaluate the middle-term effect of PSD. We found that corticosterone serum levels showed significant differences in the 96-h PSD females as compared to 96-h PSD males. In the open-field test, the 48-h and 96-h PSD females spent more time at the periphery of the field, and showed high locomotion as compared to males. In the elevated plus maze, the 48-h PSD females spent more time in closed arms than males, which is compatible with anxiety-like behavior. The forced swim test indicated that the 96-h PSD males spent more time swimming as compared to the 96-h PSD females. Remarkably, the 96-h PSD males had lower sucrose intake than the 96-h PSD females, which suggest that male mice have proclivity to develop a persistent depressive-like behavior late after PSD. In conclusion, male mice showed a significant trend to depressive-like behaviors late after sleep deprivation. Conversely, female have a strong tendency to display anxiety- and depressive-like behaviors immediately after sleep deprivation.

Effect of time of birth on maternal morbidity during childbirth hospitalization in California

OBJECTIVE

This observational study aimed to determine the relationship between time of birth and maternal morbidity during childbirth hospitalization.

STUDY DESIGN

Composite maternal morbidities were determined using International Classification of Diseases, Ninth Revision, Clinical Modification and vital records codes, using linked hospital discharge and vital records data for 1,475,593 singleton births in California from 2005 through 2007. Time of birth, day of week, and sociodemographic, obstetric, and hospital volume risk factors were estimated using mixed effects logistic regression models.

RESULTS

The odds for pelvic morbidity were lowest between 11 PM-7 AM compared to other time periods and the reference value of 7-11 AM. The odds for pelvic morbidity peaked between 11 AM-7 PM (adjusted odds ratio [AOR], 1101-1500 = 1.07; 95% confidence interval [CI], 1.06-1.09; 1501-1900 = 1.08; 95% CI, 1.06-1.10). Odds for severe morbidity were higher between 11 PM-7 AM (AOR, 2301-0300 = 1.31; 95% CI, 1.21-1.41; 0301-0700 = 1.30; 95% CI, 1.20-1.41) compared to other time periods. The adjusted odds were not statistically significant for weekend birth on pelvic morbidity (AOR, Saturday = 1.00; 95% CI, 0.98-1.02]; Sunday = 1.01; 95% CI, 0.99-1.03) or severe morbidity (AOR, Saturday = 1.09; 95% CI, 1.00-1.18; Sunday = 1.03; 95% CI, 0.94-1.13). Cesarean birth, hypertensive disorders, birthweight, and sociodemographic factors that include age, race, ethnicity, and insurance status were also significantly associated with severe morbidity.

CONCLUSION

Even after controlling for sociodemographic factors and known risks such as cesarean birth and pregnancy complications such as hypertensive disorders, birth between 11 PM-7 AM is a significant independent risk factor for severe maternal morbidity.

[Sleep disorders among physicians on shift work]

Sleep disorders in physicians who perform shift work can result in increased risks of health problems that negatively impact performance and patient safety. Even those who cope well with shift work are likely to suffer from sleep disorders. The aim of this manuscript is to discuss possible causes, contributing factors and consequences of sleep disorders in physicians and to identify measures that can improve adaptation to shift work and treatment strategies for shift work-associated sleep disorders. The risk factors that influence the development of sleep disorders in physicians are numerous and include genetic factors (15 % of the population), age (> 50 years), undiagnosed sleep apnea,, alcohol abuse as well as multiple stress factors inherent in clinical duties (including shift work), research, teaching and family obligations. Several studies have reported an increased risk for medical errors in sleep-deprived physicians. Shift workers have an increased risk for psychiatric and cardiovascular diseases and shift work may also be a contributing factor to cancer. A relationship has been reported not only with sleep deprivation and changes in food intake but also with diabetes mellitus, obesity, hypertension and coronary heart disease. Nicotine and alcohol consumption are more frequent among shift workers. Increased sickness and accident rates among physicians when commuting (especially after night shifts) have a socioeconomic impact. In order to reduce fatigue and to improve performance, short naps during shiftwork or naps plus caffeine, have been proposed as coping strategies; however, napping during adverse circadian phases is less effective, if not impossible when unable to fall asleep. Bright and blue light supports alertness during a night shift. After shiftwork, direct sunlight exposure to the retina can be avoided by using dark sunglasses or glasses with orange lenses for commuting home. The home environment for daytime sleeping after a night shift should be very dark to allow endogenous melatonin secretion, which is a night signal and supports continuous sleep. Sleep disorders can be treated with timed light exposure, as well as behavioral and environmental strategies to compensate for sleep deprivation. Fatigue due to sleep deprivation can only be systematically treated with sleep.