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American Academy of Pediatrics
Commentary

Doctors Also Need Sleep: Is It Time to Take Another Look at Our ROSTERS?

Abimbola Dairo Oguntebi and Glenn Rosenbluth
Pediatrics March 2021, 147 (3) e2020034017; DOI: https://doi.org/10.1542/peds.2020-034017
Abimbola Dairo Oguntebi
aDepartment of Pediatric Hospital Medicine, Santa Clara Medical Center, Kaiser Permanente, Santa Clara, California; and
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Glenn Rosenbluth
bDivision of Hospital Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, California
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  • Abbreviations:
    ACGME —
    Accreditation Council for Graduate Medical Education
    ROSTERS —
    Randomized Order Safety Trial Evaluating Resident-Physician Schedules
  • Despite an abundance of data that humans need sleep to perform at their best, the medical profession has lagged behind other service industries, including other health professions, in developing guidelines consistent with current data describing the negative impact of sleep deprivation on physician performance.1,2 This lack of guidelines is likely due to some combination of the heterogeneity of literature, concern about educational outcomes from decreased hours, and financial impact.2,3 In addition, the connections between physician performance, patient safety, and physician sleep deprivation have not always been clear to the public.

    Existing guidelines on physician shift lengths are centered on trainees, who account for a minority of the active physician workforce, in part because trainees have historically had more grueling schedules than practicing physicians. The Accreditation Council for Graduate Medical Education (ACGME) determines the maximum educational work hours that residents and fellows can work. ACGME guidelines are influenced by National Academy of Medicine recommendations, seminal studies on the effect of different shift durations on trainee performance and/or patient safety, requests by professional organizations, and public comments.2–7 In 2017, the ACGME reversed a previous decision of limiting first-year residents to 16-hour shifts, again allowing all residents to work shifts of up to 24 hours in duration, with up to 4 additional hours for patient safety, transitions of care, and resident education-related tasks.5,6

    In the Randomized Order Safety Trial Evaluating Resident-physician Schedules (ROSTERS) study, researchers compared the patient safety and performance impact of ≥24 hour shifts with that of ≤16 hour shifts on senior residents in PICUs.2 In this issue of Pediatrics, Rahman et al8 add to the large and consistent body of literature demonstrating that sleep deprivation, particularly via shifts lasting >16 hours, has a detrimental effect on physician performance and patient safety.9,10 The authors provide data to support the links between increased shift-length, decreased psychomotor vigilance, and increased rates of serious medical errors. Other studies have revealed a link between extended-duty shifts and attentional failures but have not specifically linked attentional failures to individual providers’ medical errors.11 In this study, the link is nicely drawn. By illustrating the link between decreased psychomotor vigilance and an increased rate of medical errors, the authors have also made it easier and less expensive for additional studies to be completed in other fields without the same need for a detailed review of medical errors. Certainly, the cause would be strengthened by doing similar studies on procedural trainees or non-procedural trainees of various specialties and levels, and we hope that others will take this opportunity.

    An important point noted in this study by Rahman et al8 is that not all shift durations <16 hours are created equal. Intentionality has to be paid to optimal shift timing in the context of the circadian rhythm because shorter shifts that are not physiologically optimized can lead to varied effects on performance.12 However, were we to optimize schedules for individual provider-level sleep benefits like minimizing day-night transitions or aligning shift start and end times with the circadian rhythm, implementing shorter shift durations would most certainly require additional staff: a point acknowledged by the National Academy of Medicine in their recommendations.7

    Another key detail of the ROSTERS study is that the study population included senior residents. Although the finding that senior residents are subject to sleep deprivation is not surprising, skeptics of the literature have identified this population as a potential gap in existing literature. Given the observed effect in senior residents, this study should further prompt us to question whether similar sleep deprivation-induced performance deficits might be seen in even more experienced, practicing physicians. Past research has revealed that these more advanced physicians are likely not immune to the impacts of sleep deprivation on performance.13 Importantly, attending physicians receive far less oversight of their work hours than trainees.

    Beyond the negative impact on patient safety and performance, sleep deprivation and prolonged shift durations impact physicians’ quality of life.9,10,14 Physician schedules with prolonged shifts are products of dogma that have persisted because of a myriad of factors, including limited funding to hire additional staff, an absence of data demonstrating similar educational outcomes with decreased hours, reticence to extend training, and individual physician preferences for condensed work schedules. Although we acknowledge these barriers, the ROSTERS study serves as a reminder that doctors are not superhuman. Our bodies show the same biological and psychomotor effects of sleep deprivation as our nonphysician colleagues. Put simply, we need sleep like everyone else, not only for our own well-being and optimal performance but also for the safety of our patients.

    Footnotes

      • Accepted November 13, 2020.
    • Address correspondence to Abimbola Dairo Oguntebi, MD, Department of Pediatric Hospital Medicine, Santa Clara Medical Center, Kaiser Permanente, 700 Lawrence Expy, Santa Clara, CA 95051. E-mail: abimbola.dairo{at}kp.org
    • Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.

    • FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

    • FUNDING: No external funding.

    • POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

    References

    1. ↵
      1. Rosenbluth G,
      2. Landrigan CP
      . Sleep, Work Hours, and Medical Performance. In: Cappuccio FP, Miller MA, Lockley SW, Rajaratnam SMW, eds. Sleep, Health, and Society: From Aetiology to Public Health, 2nd ed. Oxford, United Kingdom: Oxford University Press; 2018:198–205
    2. ↵
      1. Landrigan CP,
      2. Rahman SA,
      3. Sullivan JP, et al.; ROSTERS Study Group
      . Effect on patient safety of a resident physician schedule without 24-hour shifts. N Engl J Med. 2020;382(26):2514–2523
      OpenUrlPubMed
    3. ↵
      1. Silber JH,
      2. Bellini LM,
      3. Shea JA, et al.; iCOMPARE Research Group
      . Patient safety outcomes under flexible and standard resident duty-hour rules. N Engl J Med. 2019;380(10):905–914
      OpenUrl
      1. Bilimoria KY,
      2. Chung JW,
      3. Hedges LV, et al
      . National cluster-randomized trial of duty-hour flexibility in surgical training. N Engl J Med. 2016;374(8):713–727
      OpenUrlCrossRefPubMed
    4. ↵
      Accreditation Council for Graduate Medical Education. ACGME common program requirements (fellowship). Available at: https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRFellowship2020.pdf. Accessed October 23, 2020
    5. ↵
      1. Accreditation Council for Graduate Medical Education (ACGME)
      . ACGME common program requirements (residency). Available at: https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRResidency2020.pdf. Accessed October 23, 2020
    6. ↵
      1. Institute of Medicine Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedule to Improve Patient Safety
      . In: Ulmer C, ed. Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. Washington, DC: National Academies Press; 2009
    7. ↵
      1. Rahman SA,
      2. Sullivan JP,
      3. Barger LK, et al
      . Effect of eliminating extended work shifts on neurobehavioral performance in resident-physicians. Pediatrics. 2021;147(3):e2020009936
      OpenUrlAbstract/FREE Full Text
    8. ↵
      1. Levine AC,
      2. Adusumilli J,
      3. Landrigan CP
      . Effects of reducing or eliminating resident work shifts over 16 hours: a systematic review. Sleep. 2010;33(8):1043–1053
      OpenUrlPubMed
    9. ↵
      1. Trockel MT,
      2. Menon NK,
      3. Rowe SG, et al
      . Assessment of physician sleep and wellness, burnout, and clinically significant medical errors. JAMA Netw Open. 2020;3(12):e2028111
      OpenUrl
    10. ↵
      1. Lockley SW,
      2. Cronin JW,
      3. Evans EE, et al.; Harvard Work Hours, Health and Safety Group
      . Effect of reducing interns’ weekly work hours on sleep and attentional failures. N Engl J Med. 2004;351(18):1829–1837
      OpenUrlCrossRefPubMed
    11. ↵
      1. Folkard S,
      2. Lombardi DA
      . Modeling the impact of the components of long work hours on injuries and “accidents”. Am J Ind Med. 2006;49(11):953–963
      OpenUrlCrossRefPubMed
    12. ↵
      1. Rothschild JM,
      2. Keohane CA,
      3. Rogers S, et al
      . Risks of complications by attending physicians after performing nighttime procedures. JAMA. 2009;302(14):1565–1572
      OpenUrlCrossRefPubMed
    13. ↵
      1. Birkmeyer JD
      . Surgical resident duty-hour rules–weighing the new evidence. N Engl J Med. 2016;374(8):783–784
      OpenUrl
    • Copyright © 2021 by the American Academy of Pediatrics
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    Doctors Also Need Sleep: Is It Time to Take Another Look at Our ROSTERS?
    Abimbola Dairo Oguntebi, Glenn Rosenbluth
    Pediatrics Mar 2021, 147 (3) e2020034017; DOI: 10.1542/peds.2020-034017

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    Doctors Also Need Sleep: Is It Time to Take Another Look at Our ROSTERS?
    Abimbola Dairo Oguntebi, Glenn Rosenbluth
    Pediatrics Mar 2021, 147 (3) e2020034017; DOI: 10.1542/peds.2020-034017
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