Kristin Pascoe, a fourth-year student at Baylor College of Medicine, vividly remembers her first 24-hour shift. It was at the end of a long week on a Friday, on the labor and delivery floor at the Ben Taub Hospital in Houston, Texas. By the time 4 a.m. rolled around, her eyelids would barely stay open.
It’s a constant struggle during those shifts, Pascoe says, to stay conscious as she types notes while sitting on a comfortable couch or waits in the team room for things to progress. During down time she silently hopes for a new patient to come so the familiar adrenaline rush can breathe some life into her tired body. She relies on caffeine, power naps, and frequent trips up and down the stairs to keep her awake.
As a medical student and soon-to-be gynecology and obstetrics resident at the University of Chicago Medicine, Pascoe has learned to put sleep before most other things in her life. That means skipping the gym when she’s too tired and meal-prepping on Sunday so she doesn’t have to cook during the week.
“Something’s got to give in medical school, there’s just too many things to do,” Pascoe says. “A lot of times sleep falls by the wayside. You’ve got to prioritize.”
Recent years have seen an increase in attention to sleep among medical schools and teaching hospitals. In 2011, the Accreditation Council for Graduate Medical Education (ACGME) changed its duty-hour standards, limiting them to 80 hours per week, averaged over a four-week period. The new guidelines also state that a trainee cannot work more than 24 consecutive hours, and that an on-call nightshift should be followed by a nonworking period of no less than 16 hours.
But 80-hour weeks are still arduous, and plenty of medical students and residents like Pascoe still feel the effects of sleep deprivation. The good news is that medical schools and teaching hospitals are addressing the problem by closely monitoring duty hours, developing modules on proper sleep hygiene, and even providing sleep pods for learners to get some quick shut-eye when they’re fatigued.
“I’ve seen the culture change,” says Scott Holliday, MD, associate dean for graduate medical education at The Ohio State University College of Medicine. “I think there were some early adopters and also some early naysayers who say lack of sleep builds character. But the incorporation of science was a way to get over that hurdle.”
Research and sleep deprivation
Historically, residents have received most of their training “in-house,” meaning they were required to be at the hospital nearly 24/7, according to Rachel Salas, MD, director of interprofessional education at Johns Hopkins University School of Medicine and the Johns Hopkins Interprofessional Collaborative.
“If we look at the term ‘residency,’ back in the day, that’s what residents did. They literally stayed at the hospital,” says Salas. “What’s changed is physicians no longer live in the hospital, but patients are living longer with more complicated disease. There’s always going to be someone who needs care.”
Numerous scientific studies have shown the link between lack of sleep and problems with attention and overall health. And as suspected, data show that medical students are more at risk of sleep deprivation than nonmedical students. The effects of this can be far-reaching. In addition to affecting performance and overall functionality, sleep deprivation can lead to depression and social isolation. Another study showed that being awake for 18 to 20 hours led to cognitive and motor skill impairment equivalent to being drunk. And according to research, there is no making up for lost sleep — participants who were limited to five hours of sleep on weekdays, but allowed weekend recovery sleep, still gained nearly three pounds over two weeks and experienced metabolic disruption that would increase their risk for diabetes.
“I’ve seen the culture change. There were some early adopters and also some early naysayers who say lack of sleep builds character. But the incorporation of science was a way to get over that hurdle.”
Scott Holliday, MD
The Ohio State University College of Medicine
Research also shows a link between fatigue and medical errors. One survey showed that interns made significantly more fatigue-related errors during months with five or more overnight call shifts, compared to months with no extended shifts. Another study found that surgical residents who had been awake the previous night made 20% more errors and took 14% longer to complete a simulated laparoscopic task than their more rested colleagues.
But new research shows patient safety could be improving. A recent New England Journal of Medicine study compared 16-hour shift limits to a flexible scheduling option that usually entailed 28-hour shifts for first-year doctors. The main finding was that there was no difference in 30-day patient mortality between the two groups, and that each group was getting roughly the same amount of sleep.
“This doesn’t mean that more sleep wouldn’t be better,” says David Asch, MD, an author of the study and professor of medicine, medical ethics, and health policy at the Perelman School of Medicine at the University of Pennsylvania.
A place to rest
University of Central Florida (UCF) College of Medicine has found one solution to the problem in the form of sleek, futuristic-looking capsules where students can escape from the waking world. Two $15,000 sleep pods have been available to students in the school library since 2017. The UCF Counseling and Wellness Center did a 10-week study on 42 medical students and found, on average, they were studying more than 60 hours a week but sleeping only six hours each night. The sleep pods, which were used about 300 times during that 10-week study, are meant to give sleep-deprived students a chance to nap if they need it.
“It’s basically a chair that has a revolving cover and you can punch in the time you’re in there,” says Kristina Grabnickas, MSN, APRN, a nurse practitioner and coordinator of clinical services at UCF Health. “You wear headphones with calming music and they can sit back and relax.”
“It’s really about creating a climate where we’re acknowledging fatigue, and that also helps to destigmatize talking about it.”
Joseph Kass, MD
Baylor College of Medicine
Students and residents at the University of California, Los Angeles (UCLA) are encouraged to have “beeper buddies” — colleagues who can take their beepers for a window of time to allow for proper rest, says Karen Miotta, MD, interim director of the Behavioral Wellness Center at the David Geffen School of Medicine at UCLA and director of the UCLA Physician and Faculty Wellness Program.
“A lot of times people will try to rest but they’re on pager,” Miotta says. “They’ll always have that one eye open.”
At Baylor College of Medicine, there are a number of hotel-style rooms where students and residents can nap or stay overnight if they’re too tired to drive home. And there is particular attention paid to strict duty hour limits, says Joseph Kass, MD, associate dean of student affairs at Baylor.
“It’s not like ‘wink wink let’s turn a blind eye,’ when it comes to violating duty hours. It’s just not an acceptable thing,” Kass says. “It’s really about creating a climate where we’re acknowledging fatigue, and that also helps to destigmatize talking about it.”
Several schools are addressing the problem simply by providing information on sleep to students. The George Washington University (GW) School of Medicine and Health Sciences held a sleep event in December 2018 and brought in a sleep specialist to talk to attendees. The specialist touched on the importance of sleep, the art of napping, and tricks to stay awake, all while students munched on cookies and milk.
The event was spurred by the number of students who approached the wellness committee about sleep struggles, says Katherine Chretien, MD, associate dean for student affairs at the GW School of Medicine and Health Sciences.
“Our students were the primary drivers,” Chretien says. “It was our most popular event from the wellness committee.”
At McGovern Medical School at the University of Texas Health Science Center at Houston, doctors from the Wellness and Resilience Program give lectures on proper sleep hygiene. They stress the importance of using the bedroom only for sleeping rather than working and teach students how alcohol can interfere with the sleep cycle.
“Sleep medicine in general is becoming more popular,” says Latanya Love, MD, associate dean for admissions of student affairs at McGovern Medical School.
“Sleep is a basic human need, not a luxury. More sleep, or better quality sleep, is going to result in clearer thinking and better mood engagement, which will all have a positive effect on patient care.”
Rachel Salas, MD
Johns Hopkins University School of Medicine
UCF College of Medicine holds a sleep workshop for second-year students called “Good Sleep, Good Health, Good Life,” where students learn about the importance of sleep and the effect it has on the brain. They also learn about how to create a healthy sleep routine and are given sleep masks and chamomile tea.
“We create a list of things to improve sleep hygiene,” Grabnickas says. “I have had a lot of students asking me for medications for sleep, so we’re trying to give them other tools to use.”
The Ohio State University College of Medicine starts with simple education on duty hour rules and how it correlates with patient safety, says Holliday, associate dean for graduate medical education at The Ohio State University. Then students are introduced to specialists who give advice on how fatigue affects performance and teach ways to use caffeine and energy drinks effectively without overdoing it.
The nursing teams are trained to recognize extreme fatigue and are encouraged to say something when they see it.
“It’s really about educating students and residents to let them know sleep is a basic human need, not a luxury,” says Salas. “More sleep, or better quality sleep, is going to result in clearer thinking and better mood engagement, which will all have a positive effect on patient care.”