Protected naptime is a luxury usually reserved for the under-five-year-old set. Might it also be a tool to combat our country’s astoundingly high rates of medical errors?
Trainee fatigue has been a major focus of patient safety efforts since the mid 1980’s, after 18-year-old Libby Zion died tragically from a drug interaction that may have been precipitated by residents working long hours. In 2003, the Accreditation Council for Graduate Medical Education (ACGME) required all residents to work no more than 80 hours a week. In 2009, a Congressionally-mandated report from the Institute of Medicine called for interns to work no more than 16 hours at a time and for all residents to take a five hour nap during longer shifts. By the time I started my intern year in 2011, the ACGME had enacted the IOM recommendations – on top of the intern work hour restrictions and a cap of 24 hours for more senior residents, we were encouraged to take “strategic naps” and offered online tutorials on staying alert.
The trend toward fewer work hours and the homage to more sleep is an ostensible win for both residents and patients. But these unilateral changes are based on scant evidence. They have been challenging for programs to implement while preserving service and educational goals – we have to take care of the same number of patients and learn the same amount of clinical information, or probably more, in less time. They have also had a number of unintended consequences, some of which directly undercut their stated purpose, such as less continuous time off for residents and more, potentially dangerous hand-offs in patient care.
We need research to guide us. To this end, a study published in the Journal of the American Medical Association sheds light on one key aspect of regulatory efforts: naptime for interns.
Researchers randomized nearly 200 interns at two internal medicine sites at the University of Pennsylvania training program to either the standard schedule – an overnight shift of up to 30 hours – or the same with a protected five hour naptime starting at 12:30am (they began the study in 2009, so the latest rules weren’t in place). All of the interns wore motion and light-sensing devices on their wrists and kept diaries to track their sleep patterns. The ones with protected naptime were required to hand over their work cell phone at 12:30am to the more senior resident working there overnight.
At the end of a year, the researchers found that interns got about three hours of sleep when that time was protected, versus only two hours otherwise. Only about 6% of interns with protected sleep time had sleepless call nights, versus 14-19% of interns who did not have protected time. The hour difference in sleep time may sound trivial. But the next morning, interns with the protected time also reported being less sleepy after call nights and had faster response times on a standardized computer psychomotor test – comparable to the daytime performance of non-sleep deprived adults.
Decent results for the interns, but what about the patients they cared for? The researchers took the commendable step of addressing this question and found no differences between the groups in their lengths of stay, rates of transfer to the intensive care unit, re-admission rates, and risk of death, though their study didn’t have enough power to answer this definitively.
The study shows us how to make the 30 hour call cycle – which many argue is better for learning and for continuity of care – feasible (unfortunately, the ACGME regulations don’t give programs the flexibility to use this option). The results also highlight the importance of established norms in changing what trainees do. In other words, it’s not enough to encourage naptime; you need to force interns to physically hand over a work phone to get them to sleep. It’s also notable (but not surprising to anyone training in medicine) that the average sleep time for interns with five protected hours fell quite short of those five hours – even without manning their work phones, the interns had plenty of work writing notes or tending to emergent issues. And the intervention came with costs: At Penn, the program had to enlist extra night residents to protect intern naptime. In my program, MGH has had to hire more doctors and nurses to make up for the lost resident work-hours. The biggest takeaway, one that was well-articulated in a recent article in the New England Journal of Medicine, is that we need more studies like this one to understand the best way to train doctors while keeping patients safe.
Ishani Ganguli is a journalist and an internal medicine-primary care resident who blogs at The Boston Globe’s Short White Coat, where this article originally appeared.