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5
Impact of Duty Hours on
Resident Well-Being
As residents acquire needed skills during their educational training, the
degree of fatigue and workload they experience places them at risk for
workplace injury, driving incidents, decreased physical and mental health,
and weakened professional and personal relationships. This chapter looks
at the risks associated with each of these consequences because of working
long hours and how they affect residents’ general well-being. The com-
mittee recommends that transportation alternatives and adjustments to
work hours and schedules be put in place to prevent the harm that may
be caused to residents by the current work environment.
Workers’ schedules and lengthy work hours can affect their safety and
psychological, social, and physical well-being. Residents are no exception.
A review by Caruso assessing the impact of long work hours on the general
U.S. worker population revealed that working 50 hours or more a week
can have detrimental effects on workers, placing them at risk for sleep
deprivation or fatigue, declines in alertness or concentration, depression,
poorer general health (including weight gain, cardiovascular decline, and
muscular pain), and injuries (Caruso, 2006). Resident physicians, who typi-
cally work well over 50 hours a week, may therefore be at risk for these
negative effects on their health and well-being, although there may be some
counterbalancing effect in pursuing their desired career goal and working
in a collegial environment. Residents may thrive on and enjoy the extensive
and intensive training paramount to acquiring the necessary skills to be-
come a physician, but the time and workload demands this places on them
can impact their health and safety, and potentially affect their personal and
professional relationships (Cohen, 2002; Papp et al., 2006).
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0 RESIDENT DUTY HOURS
Since the design of duty hours can affect all these aspects of a resident’s
life, this chapter presents available evidence to guide the development of
recommendations that promote resident well-being. First, resident physi-
cal safety is examined with respect to increased work-related injuries and
driving incidents due to fatigue, followed by an examination of resident
burnout, depression, and physical health. The impact of fatigue on personal
and professional relationships and overall quality of life is also addressed.
RESIDENT SAFETY
Although safety concerns for residents stem from activities that take
place within a hospital, their demanding duty hours can create safety risks
when they leave the hospital as well. The empirical literature highlights
two main sources of resident physical injury: injuries experienced while
delivering care, such as accidental needlesticks and exposure to blood-borne
pathogens, and motor vehicle accidents.
Resident Work Injuries
Most on-the-job injuries of residents are accidental injuries, especially
percutaneous ones (those that penetrate the skin). Several well-described
multi-institutional survey-based studies have substantiated that injuries are
more likely when residents are fatigued.
A prospective cohort study surveyed 2,737 interns (first-year residents)
nationwide in a number of medical specialties in 2002-2003 before Ac-
creditation Council for Graduate Medical Education (ACGME) duty hour
reform (Ayas et al., 2006).1 Results of the survey show that first-year resi-
dents reported a higher rate of exposure to injury when fatigued. Respond-
ing to monthly web surveys, residents reported 1,551 instances in which
they were exposed to contaminated bodily fluids, 498 of which occurred
through percutaneous injuries. First-year residents reported more than
twice as many percutaneous injuries at night than during the day (1.48
per 1,000 opportunities vs. 0.70 per 1,000 opportunities; odds ratio [OR]
= 2.04, confidence interval [CI] = 1.98-2.11) and sustaining such injuries
nearly twice as often while working extended shifts (i.e., working 24 con-
secutive hours or more) compared to working a day shift only (1.31 per
1,000 opportunities vs. 0.76 per 1,000 opportunities; OR = 1.61, CI = 1.46-
1.78). Lack of concentration and fatigue were cited as major reasons for
these injuries (64 percent and 31 percent, respectively), with fatigue more
frequently cited as a contributing factor when residents worked at night
1 Medicalspecialties included internal medicine, surgery, obstetrics-gynecology, pathology,
family medicine, psychology, pediatrics, and emergency care.
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RESIDENT WELL-BEING
and when they worked extended shifts (p < .001). These results differed by
specialty, with obstetrics-gynecology (OB/GYN), pathology, and surgery
residents citing more injuries than others (Ayas et al., 2006).
Self-reported accounts of fatigue were also positively associated with
risk of injury involving sharp medical instruments and devices in a study
of 109 medical trainees (e.g., medical students, residents, fellows) in five
academic medical centers in the United States and Canada. Conducted
between 2000 and 2004, the study found that trainees were at three times
greater risk of fatigue-related injury than other healthcare workers (includ-
ing attendings and nurses) (relative risk = 2.03, CI = 1.41-2.94). Injury
among trainees was associated with less sleep before an injury and longer
work hours per week. The week prior to the injury, medical trainees slept a
median 6 hours per night compared to nontrainees’ 6.75 hours (p < .001).
Medical trainees worked on average 70 hours per week compared to other
healthcare workers’ 40 hours per week, and they had also been at work
on average 1.5 hours longer than other healthcare workers when injuries
occurred (Fisman et al., 2007). Although the study included 1 year of
data gathering post-ACGME duty hour reform, no attempt was made to
determine whether the risk of a fatigue-related injury decreased during
2003-2004.
A major risk of percutaneous injury is exposure to blood-borne patho-
gens (e.g., HIV and hepatitis B and C). A retrospective review to assess
whether resident exposure to blood-borne pathogens varied during a given
24-hour period found that residents (n = 782) were exposed more often at
night (Parks et al., 2000). Exposures resulted from needle punctures (75
percent of incidents), cuts (13 percent), and splashes of infected body fluids
(12 percent). Over a 5-year period (November 1993-July 1998), the overall
relative risk of accidental exposure to these pathogens was 1.5 times higher
during nighttime hours (6 p.m.-6 a.m.) than during the day (6 a.m.-6 p.m.);
the highest rate tended to occur from midnight to 1 a.m., and the lowest
from 6 a.m. to 7 a.m. Exposures were concentrated in five specialties: an-
esthesiology (30 percent), internal medicine (20 percent), surgery (16 per-
cent), OB/GYN (11 percent), and pediatrics (5 percent) and rarely occurred
in outpatient clinics. First- and second-year residents were the most likely
to be exposed to blood-borne pathogens (56 percent of total, 75 percent
of resident exposures) (Parks et al., 2000), and anecdotal accounts indicate
that this occurs because they perform activities such as blood-drawing
more commonly than senior residents or attendings. A more recent study
by Landrigan and colleagues attempted to assess incidence rates of occupa-
tional exposure to blood and other bodily fluids pre-post ACGME limits,
and found that reported rates of exposure for 2003 and 2004 were nearly
the same (21.6 percent), which the authors attributed to a minimal change
in actual hours worked (Landrigan et al., 2008).
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RESIDENT DUTY HOURS
Resident injuries are often affected by fatigue, sleep loss, and lower
concentration levels (and not necessarily by skill level). Preventing and
mitigating fatigue and sleep loss whenever possible may help sustain im-
proved concentration levels and thus reduce the occurrence of injuries
among residents.
Driving Incidents
Concerns regarding resident safety extend beyond the workplace. Driv-
ing home after an extended duty period on call can also be hazardous to
residents’ well-being. As the following studies indicate, residents are more
likely to be involved in a car crash or to receive a citation when driving
after working long duty periods than after working shorter ones. Fatigued
and sleepy residents on the road potentially affect not only themselves but
the public as well, raising further concerns for public safety.
In 1996, a survey of pediatric residents (n = 62) and faculty (n = 72)
at one institution showed that, on average, residents managed to sleep
2.7 hours when on call and 7.2 hours when not on call, while faculty
recalled sleeping undisturbed for an average of 6.5 hours each night.
Responses revealed that residents fell asleep more frequently at red lights
(40 percent vs. 12.5 percent) and while driving (23 percent vs. 11 percent)
than did faculty and were involved in more motor vehicle crashes (20 vs.
11) (Marcus and Loughlin, 1996). In addition, residents who fell asleep
behind the wheel did so most frequently after being on duty (90 percent
of incidents occurred after approximately a 33-hour shift). These results
indicate that the hours of rest one receives each night and the duration of
duty periods may seriously impact one’s driving capabilities.
More recently, a national sample of 682 interns who completed 12
monthly surveys reported being involved in 133 crashes during the year,
131 of which occurred upon leaving work (Barger et al., 2005). Interns
were 2.3 times more likely to be involved in a crash after working extended
shifts (their duty periods averaged 32 hours, during which they averaged
less than 3 hours sleep) than those not working extended duty periods.
These first-year residents were 5.9 times more likely to experience near-miss
crashes after extended duty periods than after non-extended shifts. After
five extended duty periods in a month, the risk of falling asleep while driv-
ing or stopped in traffic significantly increased (while driving: OR = 2.39,
CI = 2.31-2.46; stopped: OR = 3.69, CI = 3.60-3.77) (Barger et al., 2005).
Similarly, an earlier survey conducted by Steele and colleagues showed
that emergency medical residents were at greater risk of being involved in
near-miss or collision incidents after working a night shift, and that the
prevalence of incidents was positively correlated with the number of night
shifts a resident worked per month (Steele et al., 1999). The Barger et al.
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RESIDENT WELL-BEING
study was conducted prior to the 2003 duty hour limits, but residents are
still allowed to work periods of 30 consecutive hours more than five times
a month.
In another study, resident performance after working 4 weeks of heavy
call (defined as working on average 90 hours per week and being on call
every fourth or fifth night) was found to be comparable to resident perfor-
mance with blood alcohol levels of 0.04-0.05 g per 100 mL of blood.2 This
study of 34 pediatric residents also found that residents on heavy call for 4
weeks (sleeping on average slightly more than 6 hours per night) were less
alert and sleepier than those on light call (defined as working only 44 hours
per week on average), who averaged about 7.5 hours of sleep per night as
measured by wrist actigraphy. Reaction times were also slower for residents
on heavy call than those on light call (242.5 milliseconds [ms] vs. 225.9 ms,
p < .001). In addition, residents on the heavy call schedule performed more
poorly in the driving simulator than those on light call (lane variability: 7.0
feet vs. 5.5 feet, p < .001; speed variability 4.1 miles per hour [mph] vs. 2.4
mph, p < .001) (Arnedt et al., 2005).
Two separate population-based case-control studies conducted to de-
termine the greatest risk factors for sleepy drivers also support the results
of the above studies on residents. The first study of North Carolina drivers
involved in a sleep-related crash showed they were more likely to work
multiple jobs, night shifts, or other unusual schedules and averaged fewer
hours of sleep per night than drivers who were not involved in a recent
crash (Stutts et al., 2003). The second study determined that injuries from
sleep-related crashes occurred more often among drivers who had slept
less than 5 hours in the previous 24 hours (Connor et al., 2002). These
studies clearly demonstrate that sleepiness and fatigue are serious risks for
driving incidents, which is why mitigating these factors for residents will
be important to their safety.
Although residents are at high risk for fatigue-related car crashes, they,
like many other healthy but sleep-deprived adults, often fail to recognize
their degree of impairment (Arnedt et al., 2005; Van Dongen et al., 2003;
Woodrow et al., 2008). If a resident does not recognize this risk or is not
aware of his or her level of impairment and is involved in a collision when
driving after a shift in the hospital, responsibility for the resulting injuries
has been known to fall on the resident in the past. In one case, the hospi-
tal at which a resident worked was found not liable for impaired driving
incidents caused by their residents, as a court ruling in Illinois established:
“There is no liability imputed to health care providers for injuries to third
2 It is considered a crime to drive with a blood alcohol level of 0.08 g per 100 mL of blood
throughout the United States (Insurance Institute for Highway Safety, 2008) and with a level
of 0.04 g for commercial drivers (FMCSA, 2008).
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4 RESIDENT DUTY HOURS
parties who are not patients in the hospital” (IPRO, 2007). Therefore, while
the committee recommends that hospitals institute transportation services
to help prevent these incidents, residents should be aware of all risks associ-
ated with deciding to drive after working extended hours and should know
that responsibility for their actions ultimately rests with them.
Improving Resident Safety
To reduce physical harm to residents, the committee believes that it
is important to address the level of acute and chronic sleep deprivation
and fatigue they experience. Although needlesticks or other sharps injuries
to residents will not be eliminated altogether, strategies to increase sleep
should help reduce these events. Recommendations for duty hours and
work schedules that incorporate ways to protect residents against acute and
chronic sleep loss and fatigue can be found in Chapter 7.
Regarding driving incidents, the committee found only one study that
measured incidents involving residents after the 2003 rules were adopted,
and it showed no significant change in motor vehicle accidents or near-miss
motor vehicle incidents compared to before implementation for pediatric
residents at 3 institutions (Landrigan et al., 2008). Extended duration shifts
of 30 hours are still permissible, and the allowable frequency of long call
duty periods per month (seven to nine per month depending on averaging
and the ability to remain under 80 hours per week) is associated with a
greater likelihood of falling asleep at the wheel (Barger et al., 2005). Since
fatigued residents are often unable to accurately evaluate their ability to
remain alert during their drive home after an extended duty period, to
help prevent driving incidents due to fatigue or sleepiness the committee
recommends that medical training institutions take some responsibility by
implementing the following:
Recommendation 5-1: The committee recommends that sponsoring
institutions immediately begin to provide safe transportation options
(e.g., taxi or public transportation vouchers) for any resident who for
any reason is too fatigued to drive home safely.
This recommendation will be particularly important until further ad-
justments to resident work schedules are made as recommended by the
committee in Chapter 7, which incorporate time for sleep after being on
extended duty for more than 16 hours. The committee recognizes that for
such practices to become widely instituted, a culture will need to develop
among residents and other staff that is more attuned to the risks of fatigue
or sleep deprivation. Because sleeping is a voluntary and local behavior, the
committee believes that residents should own the responsibility of one’s own
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RESIDENT WELL-BEING
fatigue levels. Thus, they should behave in a manner that reflects account-
ability both on a personal and professional level when making decisions to
drive after being on extended duty. Institutions should include education
about the risks associated with fatigue and sleep deprivation in the basic
curriculum of medical students and promote greater awareness of the topic
among residents and all medical staff (ACGME, 2007; Jha et al., 2005).
Such education would help residents to be more cognizant of their risks.
However, because residents and others are not always self-aware when
fatigued, one option that the committee suggests is to have institutions pro-
vide transportation, both to and from the hospital, as the default scenario
for residents on the days they are scheduled to be on duty for more than
16 hours. This would then not be dependent on someone making a fatigue
assessment of residents; instead it would be based on hours worked. The
committee also supports evaluating alternatives, such as hospitals providing
onsite space to allow residents to sleep before driving home after these long
shifts without this counting toward duty hour limits when transportation
services are unavailable. Evidence suggests that naps are often effective in
dispelling drowsiness sufficiently to be able to drive (Philip et al., 2006).
However, residents indicated anecdotally that they would prefer to go home
to have longer periods of uninterrupted sleep. Alternatives should be as-
sessed to ensure that residents would not opt out of using services provided
and continue unsafe driving.
RESIDENT WELL-BEING AND QUALITY OF LIFE
Residents’ well-being refers to their state of overall mental and physical
health and how these factors, among others, can affect their general qual-
ity of life. This section discusses aspects of mental health such as levels of
resident burnout and depression, concerns regarding their physical fitness,
satisfaction with their personal and professional lives, and how these as-
pects have been impacted by ACGME’s duty hour regulations or fatigue.
Before discussing burnout and depression, definitions may clarify the
differences between these two similar symptoms experienced by residents.
Originally coined by Freudenberger in 1974, the term “burnout” described
a state of exhaustion or extreme fatigue resulting from an excessive demand
of energy, strength, or resources, in turn causing individuals to become
cynical about their work (Douglas Institute, 2008). Although considered a
vague notion for several years, more complete definitions came to include
physical and mental exhaustion observed by those in professions requir-
ing continuous contact with others. Maslach and colleagues eventually
identified three widely recognized core elements of burnout: emotional
exhaustion—depleted energy from overwhelming work demands; deper-
sonalization—personal detachment from one’s job; and lack of personal
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RESIDENT DUTY HOURS
accomplishment due to self-perceptions of inefficiency (Maslach et al.,
1997).
Depression, on the other hand, is characterized by “depressed mood,
inability to derive pleasure from things, weight loss or gain, insomnia or
hypersomnia, psychomotoric agitation or retardation, fatigue or loss of
energy, feelings of insufficiency or guilt, indecisiveness or inability to con-
centrate, and thoughts about death and suicide” (Brenninkmeijer et al.,
2001). Substantial evidence concerning the distinctions between burnout
and depression can be found in a literature review by Glass and McKnight
(1996) that empirically investigated the relationship between the two. The
authors concluded that burnout and depression are not identical, yet they
have symptoms in common, such as emotional exhaustion, that are posi-
tively related to both (Brenninkmeijer et al., 2001; Glass and McKnight,
1996).
Burnout
The empiric literature focuses on three main issues: the prevalence of
burnout in residents, the factors associated with burnout, and the impact
of changes in duty hours on resident burnout. Studies focused on the im-
pact of duty hour regulations tended to be of small numbers of residents,
single institutions, and specialty-specific. As discussed below, the data are
mixed—residents do experience high levels of burnout, but burnout is not
necessarily associated with the numbers of hours worked or slept. Instead,
burnout among residents has been found to be more highly associated with
managing a heavy workload or exposure to high work intensity (Thomas,
2004).
Prevalence of Burnout
Burnout is quite prevalent among residents, with rates varying from
41 to 76 percent (Fahrenkopf et al., 2008; Thomas, 2004). A study of 321
residents in one institution found that 50 percent reported experiencing
burnout during their training as measured by the Maslach Burnout Inven-
tory (MBI), a validated, widely used questionnaire. Although there were
varying rates of burnout across specialties (27 to 75 percent), these differ-
ences were not statistically significant. The number of hours worked was
also not associated with increased risk of burnout (i.e., residents working
more than 80 hours per week were not more likely to experience burnout
than those working 80 hours or less). However, first-year residents were
more likely to report burnout than more senior residents (77.3 percent and
41.8 percent, respectively) (Martini et al., 2004). A longitudinal study of
47 internal medicine interns the year prior to ACGME limits found that
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RESIDENT WELL-BEING
the prevalence of burnout increased and empathy decreased during their
first year of residency. Only 4.3 percent of residents reported high levels
of burnout at the beginning of the year compared to 55.3 percent at the
end of the year (p < .0001) (Rosen et al., 2006). Although increased sleep
deprivation was not associated with increased burnout, it was associated
with higher rates of depression.
Factors Associated with Burnout
Several factors can contribute to the dimensions of burnout. A literature
review assessing 15 studies of resident burnout published between 1983 and
2004 found that burnout was associated less with sleep deprivation than
with work intensity and work interference with home life (Thomas, 2004).
Work intensity according to residents was often related to feelings of being
overwhelmed by work demands or workload and having insufficient time
to plan or manage them (Biaggi et al., 2003; Nyssen et al., 2003). Obser-
vations of this sort can be related to a perceived lack of control over one’s
job (Nyssen et al., 2003). An additional study points to stress over financial
strains or debt that many residents experience and how this may play a role
in producing emotional exhaustion (Collier et al., 2002). Although sleep
deprivation and lack of leisure time are still commonly cited by residents
as reasons for burnout (Thomas and Brennan, 2000), specialty-specific
studies (n < 130) have shown that despite these claims by residents, no
statistically significant correlation was found between hours slept, hours
worked, or sleep deprivation and burnout (Fahrenkopf et al., 2008; Rosen
et al., 2006). These findings underscore that duty hours are merely one
factor affecting resident performance and that modifying other factors as
well—for example, moderating workload—can help improve overall train-
ing experiences.
Impact of Duty Hour Regulations on Burnout
Evidence of whether the 2003 ACGME duty hour limits reduced burn-
out is mixed, but no studies have shown that duty hour reductions or
limits have increased its prevalence. Duty hour regulations did not decrease
symptoms of burnout in a study of 33 surgical residents in six institutions
(Gelfand et al., 2004). Another study of internal medicine residents from one
institution surveyed in May 2003 (n = 121) and May 2004 (n = 106) found
that a reduction in duty hours (from 74.6 hours per week to 67.1 hours per
week) was associated with decreased emotional exhaustion (42 percent vs.
29 percent). There were however, no significant changes in depersonaliza-
tion as measured by the MBI or perceptions of personal achievement (Gopal
et al., 2005). A third study, comparing survey responses of 115 internal
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RESIDENT DUTY HOURS
medicine residents in 2001 and 118 internal medicine residents in 2004, also
found that although the number of residents reporting emotional exhaustion
as measured by the MBI decreased significantly from 53 to 40 percent after
the implementation of duty hour regulations, there was no significant change
in the percentage of residents with total scores meeting the burnout criteria
(Goitein et al., 2005). In contrast, a study comparing the scores of 220 pe-
diatric residents from three large programs found a statistically significant
decrease in the burnout rates before and after the 2003 duty hour limitations
(75.4 percent versus 57.0 percent) (Landrigan et al., 2008).
It is important to note here that the committee’s proposed changes in
duty hours without appropriate adjustments of workload could possibly
have an unintended consequence of leading to more stress or burnout.
For example, one method of moderating resident workload is to reduce or
limit the number of patient cases that a resident can handle per duty pe-
riod. However, if all less complex patient cases are taken over by physician
extenders and only more complex patients are concentrated on resident
teams (as a way to increase the educational value of time spent on duty),
the new level of work intensity could cause some degree of burnout unless
caseload is adjusted for patient severity. Because of this, burnout should be
an outcome that is studied with the proposed interventions.
Depression and Mood
Depression is a mood disorder that can affect job performance, per-
sonal and professional interactions, and health. Studies of depression in
residents generally present data on prevalence of depression among resi-
dents and the impact of duty hour regulations on depression rates. Studies
of the latter type tend to be small and specialty-specific. The study data tend
to report depression based on screening instruments rather than diagnoses
of clinical depression.
Prevalence of Depression
Statistics regarding the prevalence of depression among residents vary
widely from 7 to 56 percent based on different validated tools used to screen
for depression or detect clinical depression (Becker et al., 2006; Bellini et
al., 2002; Fahrenkopf et al., 2008; Goitein et al., 2005; Gopal et al., 2005;
Shanafelt et al., 2002). One study of 125 OB/GYN residents recruited from
23 randomly selected programs across the United States found that more
than one-third of participants (34.2 percent) were depressed, according
to the Center for Epidemiological Studies-Depression Scale (Becker et al.,
2006). Just prior to duty hour regulations, Fahrenkopf et al. (2008) found
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RESIDENT WELL-BEING
that among 123 pediatric residents evaluated, 20 percent were at high
risk for depression (determined through the Harvard National Depression
Screening Day Scale, which measures depressive symptoms, not criteria for
a diagnosis of depression). Ninety-six percent of these residents also met the
criteria for burnout (measured through the MBI) and more often reported
having poor health and having difficulty concentrating at work than their
nondepressed colleagues (Fahrenkopf et al., 2008). Becker also noted high
rates of burnout among residents who were depressed.
At least one study conducted prior to the 2003 regulations suggests
that sleep deprivation may be associated with the development of moder-
ate depression among interns (Rosen et al., 2006). In addition to finding
that the prevalence of chronic sleep deprivation increased from 9 percent
at the beginning of the year to 43 percent at the end of the year, Rosen and
colleagues reported that the prevalence of moderate depression (as mea-
sured by the Beck Depression Inventory-Short Form) among residents also
increased as the year progressed (4.3 percent to 29.8 percent; p = .0002)
and was associated with chronic sleep deprivation (OR = 7; p = .014).
In fact, chronically sleep-deprived interns had a seven times greater like-
lihood of developing depression during their first year of residency than
colleagues who obtained more sleep (Rosen et al., 2006). Further research
is needed to determine whether depression rates vary across specialties.
Impact of Duty Hour Limits on Depression
Only three studies have evaluated depression rates in residents after the
institution of duty hour regulations. Two of the three studies were limited
to a single institution and focused on a single specialty, internal medicine.
Although Gopal and colleagues (2005) reported that fewer residents had a
positive result on a depression screening instrument after the first year of
duty hour regulations than before the regulations were implemented, the
results were not statistically significant. Nor were there statistically signifi-
cant differences in the increased percentage of internal medicine residents
who screened positive on an unnamed depression screening questionnaire
(Goitein et al., 2005). The third study, involving 220 residents from three
large pediatric residency programs, found no change in the rates of depres-
sion before and after the institution of duty hour limitations (Landrigan et
al., 2008). From these studies, it appears that the ACGME regulations had
no significant impact on the prevalence of depression.
Only one single-institution study of pediatric residents assessed the
mood and fatigue levels of residents who worked night float shifts and
found that feelings of depression among night float residents can be more
prevalent than among residents on day shifts (Cavallo et al., 2002).
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Effects on Physical Health
In addition to affecting mood, at least one study suggests that the sleep
deprivation experienced by residents may have other adverse effects on
their health. Baldwin and Daugherty’s (2004) survey of 3,604 randomly
selected postgraduate year 1 (PGY-1) and PGY-2 residents during 1998-
1999 revealed that residents who reported obtaining 5 hours of sleep or
less per night were more likely to report increased use of alcohol (OR =
1.52), had “taken medications to stay awake” (OR = 1.91), and experi-
enced a significant weight change (OR = 1.51). Almost one-quarter of the
participants (22 percent) reported obtaining 5 hours or less of sleep on a
regular basis, and two-thirds reported obtaining 6 hours or less of sleep
on a regular basis throughout the year (Baldwin and Daugherty, 2004).
A more recent web-based survey of 3,971 emergency medicine residents
revealed that almost half of the participants (45 percent) were excessively
sleepy (a score of >10 on the Epworth Sleepiness Scale), and that approxi-
mately one-third of the participants had used medications and/or alcohol
to help them fall asleep at least four times in the past month (Handel et
al., 2006).
The significant changes in weight reported by residents who regularly
obtained 5 or fewer hours of sleep per night (Baldwin and Doughtery, 2004)
is not surprising in light of recent findings related to sleep loss, weight
gain, and changes in appetite regulation. In the past 7 years, at least 12
epidemiologic studies have documented a dose-dependent relationship be-
tween sleep duration and increased body mass index. Sample sizes ranged
from 422 participants to more than 68,000 participants, with some studies
focused on specific occupational groups (e.g., truck drivers [n = 4,878] or
registered nurses [n = 68,183]). Despite being conducted in different areas
of the world (Brazil, Canada, Europe, Japan, and the United States), us-
ing different methodologies, and including varying degrees of control for
other related variables (e.g., parental weight, depression, shift work), the
findings have been quite similar: short sleep durations are associated with
greater risks of weight gain and obesity. Although the exact mechanisms
linking sleep deprivation to weight gain are unknown, a number of well-
controlled laboratory experiments suggest that sleep restriction alters the
levels of leptin and other hormones involved in the regulation of appetite
(Guilleminault et al., 2003; Spiegel et al., 2004a, 2005).
Other contributions to weight gain can arise from the simple fact that
residents have limited time for leisure activities and often lack sufficient op-
portunities, or energy, to exercise. Anecdotal accounts suggest that residents
do not take the advice they give their own patients to exercise regularly and
eat healthy foods, admitting to a less healthy lifestyle during their training
(Glines, 2004).
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Additional health risks due to sleep restriction or sleep deprivation have
been demonstrated, such as increased risk of developing various types of
diabetes (Ayas et al., 2003; Spiegel et al., 2004b; Van Helder et al., 2003).
Although the incidence of residents’ being overweight or developing dia-
betes is unknown, the evidence from both epidemiological and laboratory
studies implies that residents who routinely obtain limited amounts of sleep
may be at higher risk for these health outcomes.
Regarding their physical and mental well-being, it appears that resi-
dents still experience stress and burnout, which can affect their health.
The varying quality of the research conducted on these issues suggests that
future research may benefit from using standardized measures of quality
of life, depression, and well-being, in order to assess the impact of cur-
rent regulations on health and quality of life. Research to determine the
association between burnout, sleep deprivation, and depression would be
useful as well.
Quality of Life
Residents are full-time caregivers at work and supportive family mem-
bers and friends at home. As physicians interacting closely with their
healthcare team and with patients, their health and attitude are vital to their
success and necessarily have impacts on those around them. The committee
thought it important to examine the effects of fatigue and duty hour adjust-
ments on residents’ roles outside the hospital, recognizing that success in
their training must be understood in the context of their overall lives.
Effects of Duty Hour Regulations on Quality of Life
Most studies that examine resident quality of life are based on surveys
of residents at single institutions or in a single geographic area. The term
“quality of life” was often used ambiguously or not clearly defined in the
studies, and many incorporated burnout, stress, or depression as part of
their definition. Rather than using a standard, validated instrument to
measure residents’ quality of life, institutions developed their own surveys.
Despite these methodological weaknesses, findings were similar: most resi-
dents believed that their quality of life improved as a result of duty hour
regulations.
For example, 128 residents from four training programs adhering to
ACGME duty hour regulations were surveyed for their impressions of how
the rules would continue to affect future residents. The results indicated
a strong agreement (by a Likert-type fixed response scale from “strongly
agree” to “strongly disagree”) that hour restrictions would have marked
benefits on residents’ personal lives in the future. The degree of improve-
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RESIDENT DUTY HOURS
ment foreseen varied by specialty. Family medicine residents felt most
positively about the regulations in terms of better quality of life, followed
by internal medicine residents, and to a lesser extent, OB/GYN residents.
Surgical residents were the least likely to agree that the regulations would
have a positive effect on their quality of life (Zonia et al., 2005).
Yet two separate surveys of surgical residents (98 residents from four
programs and 29 residents and 8 faculty from a single program), both
administered after duty hour regulations were implemented, reported that
these residents believed that those regulations had positive effects on their
quality of life. They reported having more time to spend with family and
friends, being able attend to important nonmedical responsibilities, and
being happier and less tired (Barden et al., 2002; Kort et al., 2004). An-
other single, one-time survey of 12 plastic surgery residents administered
6 months after implementation of duty hour regulations found residents
to be less fatigued as a result of decreased hours. These residents also saw
improvements in quality of life and morale, as well as improvements in
spousal, family, and other relationships (Basu et al., 2004).
A systematic review by Fletcher et al. (2005) examined how the quality
of life in various medical specialties was affected by duty hour reductions.
The measures of quality of life in this review encompassed several of the
factors examined in this chapter, including mood factors, sleep, relation-
ships, health, and education. The results were mixed for nearly all measures
and across specialties, indicating “that there may not be uniform benefits
for residents from these changes” (Fletcher et al., 2005, p. 1098).
Differences Between Junior and Senior Residents
Survey responses from 48 orthopedic residents indicated that junior
residents felt that their quality of life was better because of duty hour
regulations, while senior residents were more neutral. Responses from 39
orthopedic attendings also had improved perceptions of their quality of
life. The difference between junior and senior residents’ perceptions was
attributed to situations in which senior residents had to do work they pre-
viously had done as junior residents, which would not have been necessary
before implementation of the regulations. This may be valid only for senior
residents who began their training before the implementation of regulations
(Zuckerman et al., 2005). A different study that gathered 554 surveys from
orthopedic surgical residents across the country showed that PGY-3 and
more junior residents, who worked in excess of 80 hours per week more
frequently than their senior peers, still had more positive attitudes toward
duty hour regulations than the senior residents. Nonetheless, residents in
this study overall (PGY-4, -5, and -6 residents made up 68 percent of 495
responses) reported an improved quality of life (Kusuma et al., 2007).
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RESIDENT WELL-BEING
In general it seems that reduced hours improve residents’ perception
of their quality of life, and no study was reviewed that showed duty hour
restrictions were associated with poorer quality of life.
Effects of Fatigue on Professional Relationships
Residents’ perception of their quality of life can be affected by their
professional relationships as much as their personal ones. Satisfaction at
the workplace seems to play an important role in resident well-being and
depends on factors such as relationships with colleagues and patients, per-
sonal performance, and work schedules.
Professionalism is also a key component of a resident’s training and
should typify the working relationships that residents forge. It is based on
the concepts of patients as the primary focus, patient autonomy, and social
justice (Project of the ABIM Foundation et al., 2002)—the same concepts
on which patient-centered care is founded. Patient centeredness, as defined
in the Institute of Medicine (IOM) Quality Chasm series, “encompasses
qualities of compassion, empathy, and responsiveness to the needs, values,
and expressed preferences of the individual patient” (IOM, 2001, p. 48).
Effect of Fatigue on Professionalism
Given the intensity of work that residents experience, and their sus-
ceptibility to personal and professional stress, it is not surprising that
some facets of their work, namely efforts toward patient centeredness or
professionalism, may at times be neglected. For example, the Committee
of Interns and Residents provides reports of residents actively avoiding
care conversations with a patient’s family members out of fatigue. Other
residents reported growing resentful toward their patients because of feeling
too exhausted or depressed to provide adequate care (CIR/SEIU Healthcare,
2007). Relationships with coworkers are also affected. One survey study
found that sleep-deprived residents (5 hours or less of sleep per night)
were significantly more likely (between 1.41 and 1.87 times more) to be
involved in serious conflicts with other residents, attendings, or nursing
staff (Baldwin and Daugherty, 2004).
Impact of Reduced Duty Hours on Professionalism
Although professionalism is difficult to measure, a few methods exist
that attempt to capture a physician’s level of professionalism, including
surveys of peer assessment, faculty assessments, and self-reflection, as well
as objective clinical exams (Cohen, 2006; Swick, 2000). Professionalism is
acquired both formally and informally. Formally, it is taught infrequently
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4 RESIDENT DUTY HOURS
or incidentally through lectures and conferences. Informally, professional-
ism is modeled daily by medical colleagues and implicitly required through
the appropriate expectations of patients and their loved ones. In a study
of 169 internal medicine, neurology, and family practice residents in three
hospitals, 45 percent of the residents studied believed that professionalism
decreased after duty hours were reduced because of having less time to talk
with patients and families, leading to fewer opportunities to participate in
shared decision making. However, 32 percent of residents perceived no
change and 19 percent believed professionalism improved due to reduced
fatigue, allowing for increased reserves of empathy, compassion, and sensi-
tivity to patients and colleagues (Ratanawongsa et al., 2006).
In a systematic review by Fletcher and colleagues, the perceived effect
of reduced work hours on professionalism was mixed. Multiple studies of
internal medicine residents found varied opinions regarding the effects of
schedule interventions on a resident’s sense of professionalism: some be-
lieved patient-physician relationships, patient care, and continuity of care
had improved, while others felt it had decreased or stayed the same (Fletcher
et al., 2005). However, a more recent study by Fletcher and her colleagues
reported anecdotes from residents who feel they do not always participate
in important patient care activities at times (e.g., family meetings) in order
to comply with duty hour regulations (Fletcher et al., 2008).
CONCLUSION
Medical training exposes residents to real risks regarding their overall
health and quality of life. Varied study methods and reports by residents
on the impact of duty hour regulations on aspects of their mental health
and professionalism make it difficult to clearly gauge the degree to which
working reduced hours truly improves their outlook or satisfaction with
life. From the literature, it appears that residents generally feel that reduced
hours have positive effects on their well-being and personal life. Yet, several
of these positive comments are accompanied by negative perceptions of the
impact on their educational training (Fletcher et al., 2005; Gopal et al.,
2005; Whang et al., 2003) or on patient safety (Shanafelt et al., 2002; West
et al., 2006), which are discussed in Chapters 4 and 6, respectively.
These contrasting sentiments suggest that altering duty hours alone is
not a comprehensive strategy to improve the resident experience. Further-
more, promoting resident well-being does more than simply help residents
feel better. Protecting physicians’ health fitness could help increase patient
safety and care, as error rates by residents at high risk for depression have
suggested (Fahrenkopf et al., 2008). The committee suggests that other
changes, such as enhanced supervision and team support by other staff, may
help counter feelings of being overwhelmed that can lead to burnout, de-
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RESIDENT WELL-BEING
pression, and decreased professionalism. Although adjusting resident duty
hours can impact resident well-being and may help residents balance the
many requirements of training, merely changing trainee schedules cannot
substitute for a professional, supportive, and responsive learning environ-
ment to promote their success.
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