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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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0 RESIDENT DUTY HOURS 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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 RESIDENT WELL-BEING 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. REFERENCES ACGME (Accreditation Council for Graduate Medical Education). 2007. Common program re- quirements. http://acgme.org/acWebsite/dutyHours/dh_dutyhoursCommonPR07012007. pdf (accessed March 23, 2008). Arnedt, J. T., J. Owens, M. Crouch, J. Stahl, and M. A. Carskadon. 2005. Neurobehav- ioral performance of residents after heavy night call vs after alcohol ingestion. JAMA 294(9):1025-1033. Ayas, N. T., D. P. White, W. K. Al-Delaimy, J. E. Manson, M. J. Stampfer, F. E. Speizer, S. Patel, and F. B. Hu. 2003. A prospective study of self-reported sleep duration and incident diabetes in women. Diabetes Care 26(2):380-384. Ayas, N. T., L. K. Barger, B. E. Cade, D. M. Hashimoto, B. Rosner, J. W. Cronin, F. E. Speizer, and C. A. Czeisler. 2006. Extended work duration and the risk of self-reported percutane- ous injuries in interns. JAMA 296(9):1055-1062. Baldwin, D. C., Jr., and S. R. Daugherty. 2004. Sleep deprivation and fatigue in resi- dency training: Results of a national survey of first- and second-year residents. Sleep 27(2):217-223. Barden, C. B., M. C. Specht, M. D. McCarter, J. M. Daly, and T. J. Fahey III. 2002. Effects of limited work hours on surgical training. Journal of the American College of Surgeons 195(4):531-538. Barger, L. K., B. E. Cade, N. T. Ayas, J. W. Cronin, B. Rosner, F. E. Speizer, C. A. Czeisler, and Harvard Work Hours Health and Safety Group. 2005. Extended work shifts and the risk of motor vehicle crashes among interns. New England Journal of Medicine 352(2):125-134. Basu, C. B., L. M. Chen, L. H. Hollier, Jr., and S. M. Shenaq. 2004. The effect of the Ac- creditation Council for Graduate Medical Education duty hours policy on plastic surgery resident education and patient care: An outcomes study. Plastic & Reconstructive Surgery 114(7):1878-1886. Becker, J. L., M. P. Milad, and S. C. Klock. 2006. Burnout, depression, and career satisfac- tion: Cross-sectional study of obstetrics and gynecology residents. American Journal of Obstetrics & Gynecology 195(5):1444-1449. Bellini, L. M., M. Baime, and J. A. Shea. 2002. Variation of mood and empathy during intern- ship. JAMA 287(23):3143-3146. Biaggi, P., S. Peter, and E. Ulich. 2003. Stressors, emotional exhaustion and aversion to patients in residents and chief residents—What can be done? Swiss Medical Weekly 133(23-24):339-346. Brenninkmeijer, V., N. W. Van Yperen, and B. P. Buunk. 2001. Burnout and depression are not identical twins: Is superiority a distinguishing feature? Personality and Individual Differences 30:873-880. Caruso, C. C. 2006. Possible broad impacts of long work hours. Industrial Health 44(4): 531-536. Cavallo, A., J. Jaskiewicz, and M. D. Ris. 2002. Impact of night-float rotation on sleep, mood, and alertness: The resident’s perception. Chronobiology International: The Journal of Biological & Medical Rhythm Research 19(5):893.

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