Appendix 61 - Sleep

by Michael Greger, MD and United Progressive Alumni

[ Medical School Resources | Appendices | Discussion ]

And Miles to Go Before I Sleep

I find myself at the nurses' desk at 4:18 a.m. reading an article called, "Fatigue in Medical Students." In a 500 intern survey of 10 medschools, over 20% of the residents reported staying awake for two full days or longer on at least one occasion.[710]

From an article in The Lancet:

Wakefulness for 24 hours is equivalent to a blood alcohol level of 0.10% which is above the legal driving limit.... Surgeons awake all night made 20% more errors and took 14% longer to complete the tasks than those who had had a full night's sleep. The decline in performance remained significant after arousal was taken into account... suggesting that sleep deprivation mediates its effect via increased stress rather than decreased arousal.[711]

In a recent letter, a doctor asked the readership of The Lancet to consider a study of sleep-deprived versus rested surgeons. Since it would be unethical for a patient to be randomized to a sleep-deprived surgeon, he asserts, no institution that would approve such a trial. "In other words," he concludes, "the current standard of care - sleep-deprived surgeons - is indeed too unethical to be part of a clinical trial!"[712]

Bemoaning the near absence of teaching about sleep in medical schools, one doc writes, "Perhaps the medical schools do not want future house officers to know the consequences of what might happen to them. Alternately, perhaps the students are too sleepy to take in the information."[713]

Balm of hurt minds - Shakespeare

In one study, 377 house officers ranked the ten factors most detrimental to their general well being. "Lack of sufficient sleep" was ranked number one. Quoting from the Annals of Internal Medicine, "For many residents, fatigue cultivates anger, resentment, and bitterness rather than kindness, compassion, or empathy."[714] Sleep deprivation may be the reason that depression and anger emerge as the significant mood changes during residency.[715] Most episodes of depression reported in one study, for example, took place while residents were working more than 100 hours per week."[716]

These are not the only ways sleep deprivation effects the health of medical trainees. Bertrand Bell, head of the New York commission studying resident overwork, writes, "The committee also learned that sleep deprivation and chronic fatigue were killing and maiming resident physicians and medical students who attempted to drive home after working unusually long hours."[717]

"For many residents, sleep becomes a matter of survival."[718]

From JAMA,

After being on call, many residents drive home, creating a hazard for themselves and others on the road. Of seven surgical residents in our hospitals who were interviewed, six fell asleep while driving to or from work during their internships and three were involved in motor vehicle accidents.[719]

"If I can crash a car, I can certainly make mistakes in the operating room," said one resident staging a protest 'sleep in' in front of a California hospital. He had fallen asleep while driving home after a 35-hour shift in April and smashed into a utility pole...."[720]

In one study, nearly half of the residents surveyed said they had fallen asleep while stopped at a red light - invariably while driving home after a night on call. One resident said she routinely used her emergency brakes at stoplights because she was so sleepy.[721],[722]

In January 1999, as reported in the American Medical News, "third-year resident Valenti Barbulescu, MD, died in a one-car crash after falling asleep at the wheel soon after he finished working an overnight shift...." He was on his way to take a board exam.[723]


From a book called Residents: The Perils and Promise of Educating Young Doctors:

For Frank Ingulli, a third-year medical student, fatigue proved fatal as he drove home one night at one forty-five. He had just finished a grueling stint in a surgical clerkship... and accidentally turned onto an exit ramp on interstate 95. Hit head-on as he motored south on the northbound side of the highway, he was rushed back to the same operating room he had just left... [New York] State police investigators blamed the accident on fatigue.[724]

According to his sister Margaret, who spoke for her Italian immigrant parents, Frank used to say, "Ma, I'm so tired, I can't stand up anymore." What did the dean of his medical school have to say? "Medicine is a 24-hour-a-day discipline, and they have to get used to that mindset."[725]



[710] Daugherty SR. and DC Baldwin Jr. "Sleep Deprivation in Senior Medical Students and First-Year Residents." Academic Medicine 71(1996):S93-95.

[711] Taffinder, N J, et al. "Effect of Sleep Deprivation on Surgeons' Dexterity On Laparoscopy Simulator." The Lancet 352(1998):1191.

[712] Altschuler, EL. Letter. The Lancet 353(1999):501.

[713] Sloan, VS. Letter. Journal of the American Medical Association 281(1999):134.

[714] Green, MJ. "What (If Anything) is Wrong with Residency Overwork?" Annals of Internal Medicine 123(1995):512-517.

[715] Squires, BP. "Fatigue and Stress in Medical Students, Interns and Residents." Canadian Medical Association Journal 140(1989):18-19.

[716] Schwartz, AJ, et al. "Levels and Causes of Stress Among Residents." Journal of Medical Education 62(1987):744-753.

[717]Bell, BM. Letter. New York Times late ed., 9 June 1993:A20.

[718] Yam, JI. "Truck Drivers and Sleepy Doctors." King County Medical Society Bulletin 1997(December).

[719] Letter. Journal of the American Medical Association 259(1988):43.

[720] O'Leary, K. "Tired of Long Hours." Los Angeles Times Orange County ed. 28 July 1989:3.

[721] Mader, G. "Young Doctors Often Asleep at the Wheel." Press Release. 17 March 1997.

[722] "Effect of Sleep Deprivation on Driving Safety in Housestaff." Sleep 19(1996):763-766.

[723] Greene, J. "Residents Say Long Hours Hurt Patient Care." Greene, J. "Residents Say Long Hours Hurt Patient Care." American Medical News 42(1999):1, 30-31.

[724] Duncan, DE. Residents: The Perils and Promise of Educating Young Doctors. New York, NY: Scribner, 1996:108.

[725] Berger, J. "The Long Days and Short Life of a Medical Student." New York Times late ed., 30 May 1993:29.



Reader's Comments

I also had the experience of falling asleep while driving home post call. Fortunately, I was not in any crashes. This seems miraculous now. What I don't understand, now that I've left the medical field, is why it took me so long to leave. I shouldn't have tolerated more than one such dangerous event. For some reason, I let it occur repeatedly. To be sure, I was probably only "out" for seconds, but that all it takes... It is horrifying to all of a sudden become aware of the fact that you are in a car, driving. Even more so if you've veered out of the correct lane. I used to call home while driving and tell my husband to talk to me and make sure I kept responding. It was actually a drive home after a brutal call night that provided the proverbial last straw. I fell asleep more than 3 times that evening, despite the adrenaline rush that came each time I was terrified back into (partial) wakefulness. I was shaking with fear and anger when I finally made it home, and ended up calling a friend and screaming through the phone that this was wrongwrongwrong.

-- Emilia Gan, May 1, 2001
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