The impossible dream: Legislation of "enough sleep" for every physician every night

An editorial in the January 5, 2011 issue of the New England Journal of Medicine suggests the need for legislation of sleep requirements and disclosure for operators who haven't slept for 22 hours out of the past 24. Although it's ideal to have a good night's rest before performing surgery, caths, interventions, or simply writing orders on a complex case, it's not always possible. Furthermore, this ivory-tower recommendation would do a great disservice to rural America, already hurting from physician shortages and grueling schedules. I can imagine how happy Mrs Smith (who has been NPO since midnight and her five family members who took off from work and traveled a hundred miles) would be to hear me say, "Sorry Mrs Smith, I didn't sleep well last night so I'm going to cancel your case." Although I have done that in extreme situations, in the course of a busy physician's day, "less-than-ideal" circumstances are still good enough to get a safe job done. I firmly support structuring training programs to provide optimal conditions for patients and residents, but it's best to let attending physicians decide when they are too sleep-deprived to perform.

Sleep legislation is a slippery slope. It's common knowledge that students perform better on tests if they have breakfast. Should we disclose that we didn't eat the morning of a procedure? Caffeine sharpens recall but it can accentuate a tremor. Should we regulate caffeine intake for physicians? What about the time I learned my father had a Clarks level III–IV melanoma just before my workday? Should I have canceled all my cases the month my mother-in-law lay dying with terminal cancer, sometimes on the next ward? What about the nights we aren't on call yet our mind runs on like a ticker tape? Should I always report it to my patients if I had less than six hours of restful sleep before I round or cath? I've had a long surgery on two occasions in my lifetime, and I did not query my surgeon about his night. If the truth be known, he's probably better after 20 hours of work than some are with a week's vacation. Trust is an integral part of any doctor-patient relationship, and in the private-practice world, it is within this realm of trust that the sleep issue should remain.

Most mistakes in medicine are not due to sleep deprivation. They are due to distraction, too few hours during the workday, too few physicians to handle a heavy workload, and even things like an office worker filing an abnormal lab before we see it and the patient never calling to verify the results. Prevention comes from good planning, systems analysis, and surrounding ourselves with excellent coworkers, not legal constraints. I'd say I've made far more errors of omission from folks interrupting my train of thought with a phone call or a simple question than sleep deprivation. That's why I double-check just about everything, and I find mistakes before they cause an issue.

Residency programs should provide ample opportunity for sleep because those students of medicine and surgery are at the extreme end of deprivation. During my residency, a premier surgeon in training suffered a grand mal seizure while preparing to operate. While the anesthesiology student was trying to intubate the patient, the attending was on the floor trying to stabilize the resident. The young patient with a gunshot wound died after the ET tube was placed in his esophagus. The resident surgeon was not allowed to operate for 12 months, and the entire tragedy very nearly ended a career that took 23 years of training. It also ruined the lives of the family members of that unfortunate patient. Both parties could have been protected if the surgery resident, rumored to have not slept for three days, had been forced to take 12 hours off before returning to the operating room. These extreme cases require consideration, compassion, and a commonsense approach, all of which trump regulation. Program directors should have their finger on the pulse of their residents and the patients whose lives they affect. Sentinel events should be flagged, reported, addressed, and corrected. At the same time, directors must strike a balance between time off and missed opportunities for learning.

Sleep is a precious commodity for any physician but sometimes escapes us due to reasons beyond our control. Whether from emergent disruptions, patient concerns, personal stresses, or reflux from eating lunch at 9:00 pm, a restful night isn't always possible. Whether mature attending physicians are fit to perform a procedure is a personal judgment, but residents in training need just that: training to make that judgment. A good mentor provides enough direction to give them the tools to make decisions about sleep and work when the time comes.
Like many other human attributes, sleep requirements are highly variable. Ben Franklin, Leonardo da Vinci, and Napoleon Bonaparte slept two hours per night and took a 20-minute nap every four to six hours during the day. They weren't acute-care specialists but harbored the same DNA that drives scientists and inventors. These personalities often force sleep to take a back seat to work and creativity, but above all, dedication to acutely ill patients is the greatest motivator for sleep deprivation in those physicians who stand on their feet long hours during a long call night. It was once said that "every closed eye is not sleeping and every open eye is not seeing." In the end, no one can make that judgment for us, and there isn't a single piece of legislation out there that could discern the difference.

See also:

Physician groups bristle at proposed "sleep regulations"

Your comments

	The impossible dream: Legislation of "enough sleep" for every physician every night
	# 1 of 6	January 20, 2011 07:30 (EST)
	Mike	The question of 'sleep regulations' is quite provocative with the expropriation of private cardiology practices resulting in forced hospital mergers.  Previously, call schedules were beyond the purview of the hospital as they were being serviced by an 'independent contractor'.  Hospital insouciance towards a weekend/weeknight/holiday of call coverage (>90 hours straight) existed as long as practioners were willing to compromise the pleasantries of life for insufferably long hours.  This imprimatur will no longer exist once the hospitals are responsible for the call schedules as employers.  Can you imagine Walmart scheduling an employee to begin work Monday at 8am and finish Friday at 5pm? There is much more to this issue than what initially meets the eye.  I wonder if the trial lawyers will take any of these hospitals to task?  Imposition of strict work hour rules would cause a sudden, dramatic, and severe shortage of specialists.  Would this lead to a two tiered medical system as physicians 'moonlighted' outside the hospital?  Melissa, as always, thank you for introducing this topic.
	# 2 of 6	January 20, 2011 10:54 (EST)
	Melissa	You are most welcome Mike.  I recall a senior resident who could barely make rounds every morning because he would moonlight every single night of his life. If there had ever been any regulation of hours without sleep, he would have broken every single one of them. He also had extra watches on his arm in case you needed to buy one (not kidding......just like those guys that stand on the street corners in New York!).  I heard recently that he caught his teenage son skipping college classes and moonlighting as a Chippendale.  The apple doesn't fall far from the tree. Bet his son was sleepy as well! and could honestly have used a little sleep regulation in that instance! Melissa
	# 3 of 6	January 28, 2011 10:35 (EST)
	Dr Kishaloy Sur	If medical professionalism been realized as altruism,then sleep as actualized by the Physician, is equivalent to selfishness!
	# 4 of 6	January 28, 2011 04:00 (EST)
	pa	Sleep deprivation is akin to operating under the influence. Physicians are tired and make more mistakes when call and post-call. I started a program with the medicine department at my hospital 8 years ago. As a clinical pharmacist I round with the post call teams and manage the patient therapy, make corrections, teach and I am involved in the discharge planning. We have reduced errors and improved care as a result of these changes. So its possible but you need to allow other qualified healthcare providers take some of the responsibilities that physicians now shoulder to do it. Its best for the health of the patient and physician.
	# 5 of 6	January 31, 2011 08:44 (EST)
	Marshall Crenshaw	My guess is that the first sentence should read something like "slept less than 8 hours out of the last 24" instead of 22! The scientific method should be followed for regulations regarding sleep.  A controlled study should be done to document that mandating working hours improves care and decreases errors.  The airline industry has taught us the unintended consequences of changes can be worse than the problem.  My experience with these regulations includes resident and intern call teams admitting patients overnight, and then leaving by noon the next day.  Every patient is handed off during the time when most of the initial test results are obtained and decisions need to be made.  No matter how good a signout you attempt, they don't know the patient as well as the primary team.  If you sign out to the team that is on call that night, they are busy with all their new admissions.  If you sign out to the team that is not on call, then they have to sign out yet again at 6pm, doubling the chance for errors.  My guess is that in the next few years physicians (trainees as well as those employed by any group) will have to use a time clock to punch in and out to document work hours.  Patients will not have a doctor, but a shift worker.  I already see the loss of responsibility and caring this is teaching young doctors today.
	# 6 of 6	August 17, 2011 11:26 (EDT)
	Eliza Winters	I completely agree with you that everyone in actually any program should be alloted enought time to get the sleep that they actually need. I am not a physician but I do handle medical billing ( http://advrevenuesolutions.com ) and there have been times when we have been worked to our limits without taking breaks trying to fix errors and what not for people and though were able to do it I am absolutely amazed that we did not make some sort of catastrophic mistake. I would think that any patient would like to know that their physician was well rested before he took their life in their hands.

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