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• AASM Public Safety Committee response
  Amy Licis, Andrew M. Namen and Amara Emenike
  Published on: 26 July 2023

• Published on: 26 July 2023

  AASM Public Safety Committee response

  • Amy Licis, MD, Specialty: Sleep Medicine American Academy of Sleep medicine, Public Safety Committee member
  • Other Contributors:
    • Andrew M. Namen, MD, FAASM, FCCP Pulmonologist, sleep medicine specialist
    • Amara Emenike, MD, Internal Medicine and sleep medicine specialist

  Dear Editor,

  As members of the American Academy of Sleep Medicine (AASM) Public Safety Committee, we commend Barger LK et al. 1 for this important and timely study evaluating the impact of long weekly work hours and shifts of extended duration in senior resident physicians.
  Residency programs face increasing pressure to meet the rising demands in clinical workloads posed by insufficient staffing at medical centers. Meeting this demand requires that residents work both longer shifts and greater cumulative hours per week, and therefore become vulnerable to chronic sleep deprivation. Sleep deprivation compromises cognitive functions, including executive functioning, and impairs one’s own ability to perceive performance impairment.

  Accordingly, past data show that first-year residents experience an increased risk for personal safety and patient-care errors when they work longer than 16 hours per day, or more than 50 hours per week. Following a detailed review of the literature, the National Academy of Medicine (NAM)2 in 2011 issued its most recent work hour recommendations for physicians-in-training, which the Accreditation Council for Graduate Medical Education (ACGME) adopted. These rules imposed work hour restrictions specifically among first-year residents. Other data seemed to suggest that more senior residents (defined as > 1 year clinical training) experience less risk from the effects of sleep deprivation, including the risk for committing...

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  Dear Editor,

  As members of the American Academy of Sleep Medicine (AASM) Public Safety Committee, we commend Barger LK et al. 1 for this important and timely study evaluating the impact of long weekly work hours and shifts of extended duration in senior resident physicians.
  Residency programs face increasing pressure to meet the rising demands in clinical workloads posed by insufficient staffing at medical centers. Meeting this demand requires that residents work both longer shifts and greater cumulative hours per week, and therefore become vulnerable to chronic sleep deprivation. Sleep deprivation compromises cognitive functions, including executive functioning, and impairs one’s own ability to perceive performance impairment.

  Accordingly, past data show that first-year residents experience an increased risk for personal safety and patient-care errors when they work longer than 16 hours per day, or more than 50 hours per week. Following a detailed review of the literature, the National Academy of Medicine (NAM)2 in 2011 issued its most recent work hour recommendations for physicians-in-training, which the Accreditation Council for Graduate Medical Education (ACGME) adopted. These rules imposed work hour restrictions specifically among first-year residents. Other data seemed to suggest that more senior residents (defined as > 1 year clinical training) experience less risk from the effects of sleep deprivation, including the risk for committing medical errors and preventable fatal and non-fatal adverse events, when weekly work hours exceeded 50/week. Due to conflicting evidence, then, the ACGME did not impose similar work hour restrictions for residents beyond the first year of their training.3
  To address this lack of clarity, the current study by Barger et al 1 examined the effects of long weekly work hours (defined variably as greater than 48, 60, 70, or 80 hours/week) and shifts of extended duration (≥24 hours) specifically among senior residents. They confirmed an increased risk of preventable adverse events among senior residents who worked more than 50 hours, and the risk was dose-dependent, with further increases with each additional decile of hours worked, with up to a 4-fold increase at 80 hours/week. Risks to patient safety were even higher in senior residents who experienced a combination of long weekly hours plus extended-duration work shifts. Additionally, extended work hours were associated with a 4-fold increase in occupational and percutaneous injuries and a 5-fold increase in motor vehicle accidents and near-miss accidents, in a dose-dependent manner. Therefore, this study affirms that senior residents, like first-year residents, are also at risk for both patient safety and personal and public safety risks with long work hours.

  These data, along with the evidence that sleep loss may increase the risk for physician burnout, are a call to action.4 As a community, we must work to mitigate preventable medical errors and injuries to our early learners, and improve workforce longevity with strategies that limit provider exhaustion and sleepiness. This study confirms that longer hours erode workplace safety, an important health systems priority.
  The AASM has consistently maintained the position4 that physicians-in-training need sufficient quantity and quality of sleep to support functioning and improve patient safety and the safety of our communities. The impacts of extended work hours on senior residents are consistent with prior studies on junior residents,5 highlighting the need for meaningful policy by the ACGME to further limit work hours for all resident physicians as a matter of public safety.

  Sincerely,

  Amy Licis, MD Andrew M. Namen, MD FAASM, FCCP and Amara Emenike, MD representing the AASM Public Safety Committee

  References:
  1. Barger LK, Weaver MD, Sullivan JP, Qadri S, Landrigan CP, Czeisler CA. Impact of work schedules of senior resident physicians on patient and resident physician safety: nationwide, prospective cohort study. BMJ Med. 2023 Mar 30;2(1):e000320. doi: 10.1136/bmjmed-2022-000320. PMID: 37303489; PMCID: PMC10254593.
  2. Institute of Medicine (US) Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedule to Improve Patient Safety. Resident duty hours. In: Ulmer C, Wolman DM, Johns MME, eds. Enhancing sleep, supervision, and safety. Washington, D.C: The National Academies Press, 2008: 1–322.
  3. Accreditation Council for Graduate Medical Education. Common program requirements; 2010.
  4. Kancherla BS, Upender R, Collen JF, Rishi MA, Sullivan SS, Ahmed O, Berneking M, Flynn-Evans EE, Peters BR, Abbasi-Feinberg F, Aurora RN, Carden KA, Kirsch DB, Kristo DA, Malhotra RK, Martin JL, Olson EJ, Ramar K, Rosen CL, Rowley JA, Shelgikar AV, Gurubhagavatula I. Sleep, fatigue and burnout among physicians: an American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2020 May 15;16(5):803-805.
  5. Landrigan, Christopher P., et al. "Effect of reducing interns' work hours on serious medical errors in intensive care units." New England Journal of Medicine 351.18 (2004): 1838-1848.

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  Conflict of Interest:
  None declared.

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