Postgraduate Medicine

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Sleep Deprivation in Resident Physicians, Work

Hour Limitations, and Related Outcomes: A
Systematic Review of the Literature

Meghna P. Mansukhani, Bhanu Prakash Kolla, Salim Surani, Joseph Varon &
Kannan Ramar

To cite this article: Meghna P. Mansukhani, Bhanu Prakash Kolla, Salim Surani, Joseph Varon
& Kannan Ramar (2012) Sleep Deprivation in Resident Physicians, Work Hour Limitations, and
Related Outcomes: A Systematic Review of the Literature, Postgraduate Medicine, 124:4, 241-249,
DOI: 10.3810/pgm.2012.07.2583

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Sleep Deprivation in Resident Physicians,  Work
Hour Limitations, and Related Outcomes:
A Systematic Review of the Literature
Meghna P. Mansukhani,
MBBS 1
Bhanu Prakash Kolla, MBBS,
MRCPsych 2
Salim Surani, MD, MPH,
FAASM, FCCP 3
Joseph Varon, MD, FACP,
FCCP, FCCM 4,5,6
Kannan Ramar, MD 7
1
Fellow, Center for Sleep Medicine,
Mayo Clinic, Rochester, MN;
2
Assistant Professor of Psychiatry,
Mayo Clinic, Rochester, MN;
3
Associate Professor of Medicine,
Division of Pulmonary and Critical
Care Medicine, Texas A&M
University, College Station, TX;
4
Professor of Acute and Continuing
Care,  T he University of Texas Health
Science Center at Houston, Houston,
TX; 5Professor of Clinical Medicine,
The University of Texas Medical
Branch at Galveston, Galveston,
TX; 6Chief of Critical Care Services,
University General Hospital,
Houston, TX; 7Assistant Professor
of Medicine, Division of Pulmonary,
Sleep and Critical Care Medicine,
Mayo Clinic, Rochester, MN
Correspondence: Salim Surani, MD,
7613 Lake Bolsena,
Corpus Christi, TX 78413.
Tel: 361-885-7722
E-mail: srsurani@hotmail.com
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C L I N I C A L F E AT U R E S
DOI: 10.3810/pgm.2012.07.2583
Abstract: Extended work hours, interrupted sleep, and shift work are integral parts of medical
training among all specialties. The need for 24-hour patient care coverage and economic factors
have resulted in prolonged work hours for resident physicians. This has traditionally been
thought to enhance medical educational experience. These long and erratic work hours lead
to acute and chronic sleep deprivation and poor sleep quality, resulting in numerous adverse
consequences. Impairments may occur in several domains, including attention, cognition, motor
skills, and mood. Resident performance, professionalism, safety, and well-being are affected by
sleep deprivation, causing potentially adverse implications for patient care. Studies have shown
adverse health consequences, motor vehicle accidents, increased alcohol and medication use,
and serious medical errors to occur in association with both sleep deprivation and shift work.
Resident work hour limitations have been mandated by the Accreditation Council for Graduate
Medical Education in response to patient safety concerns. Studies evaluating the impact of these
regulations on resident physicians have generated conflicting reports on patient outcomes, dem-
onstrating only a modest increase in sleep duration for resident physicians, along with negative
perceptions regarding their education. This literature review summarizes research on the effects
of sleep deprivation and shift work, and examines current literature on the impact of recent work
hour limitations on resident physicians and patient-related outcomes.
Keywords: internship; medical training; residency; hours; stress; psychological; clinical
competence; quality of life; well-being; burnout; medical errors; safety; fatigue; sleep loss;
sleep deprivation
Introduction
An adequate quantity and quality of sleep are needed to function effectively during the
day, and are of paramount importance in maintaining a healthy lifestyle. The increas-
ing complexity of patient care due to multiple comorbidities and polypharmacy, and
the need for 24-hour hospital coverage, have placed significant stress on physicians in
training and other health care providers.1,2 During their training, resident physicians are
required to work extended hours and shifts, and to be on call. This can result in acute
and chronic sleep deprivation, which can impact the well-being of resident physicians
and patient care.3–5
In response to the death of Libby Zion, an 18-year-old patient whose death
was thought to be related in part to resident physician sleep deprivation, the Bell
Commission issued a report recommending specific limitations on resident work
hours.6 In 1989, New York State enacted changes in its health code whereby resident
physicians could work no more than an average of 80 hours per week.7 Also, the
Accreditation Council for Graduate Medical Education (ACGME) mandated work
Mansukhani et al
hour limitations (WHLs) in July 2003; these were recently
updated (Table 1).6 This has stimulated an intense debate on
the optimal balance between patient care, resident education,
and patient and physician well-being.8
The purpose of this systematic review is to present
published data on the impact of sleep deprivation on resident
physicians, as well as its consequences, and ways to prevent
it from harming patients and residents without compromising
medical training.
Methods
Eligibility Criteria
Studies that evaluated the effects of sleep loss on physicians
in training were eligible for review. Due to the limited number
of studies available on this topic, we accepted all reported
outcome measures. All authors independently identified trials
for inclusion. Primarily, titles and abstracts of the records
retrieved by the search were assessed in order to exclude
studies that did not report any outcome data. Disagreements
between the reviewers were resolved by discussion with the
senior author (KR).
Information Sources and Search Methods
A comprehensive literature search of electronic databases
(Medline, EMBASE, and PubMed) was conducted, irrespective
of publication date. The search keywords used were internship,
medical training, residency, hours, stress, psychological, clini-
Table 1.  ACGME Resident W
  ork Hours
• Duty hours must be limited to 80 hours per week, averaged over
a 4-week period, inclusive of all in-house call activities and all
moonlighting.
• Residents must be scheduled for a minimum of 1 day free of duty
every week (when averaged over 4 weeks).  At-home call cannot be
assigned on these free days.
• Duty periods of PGY-1 residents must not exceed 16 hours in duration.
• Duty periods of PGY-2 residents and above may be scheduled to
a maximum of 24 hours of continuous duty in the hospital. Strategic
napping, especially after 16 hours of continuous duty and between
the hours of 10:00 PM and 8:00 AM, is strongly suggested.
• Residents must not be assigned additional clinical responsibilities after
24 hours of continuous in-house duty.
• PGY-1 residents should have 10 hours, and must have 8 hours, free
of duty between scheduled duty periods. Intermediate-level residents
should have 10 hours free of duty.
• Residents must not be scheduled for . 6 consecutive nights of night float.
• PGY-2 residents and above must be scheduled for in-house call no
more frequently than every third night.
Adapted from the 2011 ACGME Common Program Requirements.6
Abbreviations: ACGME, Accreditation Council for Graduate Medical Education;
PGY, postgraduate year.
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cal competence, quality of life, well-being, burnout, medical
errors, safety, fatigue, sleep loss, and sleep deprivation.
Results
Acute and Chronic Sleep Deprivation
Among Residents
Acute sleep loss causes a dose-dependent decrement in mood,
cognitive performance, and motor skills.9,10 Progressive
wakefulness between 14 and 26 hours results in an hourly
decline in cognitive psychomotor performance similar to a
0.04% increase in blood alcohol concentration.11 Resident
performance after long work hours (90 hours per week and
mandated on-call shift every fourth or fifth night for 34–36
consecutive hours) is comparable with impairment associated
with a 0.04 to 0.05 g% blood alcohol concentration.12 Long
work hours resulted in poor performance on tasks requiring
sustained attention and vigilance, resulting in an increased
number of errors and delayed reaction time.12 Acute sleep
loss could, thus, pose a significant threat to work-related per-
formance and the safety of patients and resident physicians.
The effects of chronic sleep deprivation are similar, resulting
in attention lapses, sluggish working memory, depressed mood,
and reduced cognitive performance (Table 2).13 The adverse
effects of partial sleep loss may be cumulative, particularly
with a lack of adequate recovery sleep.14 Restriction of sleep
to , 6 hours per night for # 2 weeks results in cognitive per-
formance deficits equivalent to up to 48 hours of total sleep
loss.14 Subjective awareness of sleepiness seems to plateau
with time, resulting in a situation in which the individual is
unaware of the level of his or her impairment.14
Individual differences in the global response to sleep
loss and variations in the degree to which several of the
neurocognitive domains are affected can impact the response
Table 2.  Effects of Sleep Loss on Cognitive Functioning
Cognitive Domain Effect of Sleep Loss
Executive functioning Increased difficulty with switching tasks,
increased errors while performing tasks
requiring behavioral inhibition, performance
worsening with increasing complexity of tasks
Memory Possible reduction in digit recall and visuospatial
memory
Reaction time Reduced speed of response and diminished
accuracy
Attention and Worsening response on psychomotor vigilance
concentration tasks that improve after a recovery sleep period
Emotional regulation Reduced self-regard, empathy, impulse control,
and positive thinking
Adapted from J Int Neuropsychol Soc.13
 Sleep Deprivation  Among Residents

to sleep deprivation. 15 Environmental factors, such as
motivation, body posture, light, and noise, can also affect the
overall response to sleep loss.16 These conditions are often
suboptimal in a busy hospital environment, particularly out
of normal working hours, and could exacerbate the effects
of acute and chronic sleep loss on residents.
Improve Patient Safety proposed changes to the ACGME
regulations in 2008 (Table 2).18 The ACGME has accepted
these recommendations and has mandated residency programs
to implement the changes from July 1, 2011. The financial
impact of the proposed changes is considerable, with an esti-
mated annual cost of $1.6 billion for their implementation.19

Shift W
  ork  Among Residents
Shift work is common in medical training and necessary for
24-hour hospital coverage. This poses difficulties not only
with a loss of actual number of hours of sleep, possibly due
to insufficient sleep opportunities and circumstances for
daytime sleep in many cases, but also causes a major disrup-
tion in the normal circadian process.17 Shift work disorder is
associated with insomnia during desired sleep periods and
excessive sleepiness and/or decreased alertness during work
shifts, with implications for impaired performance and safety
of physicians in the workplace.
The Institute of Medicine Committee on Optimizing
Graduate Medical Trainee Hours and Work Schedules to
Effects of Sleep Loss
The existing literature that largely assesses the effects of
sleep deprivation among physicians in training is method-
ologically limited, as most are survey studies that are prone
to recall bias. It is difficult to ascertain the degree to which
the adverse effects and impairments are attributable to sleep
loss or scheduling factors resulting in residents having to
work during their natural sleep time. Although there is some
conflicting evidence as to whether actual sleep deprivation or
circadian process disturbances are responsible for the com-
mission of medical errors, overall, the data suggest that there
is a deleterious effect of long work hours and shift work on
numerous resident- and patient-related outcomes (Table 3).

Table 3.  Effects of Sleep Loss on Resident Performance and Well-Being

Study Study Population Design Results
Papp et al20
149 residents Standardized, semi-structured Increased sleepiness, reduced empathy and concern
discussion groups and questionnaire for patients, impaired cognition, and adverse impact
on interpersonal relationships
Taffinder et al21 6 surgical trainees Dexterity measured by Imperial Increased errors and increased time to complete
College Surgical Assessment Device tasks
Grantcharov 14 surgical trainees Minimally invasive surgical trainer Impaired speed and accuracy
et al22 (virtual-reality testing)
Lingenfelser 40 residents Neuropsychological measures and Worsening neuropsychological tests and ECG
et al23 ECG interpretation interpretation
Rosen et al24 132 incoming interns Survey study Dozing while writing charts, reviewing medications,
and house staff interpreting laboratory results, and writing orders
Ayas et al25 2737 interns Prospective web-based survey Increased risk of needle-stick injuries after
extended shifts
Baldwin and 3604 residents 5-page mailed survey Serious accidents, conflict with other medical staff,
Daugherty27 increased alcohol use, and increased medication use
Leonard et al28 16 interns Psychological parameters, tests Increased mood disturbance, reduced alertness and
of alertness concentration
Brandenberger 14 surgical residents Visuohaptic simulations Greater deterioration in surgical proficiency after
et al38 a night of being on call
Gander et al39 1366 physicians Questionnaire-based study Increased sleepiness, fatigue, clinical errors, and
in training falling asleep while driving
McBeth et al29 2397 emergency Survey questionnaire Increased use of zolpidem and modafinil during
medicine residents training
Barger et al30 2737 residents Web-based surveys Increased motor vehicle accidents
Marcus and 70 pediatric residents Questionnaire-based study Increased sleepiness while driving, traffic citations,
Loughlin31 and motor vehicle accidents compared with faculty
Steele et al32 1554 emergency Questionnaire-based study Increased motor vehicle accidents with increased
medicine residents number of night shifts worked
Abbreviation: ECG, electrocardiogram.

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Mansukhani et al
Physician Performance
In a study involving 149 residents from 5 US academic
medical centers and 6 different specialties, multiple adverse
effects of sleep loss on the ability to learn and think, cognitive
function, attention, professionalism, and task performances
were described.20 Residents felt a lack of motivation to
learn, as well as an impairment in their short- and long-term
acquisition of knowledge and higher-order thinking skills
pertaining to medical decision making. The subjects also
admitted to feeling moderately sleepy during teaching and
grand rounds. Most residents expressed frequent concerns
about errors in patient care, such as misdiagnoses, not
entering relevant information in the patient’s record, writing
prescriptions with incorrect dosages, or prescribing medica-
tion to the wrong patient. The effects remained consistent
across academic centers, specialties, years in training, age,
sex, marital status, and parental status. Most (84%) subjects
had a mean Epworth Sleepiness Scale score of 14.6 out of 24,
indicating daytime sleepiness that would require clinical
intervention.
In a study of resident surgeons assessing psychomotor
skills on a simulator, Taffinder et al21 identified 20% more
errors made and 14% more time required to complete tasks
for subjects after a night of being on call (during which they
were awake all night) compared with those who had a full
night of sleep. Increased stress paralleled the decrease in task
performance. However, in this study, a third group that was
on a “sham night on call” (during which residents were not
on call but their sleep was disrupted on 3 occasions) was no
different from the group that had a full night of sleep.
In another study, gastroenterological surgeons in training
demonstrated impaired speed and accuracy in a simulated
laparoscopic performance after a night being on call, during
which they received , 3 hours of sleep.22 After being on call,
medical residents showed a significant decrease in the effi-
ciency and accuracy of electrocardiogram interpretation com-
pared with residents who obtained 6 hours of uninterrupted
sleep.23 These studies show the negative consequences of sleep
deprivation on cognitive processing, speed, and accuracy.
In a survey of residents at the University of Pennsylvania
(Philadelphia, PA), 34% experienced acute sleep deprivation
and 64% experienced chronic sleep deprivation compared
with incoming interns.24 The house staff also admitted to the
possibility of dozing off while writing patients’ charts (69%),
reviewing medication lists (61%), interpreting laboratory
results (51%), or writing orders (46%). In this survey, sleepi-
ness did not vary with call status or call cycle, suggesting
that sleepiness was chronic.
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In a prospective cohort study of  2737 interns, percutaneous
injuries were more common after extended work hours.25 The
odds of percutaneous needle-stick injuries were 1.6 after an
extended overnight shift compared with a regular shift. The
main reasons cited for the injuries were lapses in concen-
tration and fatigue. A recent meta-analysis concluded that
sleep loss of , 30 hours reduced overall performance and
clinical performance by nearly 1 and 1.5 standard deviations,
respectively.26
Professionalism
In a study by Papp et al,20 most sleep-deprived residents
felt a lack of empathy and concern for their patients. They
described themselves as inattentive and abrupt in their rela-
tionships and interactions with patients and their families.
They felt that sleep loss negatively affected their interaction
with other health care staff, including a lack of interest in
teaching junior residents. Another study showed that most
(66%) resident physicians slept an average of , 6 hours
per night.27 Those who averaged , 5 hours per night were
twice as likely to report a significant medical error or have
a serious accident, injury, or conflict with other health
care professionals.
Personal  Well-Being and Quality of Life
In 1 study, most residents felt that sleep loss adversely
affected their physical and psychological health and mood.20
They perceived a lack of time for activities of daily living
and leisure. They described difficulties with starting or
maintaining relationships and being effective parents during
their training period. In this survey, residents reported being
more irritable with their children and feeling guilty about not
spending enough time with them.
Residents obtaining , 5 hours of sleep per night reported
a noticeable change in weight, use of medications to stay
awake, and increased alcohol consumption.27 A study assess-
ing the effects of a 32-hour on-call shift for junior doctors
in Dublin, Ireland found that they obtained an average of
4.5 hours of sleep.28 Trainees reported increased tension and
anxiety and reduced vigor and activity. Tests of executive
function and trail-making tests showed significant deteriora-
tion after sleep deprivation, while other tests, such as delayed
story recall, were not affected. Loss of sleep significantly
affected their psychological well-being and ability to perform
simple tasks. A survey of emergency medicine residents
found that 2.4% of residents used modafinil and 21.8% used
zolpidem.29 The majority started using these agents after
starting their residency.

Safety and  Accidents
Sleep-deprived residents have been found to be at risk for
motor vehicle accidents related to drowsiness while driving.20
Residents on extended–work hour shifts were 2.3 times more
likely to report a motor vehicle accident and 5.9 times more
likely to report a near-miss accident.30 Residents working $ 5
extended–work hour shifts per month reported an increased
risk of falling asleep while driving or when idle in traffic.
In this study, residents commuting from work after an
extended–work hour shift were more likely to have a motor
vehicle accident than at other times.
Similar results were seen in a survey of pediatric residents
who were on call every fourth night, compared with faculty
members who were rarely disturbed at night.31 Residents
were more likely to report falling asleep while idle at a traf-
fic light (44% of residents compared with 12.5% of faculty
members) or while driving (23% of residents compared with
8% of faculty members). In a survey of emergency medicine
residents from 78 participating programs, nearly three-fourths
of motor vehicle accidents and near-miss accidents occurred
after a night shift.32 The survey revealed a positive correlation
between the number of night shifts worked per month and
motor vehicle accidents.
Shift Work
Shift work, which is common in the medical field, poses health
risks and concerns for physicians in training and practicing
physicians. Various studies have shown an increased inci-
dence of peptic ulcer disease and metabolic syndrome, and
increased mortality rates, as well as other negative health
consequences associated with shift work and sleep depriva-
tion.33–36 In a recent survey of emergency medicine residents,
89% reported use of caffeine during their night shifts, with
more than half of them using it on every night shift.37 Thirty-
eight percent reported using sedatives to fall asleep after their
night shift, the most common being antihistamines (31%),
zolpidem (14%), melatonin (10%), and benzodiazepines (9%).
Recent studies have emphasized the importance of
circadian factors on safety outcome measures for residents,
with self-reported cutaneous injuries being twice as common
during the night than during the day,25 and motor vehicle
accidents showing a positive correlation with the number
of night shifts worked.30–32 One study revealed a negative
correlation between shift work tolerance, as measured by
the Morningness-Eveningness questionnaire, and the likeli-
hood of having a motor vehicle accident.32 These studies
demonstrate the negative effects of sleep deprivation coupled
with circadian-process changes associated with shift work.
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Sleep Deprivation  Among Residents
Decreased proficiency in simulated surgical skills in
night-float trainees compared with those working a similar
number of hours during the day has been demonstrated.38,39
The study included only first-year residents and showed that
cognitive skills were more affected than psychomotor skills.
Similarly, a survey of junior physicians (defined as physi-
cians in postgraduate year 1–3 and higher training) in New
Zealand showed that night work and schedule instability,
and not total work hours, were independent risk factors for
fatigue-related medical errors.39
Compliance with WHLs
A single anonymous survey of surgical residents performed
in 2007 revealed that 64.6% of residents were not compliant
with WHLs.40 Although the residents were in agreement with
the WHLs, they cited education and continuity of patient care
as the main reasons for noncompliance.
Impact of WHLs
Literature on outcome measures related to physicians in train-
ing and patient safety after the implementation of WHLs, and
strategies designed to increase total sleep time, are limited
and equivocal.41–45
The first study to demonstrate the benefits of curtailing
resident physicians’ work hours was by Landrigan et al,46
in which they prospectively evaluated intern errors in the
intensive care unit setting. A modified shift schedule of up to
16 hours resulted in 14 to 21 fewer hours of work per week
compared with the traditional extended-shift schedule. Interns
on the traditional schedule made 36% more serious medical
errors and 5.6 times more serious diagnostic errors compared
with those on the modified schedule. However, patient mortal-
ity rates and intensive care unit length of stay did not differ
between the 2 groups.46,47
The European Working Time Directive specified a 48-hour/
week limit for medical trainees in August 2009.48 Cappuccio
et al49 compared residents on the new directive with those on
the previous limit of 56 hours. They found that there was 32.7%
less total medical errors, including 82.6% less intercepted
potential adverse events and 31.4% less nonintercepted poten-
tial adverse events. Although the residents on reduced work
hours did report more sleep overall, the difference did not reach
statistical significance. Of note, recovery sleep after an evening
shift was significantly longer than after a traditional shift. The
residents on reduced work hours expressed concerns that their
educational opportunities were compromised.
Since the implementation of the ACGME WHLs in the
United States, recent large studies have demonstrated a
Mansukhani et al
neutral effect on or a decrease in patient mortality rates. One
study reported an increase in nonfatal surgical complications
after implementation of the 80-hour WHLs.50 The authors of
this study speculate that the increase in complication rates
could be related to the implementation of the 80-hour work
week. Another study, however, showed no difference in
complications or mortality rates in trauma surgery performed
at night by residents who worked for . 16 hours compared
with those performed during the day, calling into question
the 16-hour ACGME rule.45
A recent systematic review showed that the odds of
patient death before implementation of the WHLs were
slightly higher (odds ratio, 1.12; 95% CI, 1.07–1.17) than
after implementation.27,51 Findings were consistent across
specialties. In this study, only small differences in mor-
tality rates were noted despite a significant reduction in
work hours, and findings were similar in teaching versus
non-teaching hospitals, calling into question whether it
was the reduction in work hours alone or overall improve-
ments in health care delivery that were responsible. Hence,
it is difficult to discern whether the observed difference is
actually due to the implementation of the new ACGME
regulations, particularly in the absence of prior evidence
directly associating physician fatigue with patient mortality.
Another systematic review that examined patient outcomes
and resident education outcomes found that there was no
increase in patient mortality rates after the implementation of
the 80-hour work week.52 This study did not find an adverse
impact on resident education.
Studies have continued to show a severe degree of sleepi-
ness in residents and fellows even after the implementation of
the WHLs.53,54 A web-based nationwide survey of residents
1 year after the implementation of ACGME WHLs demon-
strated an increase in mean nightly sleep duration of only
22 minutes (from 5.91 to 6.27 hours), despite a decrease in
overall weekly work hours and duration of shifts.46 However,
84% of 1278 interns in the survey reported work hours in
violation of the standards, especially with the 30-hour rule.
These findings indicate that limiting work hours alone may
not serve as a sufficient strategy to address sleep deprivation
among residents. Additionally, a study of post­–on-call anes-
thesia residents showed that they were poor judges of how
sleepy they felt, and that extending their sleep times resulted
in a normalization of their daytime sleepiness.55
Scheduled naps have been suggested as a way to offset
sleepiness in residents. A study that looked at the effects
of a nap during the extended–work hour shift reported that
while interns reported less overall post–on-call fatigue on
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the nap schedule compared with the standard schedule, use
of alternative coverage during the nap period was impaired
by the desire to take care of their patients and concerns
about continuity of care.56 Educational interventions, such
as the Sleep, Alertness, and Fatigue Education in Residency,
focusing on sleep loss and recovery in residents adhering to
ACGME WHLs, found no significant effect on residents’
pre– or post–on-call sleep.57
Surveys of residents across specialties have suggested an
overall improved quality of life, but the effects on perceived
patient care and learning have varied.58,59 In an online survey
of 720 family medicine residents, 83% indicated that reason-
able work hours would be 60 to 80 hours/week, approximately
half perceived the revision of supervision favorably, and 18%
admitted under-reporting duty hours. Overall satisfaction
with future WHLs were mixed, with 41% being unsatisfied
or very unsatisfied. Selection and recall bias were potential
limitations of this study.60
Resident and Faculty Opinions
About the WHLs
Recent surveys pertaining to the WHLs have revealed nega-
tive feedback from program directors and clinical faculty.61,62
Supervising physicians consistently perceived that the resi-
dent educational experience worsened, patient continuity of
care was affected, and that the faculty incurred more clinical
work. It is thought that the lack of continuity of care will
increase the number of handovers, which has previously been
shown to be a source of medical errors.63,64 Some studies have
expressed concern from faculty regarding reduced operative
experiences for surgical residents.65 A recent e-mail survey
involving 464 respondents of 719 eligible programs revealed
that surgery directors were more likely than internal medi-
cine directors to believe that the new ACGME regulations
would decrease residents’ competency, medical knowledge,
practice-based learning/improvement, communication skills,
and professionalism.66 Many program directors believed that
the changes would not affect resident fatigue. Directors of
small, community-based programs were nearly 3 times more
likely to believe that education would be adversely affected
compared with directors of university-based programs.
Although the surveys of residents and program directors
are equivocal, the single survey of public opinion about
resident work hours indicates that the US public underesti-
mates the hours worked by most residents. They estimate that
residents work 12.9-hour shifts and 58.3-hour work weeks.67
This survey probably suggests that the US public believes
that the maximum ideal shift length should be 10.9 hours and

50 hours per work week. Only 1% of the people surveyed
felt that shifts . 24 hours were feasible.
Discussion
The homeostatic and circadian processes of the sleep–wake
cycle in physicians in training are challenged by the number
of consecutive work hours, interruption of sleep from pagers
and phone calls, inadequate sleep recovery, and shift work.
The consequences are acute and chronic sleep deprivation
and poor sleep quality, with concomitant deterioration in
performance and patient safety.
Evidence points toward impaired performance, cognition,
mood, and overall well-being and safety, particularly among
physicians in training.68 There appears to be a dose-response
relationship between the number of hours of acute sleep debt
and these impairments. Chronic partial sleep deprivation
causes similar consequences on mood, cognition, and motor
skills.68 The adverse effects may accumulate dangerously over
time with inadequate recovery sleep. Studies have shown
that subjective awareness of sleepiness plateaus with time,
potentially placing residents and patients at even higher risk
from the effects of sleep loss.14
Attention, memory, cognitive processing, and the ability to
learn all appear to be affected by extended–work hour shifts,
impacting complex medical decision making and increasing
medical errors.13 Speed and accuracy of motor skills have
been shown to decline in several studies, and the number of
needle-stick injuries has been found to increase after a night
of being on call.21–25 Impairments in multiple domains sig-
nificantly impair resident performance. Despite these impair-
ments, the current literature does not demonstrate a consistent,
unequivocal improvement in patient-related outcomes since
implementation of the WHLs.20,21,25
In addition to errors in the workplace, residents working
long hours and night shifts relate increased rates of motor vehi-
cle accidents, particularly while commuting from work.30–33
Therefore, sleep deprivation has major negative consequences
on the safety of society in general. Mood and irritability appear
to be affected early on, with a perceived lack of time for daily
activities, guilt about not spending enough time with family,
and difficulties with parenting and interpersonal relationships
reported by physicians in training.20 Professionalism is nega-
tively affected, with medication use, alcohol consumption,
and conflicts with colleagues escalating with increased sleep
loss.29 These factors significantly affect the overall well-being
of many young physicians and their families.
Shift work, endemic in medical training and in the health
care system in general, results in substantial additional stress
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Sleep Deprivation  Among Residents
by disrupting circadian processes in already sleep-deprived
physicians. Several adverse health consequences have been
associated with shift work and sleep deprivation, including an
elevated incidence of metabolic syndrome and increased risk
of cancer.69,70 An increase in motor vehicle accidents has been
reported by physicians working long shifts, and impairments
in cognitive and psychomotor skills and increased medical
errors have been noted, independent of the total number of
hours worked.
Most of the studies evaluating the repercussions of sleep
loss in residents are survey based. Therefore, they are prone
to selection and/or recall bias. The actual contribution of
sleep deficiency or circadian factors independent of other
variables that can affect alertness and performance is not
clear. However, the overwhelming detrimental consequences
of long work hours and shift schedules on several resident-
and patient-related outcomes highlights the importance and
urgent need for measures to address sleep loss in residents
and the need to objectively assess the effectiveness of such
interventions. The financial burden of these interventions is
likely to be immense, and a cost–benefit analysis will need to
be included in future studies to fully gauge the overall effects.
The early impact of the ACGME WHLs is perceived as
mixed with regard to various resident- and patient-related out-
comes. Statistics on patient complications and mortality rates
are conflicting. The actual number of hours of sleep obtained
after decreasing weekly work hours is modest. Educational
programs designed to increase physician awareness of sleep
loss and recovery have not resulted in a significant increase
in sleep duration. Although most surveys suggest an overall
improvement in quality of life, perceptions regarding learn-
ing opportunities for physicians in training and continuity
of patient care are variable.66 Senior physicians, particularly
faculty members, have reported increasing workloads and
worsening educational experiences for residents. However,
there are few studies examining the impact of WHLs on
faculty members.71 Studies have shown possible reduced
operative experiences for surgical residents after the imple-
mentation of WHLs.72,73 To understand the true influence of
these changes, long-term studies are needed once the WHLs
are universally adopted and enforced more stringently.
Further studies are also needed to assess the effects of
the WHLs not only on outcomes such as medical errors,
motor vehicle accidents, and physician well-being, but
also on resident motivation and longitudinal educational
experiences. Continuity and quality of patient care will need
to be assessed. Environmental and individual factors, such as
lighting and noise in the workplace, may need to be taken into
Mansukhani et al
consideration when designing programs to limit work hours
and assessing the impact of such interventions. Research
on the effects of sleep deprivation on physicians already in
medical practice, including those in a supervisory role, as
well as other health care workers, is, unfortunately, lacking.
Conclusion
Sleep deprivation and fragmentation, as well as shift work,
have severe consequences on resident health, safety, and
well-being, and adversely affect patient care. Counter-
measures devised in response to these challenges, such as the
institution of WHLs for physicians in training, have major
financial implications and have shown mixed results in the
early stages of implementation. Further long-term studies are
required after defining specific resident- and patient-related
outcomes more clearly, as well as the other variables that
may influence these outcomes, in order to fully assess the
influence of these changes. In particular, the impact of WHLs
on physician education, motivation, and quality of patient
care need to be addressed.
Conflict of Interest Statement
Meghna P. Mansukhani, MBBS, Bhanu Prakash Kolla,
MBBS, MRCPsych, Joseph Varon, MD, FACP, FCCP,
FCCM, and Kannan Ramar, MD disclose no conflicts of
interest. Salim Surani, MD, MPH, FAASM, FCCP discloses
conflicts of interest with Boehringer Ingelheim, Forest Phar-
maceuticals, and GlaxoSmithKline.
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