Young hospital doctors after night duty: their task-specific cognitive status and emotional condition

The effects of work on cognitive functions: a systematic review

Introduction

Cognitive functions play a crucial role in individual's life since they represent the mental abilities necessary to perform any activity. During working life, having healthy cognitive functioning is essential for the proper performance of work, but it is especially crucial for preserving cognitive abilities and thus ensuring healthy cognitive aging after retirement. The aim of this paper was to systematically review the scientific literature related to the effects of work on cognitive functions to assess which work-related factors most adversely affect them.

Method

We queried the PubMed and Scopus electronic databases, in February 2023, according to the PRISMA guidelines (PROSPERO ID number = CRD42023439172), and articles were included if they met all the inclusion criteria and survived a quality assessment. From an initial pool of 61,781 papers, we retained a final sample of 64 articles, which were divided into 5 categories based on work-related factors: shift work (n = 39), sedentary work (n = 7), occupational stress (n = 12), prolonged working hours (n = 3), and expertise (n = 3).

Results

The results showed that shift work, occupational stress, and, probably, prolonged working hours have detrimental effects on cognitive functioning; instead, results related to sedentary work and expertise on cognitive functions are inconclusive and extremely miscellaneous.

Discussion

Therefore, workplace health and well-being promotion should consider reducing or rescheduling night shift, the creation of less demanding and more resourceful work environments and the use of micro-breaks to preserve workers' cognitive functioning both before and after retirement.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023439172, identifier CRD42023439172.

On-Call Duties: The Perceived Impact on Veterinarians' Job Satisfaction, Well-Being and Personal Relationships

Objective: To assess the impact of on-call duties on veterinarians' job satisfaction, well-being and personal relationships.

Design: Cross-sectional survey.

Sample: The sample was obtained from Veterinary Information Network (VIN) members in private practice within the United States.

Procedures: A link to an anonymous online survey was distributed via an email invitation to all Veterinary Information Network (VIN) members with access from August 15, 2017 to October 21, 2017.

Results: A total of 1,945 responses were recorded. The majority of those who reported having on-call duties were female associates. Composite scales were created to assess the impact of on-call shifts on job satisfaction and well-being. Multiple linear regression was conducted and found that gender (p = 0.0311), associate status (p < 0.0001), and age (p = 0.0293) were all significantly associated with on-call related job satisfaction. Additionally, multiple linear regression found that gender (p = 0.0039), associate status (p < 0.0057), and age (p < 0.0001) were all significantly associated with on-call related well-being. On-call shifts were reported by many to have a negative impact on job satisfaction and well-being; this was especially pronounced for female associates. Females had on-call related job satisfaction scores that were, on average, 1.27 points lower than that of males (lower scores equates to lower job satisfaction). Further, females' average on-call related well-being scores were 1.15 points higher than that of males (lower scores equates to higher well-being).

Conclusions and Clinical Relevance: This study suggests that on-call shifts have a negative impact on veterinarian job satisfaction, well-being and personal relationships. The negative impact on job satisfaction and well-being is greatest for female associates. Veterinary medicine has been identified as a stressful occupation that can lead to psychological distress. It is therefore important to critically assess current practices that appear to increase stress and reduce emotional well-being. For this reason, it is suggested that veterinary hospitals explore alternative options to traditional on-call shifts.

Sleepy Surgeons: A Multi-Method Assessment of Sleep Deprivation and Performance in Surgery

BACKGROUND

Minimum rest is mandated in high stake industries such as aviation. The current system of healthcare provision permits on-call surgeons to work in sleep deprived states when performing procedures. Fatigue has been demonstrated to negatively affect performance. This study aimed to explore measurements of sleep deprivation and their impact on simulated performance.

METHODS

This was a single site study conducted between September 2019 and February 2020. Surgical trainee and consultants were conveniently sampled from a single site. All testing was done between 7 AM and 9 AM. Participants completed electroencephalogram testing using a modified Multiple Sleep Latency Test testing for objective sleep measurement, the Pittsburgh Sleep Quality Index, Chalder Fatigue Scale and Epworth Sleepiness Scale for subjective sleep measurement. The Psychomotor Vigilance Task and the SIMENDO simulated tasks were used for standardized performance assessment.

RESULTS

Surgeons entered sleep in 6 min, on average pre-call. This significantly decreased to an average of 164 s post-call (P = 0.016). Pittsburgh Sleep Quality Index scoring was 5, indicating poor baseline sleep quality. There was higher self-reported fatigue and sleepiness in post-call states. Performance decrements were noted in cognitive performance reaction time and aspects of technical instrument proficiency.

CONCLUSIONS

Surgeons are objectively sleep deprived pre-call according to internationally recognized guidelines. This sleep deprivation increases significantly in post-call states. Tasks with higher cognitive demands showed greater levels of diminished performance compared to those with lower cognitive demands. Current models of provision of surgical on-call are not conducive to optimizing sleep in surgeons. Prioritization of workload in post-call states, focusing on preserving individuals cognitive resources and utilizing lower cognitively demanding aspects of work is likely to have positive impacts on performance outcomes.

Self-reported surgeon health behaviours: A multicentre, cross-sectional exploration into the modifiable factors that impact surgical performance with the association of surgeons in training

Introduction

Surgeons regularly educate patients on health promoting behaviours including diet, sleep and exercise. No study thus far has explored surgeons’ personal compliance with these health behaviours and their relationship with surgical performance. The primary outcomes of this study were self-reported health, health related behaviours, wellbeing, fatigue and surgical performance.

Methods

A survey of validated themes on health related behaviours, workplace variables and performance was distributed to surgical trainees and consultants in the UK and Ireland through the Association for Surgeons in Training (ASiT). Non-parametric analysis was used to determine inferential associations.

Results

Ninety five surgeons (51.5% female, 39.9% registrars) completed the survey. 94% and 74% reported ‘good’ or better overall health and mental wellbeing respectively. The majority (54.7%) reported inconsistent sleep patterns. Less than a quarter engage in regular exercise. Sixty two and 64.2% reported being regularly fatigued and bothered by feelings of anxiety and/or depression respectively. Poor self-reported health and wellbeing were associated with poorer reported off-call performance (p < .01). Higher levels of fatigue negatively impacted self-reported surgical and non-surgical task proficiency (p < .01).

Discussion and conclusion

Surgeons reported high levels of overall health. However, healthy behaviours around sleep, diet and exercise were not consistently reported. Fewer reported good mental health and emotional well-being. Self-reported health behaviours including sleep and physical activity were associated with surgical performance. Strategies to improve modifiable lifestyle factors which will optimise physical health, mental wellbeing and levels of fatigue may optimise surgical performance.

•

94% and 74% respectively reported having at least ‘good’ health and well-being.

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A majority reported being regularly fatigued and inconsistent sleep patterns.

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Poorer health and wellbeing were associated with poorer performance off-call (p < .01).

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Higher levels of fatigue negatively impacted technical and non-technical performance.

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Improving modifiable factors to optimise health and wellbeing may improve performance.

Association between shift work and cognitive performance on the Trail Making Test in emergency department health officers

OBJECTIVE

Shift work has been proposed to disturb alertness and decrease cognitive efficiency. However, studies so far have had varied findings. The aim of the present study was to compare cognitive function following shifts at different times of the day in an Australian ED context.

METHODS

A prospective, self-controlled observational study was conducted on medical and nursing staff at a tertiary referral centre and regional hospital ED. Participants were required to complete the Trail Making Test (TMT), a neurocognitive test consisting of two parts (TMT-A and TMT-B), at baseline (at the start of the day) and at the end of their shift (day, evening or night). Related samples Wilcoxon signed-rank tests were used to compare post-shift TMT performance to baseline in medical and nursing staff.

RESULTS

Over a 5-month period, 140 ED staff were recruited including 109 doctors and 31 nurses. After a night shift, medical staff (n = 85) and nursing staff (n = 29) took longer to complete the TMT-B by 3.4 s (P < 0.001) and 7.1 s (P = 0.01), respectively, compared to baseline. Post-evening shift, medical staff (n = 59) took longer to complete the TMT-A by 0.3 s (P = 0.02).

CONCLUSIONS

Night shift work was associated with a longer TMT time. This may indicate a decrease in cognitive performance, in particular, visual attention, processing speed, task switching and executive function and may implicate the quality of care for patients and worker safety.

Acute and chronic sleep deprivation in residents: Cognition and stress biomarkers

OBJECTIVES

Insufficient sleep affects circadian hormonal profiles and inflammatory markers and may modulate attention, executive functioning and decision-making. Medical professionals and specifically resident physicians, who are involved in long-term nightshift schedules during their post-graduate training, are prone to acute and chronic sleep deprivation and disruption, putting them at risk for making medical errors. The aim of the study was to evaluate the impact of chronic and acute-on-chronic sleep deprivation and disruption among residents on selected physiological and cognitive measures.

METHODS

Thirty-three medical and surgical residents were evaluated twice - at baseline and after a 26-hour shift. Eighteen young attending physicians who did not engage in nightshift schedules served as controls and were evaluated once. Measures included morning cortisol and high-sensitivity C-reactive protein (hs-CRP), computerised tests of attention and behaviour, the Behaviour Rating Inventory of Executive Function, a risk-taking questionnaire and the Pittsburgh Sleep Quality Index.

RESULTS

Residents, but not attendings, reported chronic sleep disruption and deprivation. Residents at baseline exhibited reduced morning cortisol levels and elevated hs-CRP levels, compared to attendings. Residents at baseline had impaired global executive function compared to attendings. A nightshift with acute sleep deprivation further reduced residents' executive function. Residents at baseline and after a nightshift demonstrated increased impulsivity and slower processing time than attendings. Residents and attendings did not differ in risk-taking tendencies which were assessed in a separate cohort.

CONCLUSIONS

In a real-life setting, resident physicians exhibit increased low-grade systemic inflammation (hs-CRP) and impaired HPA-axis function. Their chronic sleep curtailment is associated with greater impulsivity, slower cognitive processing, and impaired executive function. Future research is warranted to understand how improving working schedule by increasing sleep duration may minimise the short-term and potential long-term risks to physicians in training.

Are prolonged sitting and sleep restriction a dual curse for the modern workforce? a randomised controlled trial protocol

INTRODUCTION

Prolonged sitting and inadequate sleep are a growing concern in society and are associated with impairments to cardiometabolic health and cognitive performance. However, the combined effect of prolonged sitting and inadequate sleep on measures of health and cognitive performance are unknown. In addition, the circadian disruption caused by shiftwork may further impact workers' cardiometabolic health and cognitive performance. This protocol paper outlines the methodology for exploring the impact of simultaneous exposure to prolonged sitting, sleep restriction and circadian disruption on cardiometabolic and cognitive performance outcomes.

METHODS AND ANALYSIS

This between-subjects study will recruit 208 males and females to complete a 7-day in-laboratory experimental protocol (1 Adaptation Day, 5 Experimental Days and 1 Recovery Day). Participants will be allocated to one of eight conditions that include all possible combinations of the following: dayshift or nightshift, sitting or breaking up sitting and 5 hour or 9 hour sleep opportunity. On arrival to the laboratory, participants will be provided with a 9 hour baseline sleep opportunity (22:00 to 07:00) and complete five simulated work shifts (09:00 to 17:30 in the dayshift condition and 22:00 to 06:30 in the nightshift condition) followed by a 9 hour recovery sleep opportunity (22:00 to 07:00). During the work shifts participants in the sitting condition will remain seated, while participants in the breaking up sitting condition will complete 3-min bouts of light-intensity walking every 30 mins on a motorised treadmill. Sleep opportunities will be 9 hour or 5 hour. Primary outcome measures include continuously measured interstitial blood glucose, heart rate and blood pressure, and a cognitive performance and self-perceived capacity testing battery completed five times per shift. Analyses will be conducted using linear mixed models.

ETHICS AND DISSEMINATION

The CQUniversity Human Ethics Committee has approved this study (0000021914). All participants who have already completed the protocol have provided informed consent. Study findings will be disseminated via scientific publications and conference presentations.

TRIAL REGISTRATION DETAILS

This study has been registered on Australian New Zealand Clinical Trials Registry (12619001516178) and is currently in the pre-results stage.

Work-Life Integration and Time Management Strategies

When choosing a career as a surgeon, we knowingly dedicate ourselves to a lifetime of service and education. Our commitment as physicians is but one of many commitments in the larger scheme of life where we function as family members, friends, athletes, and numerous other roles. Work and life are often described as two separate entities diametrically opposed to each other. In reality, personal and professional goals are part of a continuum where work is a major part of our lives and who we are as people and is not necessarily separate from the others. The goal-directed nature with which we approach our responsibilities as surgeons should be applied to all domains of life. As we progress along the training paradigm from intern to attending, control over time allocation increases. Understanding oneself, determining priorities, applying realistic expectations, cultivating a supportive environment, setting personal and professional goals, and being held accountable for progress and completion of these goals will allow us to utilize limited time efficiently to achieve what we individually desire from life.

Influence of Time of Mission on Correct Diagnosis by the Prehospital Emergency Physician: A Retrospective Study

Objectives

The objective of this retrospective study was to examine the diagnostic matching (DM) between the prehospital diagnosis by the prehospital emergency physicians and the hospital discharge diagnosis, adjusted for time of mission.

Methods

Over a period of 12 months, all patient care reports of the emergency medical services in Bad Belzig were examined. By systematically comparing the prehospital suspected diagnosis to the discharge diagnosis, the DM was determined after careful examination of the entire course of each patient's case, blinded to time of mission. The results were tested for statistically significant results using the Chi-square test for nominal data and the Mann-Whitney U test for nonnormally distributed independent samples.

Results

The DM occurred in 52%, it occurred partially in 24%, and it did not occur in 24% of 580 included cases. The DM showed clear fluctuation over 24 hours, with the worst results at 4 and 5 a.m. and the best results at 6 a.m. and 3 p.m.

Conclusions

The DM appears to depend directly on the time of mission. Decreased performance and concentration at night might be a cause for incorrect diagnoses by prehospital emergency physician in the early morning hours. Future studies need to investigate the effect of different shift planning on performance.

Foetal Morbidity Depending on the Day and Time of Delivery

Introduction It is known that perinatal mortality is increased with births at night and at the weekend. The aim of the study was to investigate whether there is also an association between the time of delivery (weekday, night, weekend) and perinatal morbidity. Material and Methods All births at Hannover Medical College between 2000 and 2014 were included in a retrospective data analysis. Multiple births, primary sections, severe foetal malformations and intrauterine deaths were not included. A 5-minute Apgar score ≤ 5 and cord arterial pH < 7.10 were defined as perinatal morbidity. Besides the time of delivery, different variables that are regarded as risk factors for increased perinatal morbidity were studied. Univariate logistical regression analysis was performed, followed by multivariate analysis. Results 18 394 deliveries were included in the study. Pathological prepartum Doppler, medical induction of labour and delivery at night and/or at the weekend significantly increased the probability of an Apgar score ≤ 5 after 5 minutes. The probability that a child will have cord arterial pH < 7.1 post partum is significantly increased with a BMI > 25 before pregnancy, primiparity, medical induction of labour, peripartum administration of oxytocic agents, when the delivery took place at night and weekend combined, but also when the delivery took place at night or at the weekend/on a public holiday. Multivariate regression analysis showed that a time of delivery at night and/or at the weekend or on a public holiday is not a prognostic factor for a 5-minute Apgar score ≤ 5 (p = 0.2377) but is a prognostic factor for cord arterial pH < 7.1 (p = 0.0252). Conclusion The time of delivery at night or at the weekend/on a public holiday increases the risk for cord arterial pH < 7.1 by ~ 30% compared with delivery on a weekday. However, the time of delivery at night or at the weekend/on a public holiday does not increase the risk for the baby of having a 5-minute Apgar score ≤ 5.

Effects of partial sleep deprivation on reaction time in anesthesiologists

BACKGROUND

Fatigue in anesthesiologists may have implications that extend beyond individual well-being.

AIM

The aim of the present study was to evaluate the impact of sleep deprivation on the reaction time in anesthesiologists either after an overnight call or regular working hours. Moderation of this effect by coping strategies was observed.

METHODS

Psychomotor vigilance test was used to assess reaction time in 23 anesthesiologists at two time-points: (i) on a regular non-call day and (ii) after a 17-h in-house call. Student's paired t-test was used to compare Psychomotor Vigilance Task data at these two moments. Change score regression was performed to determine the association between coping strategies, assessed using the Coping Strategy Indicator instrument, and decline in reaction time after night call.

RESULTS

Twenty-one colleagues completed the psychomotor vigilance test measurements after two decided to end their participation for personal reasons. Post-call psychomotor vigilance test mean reaction time decreased by an average of 31.2 ms (95% CI: 0.5, 61.9; P = 0.047) when compared to regular day. Reliance on specific coping mechanisms, indicated by Coping Strategy Indicator scale scores, included problem-solving (28 ± 4), followed by seeking social support (23 ± 5) and avoidance (19 ± 4). The change score regression model (r² = 0.48) found that greater reliance on avoidance was associated with greater increase in reaction time after night call.

CONCLUSION

Reaction time increased considerably in anesthesiologists after a night call duty. Greater subjective reliance on avoidance as a coping strategy was associated with greater deterioration in performance.

The 2016 AANS Presidential Address: Leading the way

This AANS presidential address focuses on enduring values of the neurosurgical profession that transcend the current political climate. The address was delivered by Dr. Batjer during a US presidential election year, but the authors have intentionally avoided discussing the current chaos of the American health care system in the knowledge that many pressing issues will change depending on the outcome of the 2016 elections. Instead, they have chosen to focus on clarifying what neurosurgeons, and the American Association of Neurological Surgeons, in particular, stand for; identifying important challenges to these fundamental principles and values; and proposing specific actions to address these challenges. The authors cite "de-professionalism" and commoditization of medicine as foremost among the threats that confront medicine and surgery today and suggest concrete action that can be taken to reverse these trends as well as steps that can be taken to address other significant challenges. They emphasize the importance of embracing exceptionalism and never compromising the standards that have characterized the profession of neurosurgery since its inception.

Call Schedule and Sleep Patterns of Urology Residents Following the 2011 ACGME Reforms

INTRODUCTION

In response to the 2011 Accreditation Council for Graduate Medical Education duty hour restrictions, many residency programs adopted a night float system. Due to concerns regarding the effects of night float on sleep and subsequently on patient care, we examined sleep patterns of residents on different call schedules.

METHODS

Urology residents assigned to day shift (Monday-Friday, 6am-6pm), night float (Sunday-Friday, 6pm-6am) or 24-hour home call and attending physicians were monitored for two-week periods using actigraphy bands. Total sleep time, light versus deep sleep time, sleep latency and number of sleep disruptions were measured. Comparative statistics and logistic regression were used to compare call systems and to determine predictors of sleep metrics.

RESULTS

When comparing day shift, night float, and 24-hour home call, the only significant difference was in sleep latency. All sleep variables except sleep latency were significantly different among residents of various levels (junior, senior, research year). Compared to residents, attendings had shorter sleep latency and were woken less frequently. Being a research year resident was the only significant univariate predictor of total sleep. Age and being a research year resident were significant univariate predictors of sleep latency.

CONCLUSIONS

This pilot study demonstrates the feasibility of actigraphy in measuring sleep patterns of urology house officers. It also suggests that night float does not significantly impact total sleep or quality of sleep. Further research is needed to confirm these findings and to determine the effects of night float rotations on resident quality of life and patient safety.

Impact of extended duty hours on medical trainees

Many studies on resident physicians have demonstrated that extended work hours are associated with a negative impact on well-being, education, and patient care. However, the relationship between the work schedule and the degree of impairment remains unclear. In recent years, because of concerns for patient safety, national minimum standards for duty hours have been instituted (2003) and revised (2011). These changes were based on studies of the effects of sleep deprivation on human performance and specifically on the effect of extended shifts on resident performance. These requirements necessitated significant restructuring of resident schedules. Concerns were raised that these changes have impaired continuity of care, resident education and supervision, and patient safety. We review the studies on the effect of extended work hours on resident well-being, education, and patient care as well as those assessing the effect of work hour restrictions. Although many studies support the adverse effects of extended shifts, there are some conflicting results due to factors such as heterogeneity of protocols, schedules, subjects, and environments. Assessment of the effect of work hour restrictions has been even more difficult. Recent data demonstrating that work hour limitations have not been associated with improvement in patient outcomes or resident education and well-being have been interpreted as support for lifting restrictions in some specialties. However, these studies have significant limitations and should be interpreted with caution. Until future research clarifies duty hours that optimize patient outcomes, resident education, and well-being, it is recommended that current regulations be followed.

Association of Resident Duty Hour Restrictions on Mortality of Nervous System Disease and Disorder

BACKGROUND

The impact of the 2003 residency duty hour reform on patient care remains a debated issue.

OBJECTIVE

Determine the association between duty hour limits and mortality in patients with nervous system pathology.

METHODS

Via a retrospective cohort study using the Nationwide Inpatient Sample from 2000-2010, the authors evaluated in-hospital mortality status in those with a primary discharge level diagnosis of disease or disorder of the nervous system. Odds ratios were calculated, and Bonferroni corrected P values and confidence intervals were determined to account for multiple comparisons relating in-hospital mortality with teaching status of the hospital by year.

RESULTS

The pre-reform (2000-2002) and peri-reform (2003) periods revealed no significant difference between teaching and nonteaching hospital mortality (P > .99). The post-reform period (2004-2010) was dominated by years of significantly higher mortality rates in teaching hospitals compared to nonteaching hospitals: 2004 (P < .001); 2006 (P = .043); 2007 (P = .042); and 2010 (P = .003). However, data for 2005 (P ≥ .99), 2008 (P = .80), and 2009 (P = .09) did not show a significant difference in mortality.

CONCLUSIONS

Teaching and nonteaching hospital mortality was similar in patients with nervous system pathology prior to the duty hour reform. While nonteaching institutions demonstrated steadily declining mortality over the decade, teaching hospital mortality spiked in 2004 and declined at a more restricted rate. The timing of these changes could suggest a negative correlation of duty hour restrictions on outcomes of patients with nervous system pathology.

Resident duty hour modification affects perceptions in medical education, general wellness, and ability to provide patient care

BACKGROUND

Resident duty hours have recently been under criticism, with concerns for resident and patient well-being. Historically, call shifts have been long, and some residency training programs have now restricted shift lengths. Data and opinions about the effects of such restrictions are conflicting. The Internal Medicine Residency Program at Dalhousie University recently moved from a traditional call structure to a day float/night float system. This study evaluated how this change in duty hours affected resident perceptions in several key domains.

METHODS

Senior residents from an internal medicine training program in Canada responded to an anonymous online survey immediately before and 6 months after the implementation of duty hour reform. The survey contained questions relating to three major domains: resident wellness, ability to deliver quality health care, and medical education experience. Mean pre- and post-intervention scores were compared using the t-test for paired samples.

RESULTS

Twenty-three of 27 (85 %) senior residents completed both pre- and post-reform surveys. Residents perceived significant changes in many domains with duty hour reform. These included improved general wellness, less exposure to personal harm, fewer feelings of isolation, less potential for error, improvement in clinical skills expertise, increased work efficiency, more successful teaching, increased proficiency in medical skills, more successful learning, and fewer rotation disruptions.

CONCLUSIONS

Senior residents in a Canadian internal medicine training program perceived significant benefits in medical education experience, ability to deliver healthcare, and resident wellness after implementation of duty hour reform.

Resident fatigue in otolaryngology residents: a Web based survey

IMPORTANCE

Resident fatigue has become a point of emphasis in medical education and its effects on otolaryngology residents and their patients require further study.

OBJECTIVE

The purpose of our study was to evaluate the prevalence and nature of fatigue in otolaryngology residents, evaluate various quality of life measures, and investigate associations of increased fatigue with resident safety.

STUDY DESIGN

Anonymous survey.

SETTING

Internet based.

PARTICIPANTS

United States allopathic otolaryngology residents.

INTERVENTION

None.

MAIN OUTCOME(S) AND MEASURES

The survey topics included demographics, residency structure, sleep habits and perceived stress. Responses were correlated with a concurrent Epworth Sleep Scale questionnaire to evaluate effects of fatigue on resident training and quality of life.

RESULTS

190 residents responded to the survey with 178 completing the Epworth Sleep Scale questionnaire. Results revealed a mean Epworth Sleep Scale score of 9.9±5.1 with a median of 10.0 indicating a significant number of otolaryngology residents are excessively sleepy. Statistically significant correlations between Epworth Sleep Scale and sex, region, hours of sleep, and work hours were found. Residents taking in-house call had significantly fewer hours of sleep compared to home call (p=0.01). Residents on "head and neck" (typically consisting of a large proportion of head and neck oncologic surgery) rotations tended to have higher Epworth Sleep Scale and had significantly fewer hours of sleep (p=.003) and greater work hours (p<.001). Additionally, residents who reported no needle stick type incidents or near motor vehicle accidents had significantly lower mean Epworth Sleep Scale scores. Only 37.6% of respondents approve of the most recent Accreditation Council for Graduate Medical Education work hour restrictions and 14% reported averaging greater than 80hours of work/week.

CONCLUSION AND RELEVANCE

A substantial number of otolaryngology residents are excessively sleepy. Our data suggest that the effects of fatigue play a role in resident well-being and resident safety.

Recovery of Sleep or Recovery of Self? A Grounded Theory Study of Residents' Decision Making Regarding How to Spend Their Nonclinical Postcall Time

PURPOSE

As resident work hours policies evolve, residents' off-duty time remains poorly understood. Despite assumptions about how residents should be using their postcall, off-duty time, there is little research on how residents actually use this time and the reasoning underpinning their activities. This study sought to understand residents' nonclinical postcall activities when they leave the hospital, their decision-making processes, and their perspectives on the relationship between these activities and their well-being or recovery.

METHOD

The study took place at a Liaison Committee on Medical Education-accredited Canadian medical school from 2012 to 2014. The authors recruited a purposive and convenience sample of postgraduate year 1-5 residents from six surgical and nonsurgical specialties at three hospitals affiliated with the medical school. Using a constructivist grounded theory approach, semistructured interviews were conducted, audio-taped, transcribed, anonymized, and combined with field notes. The authors analyzed interview transcripts using constant comparative analysis and performed post hoc member checking.

RESULTS

Twenty-four residents participated. Residents characterized their predominant approach to postcall decision making as one of making trade-offs between multiple, competing, seemingly incompatible, but equally valuable, activities. Participants exhibited two different trade-off orientations: being oriented toward maintaining a normal life or toward mitigating fatigue.

CONCLUSIONS

The authors' findings on residents' trade-off orientations suggest a dual recovery model with postcall trade-offs motivated by the recovery of sleep or of self. This model challenges the dominant viewpoint in the current duty hours literature and suggests that the duty hours discussion must be broadened to include other recovery processes.

Time to talk about work-hour impact on anesthesiologists: The effects of sleep deprivation on Profile of Mood States and cognitive tasks

BACKGROUND

A physician's fatigue raises significant concerns regarding personal and patient safety. Effects of sleep deprivation on clinical performance and the quality of patient care are major considerations of today's health care environment.

AIM

To evaluate the impact of partial sleep deprivation after a 17-h overnight call (3 pm-7 am) on the mood status and cognitive skills of anesthesiologists in an academic clinical hospital setting, as compared to these parameters during regular working hours.

METHODS

Taking circadian rhythm into account, the following measures were assessed in 21 pediatric anesthesiologists at two time points over the course of the study; (i) between 7 and 8 am on a regular non call day, and (ii) between 7 and 8 am after a 17-h in-house call (3 pm-7 am). Six mood states were assessed using the Profile of Mood States. A Total Mood Disturbance (TMD) score was obtained as the sum of all mood scores minus vigor. The total score provides a global estimate of affective state. Simple cognitive tests were similarly administered to assess cognitive skills. A two-tailed paired t-test was used to compare data between regular and post call days. A P < 0.05 was used.

RESULTS

The study cohort included 21 pediatric anesthesiologists at a tertiary care children's hospital. Tension, anger, fatigue, confusion, TMD, irritability, feeling jittery, and sleepiness were significantly affected (P < 0.05). A decrease in vigor, energy, and confidence was observed after a night call shift (P < 0.05). There was also a decrease in being "talkative" after the call shift (P < 0.05).

CONCLUSION

Partial sleep deprivation affects the total mood status of anesthesiologists and impacts their cognitive skills. These findings are particularly relevant in a context of increased work expectation, particularly on clinical performance in our modern medical system. Such observations suggest that there may be changes that impact the safety of our patients and the quality of health care that is provided.

Impact of Acute Sleep Deprivation on Sarcasm Detection

There is growing evidence that sleep plays a pivotal role on health, cognition and emotional regulation. However, the interplay between sleep and social cognition remains an uncharted research area. In particular, little is known about the impact of sleep deprivation on sarcasm detection, an ability which, once altered, may hamper everyday social interactions. The aim of this study is to determine whether sleep-deprived participants are as able as sleep-rested participants to adopt another perspective in gauging sarcastic statements. At 9am, after a whole night of sleep (n = 15) or a sleep deprivation night (n = 15), participants had to read the description of an event happening to a group of friends. An ambiguous voicemail message left by one of the friends on another's phone was then presented, and participants had to decide whether the recipient would perceive the message as sincere or as sarcastic. Messages were uttered with a neutral intonation and were either: (1) sarcastic from both the participant’s and the addressee’s perspectives (i.e. both had access to the relevant background knowledge to gauge the message as sarcastic), (2) sarcastic from the participant’s but not from the addressee’s perspective (i.e. the addressee lacked context knowledge to detect sarcasm) or (3) sincere. A fourth category consisted in messages sarcastic from both the participant’s and from the addressee’s perspective, uttered with a sarcastic tone. Although sleep-deprived participants were as accurate as sleep-rested participants in interpreting the voice message, they were also slower. Blunted reaction time was not fully explained by generalized cognitive slowing after sleep deprivation; rather, it could reflect a compensatory mechanism supporting normative accuracy level in sarcasm understanding. Introducing prosodic cues compensated for increased processing difficulties in sarcasm detection after sleep deprivation. Our findings support the hypothesis that sleep deprivation might damage the flow of social interactions by slowing perspective-taking processes.

The Case for Addressing Operator Fatigue

Sleep deficiency, which can be caused by acute sleep deprivation, chronic insufficient sleep, untreated sleep disorders, disruption of circadian timing, and other factors, is endemic in the U.S., including among professional and non-professional drivers and operators. Vigilance and attention are critical for safe transportation operations, but fatigue and sleepiness compromise vigilance and attention by slowing reaction times and impairing judgment and decision-making abilities. Research studies, polls, and accident investigations indicate that many Americans drive a motor vehicle or operate an aircraft, train or marine vessel while drowsy, putting themselves and others at risk for error and accident. In this chapter, we will outline some of the factors that contribute to sleepiness, present evidence from laboratory and field studies demonstrating how sleepiness impacts transportation safety, review how sleepiness is measured in laboratory and field settings, describe what is known about interventions for sleepiness in transportation settings, and summarize what we believe are important gaps in our knowledge of sleepiness and transportation safety.

The effect of chronotype on sleepiness, fatigue, and psychomotor vigilance of ICU nurses during the night shift

PURPOSE

In general, sleeping and activity patterns vary between individuals. This attribute, known as chronotype, may affect night shift performance. In the intensive care unit (ICR), night shift performance may impact patient safety. We have investigated the effect of chronotype and social demographics on sleepiness, fatigue, and night shift on the performance of nurses.

METHODS

This was a prospective observational cohort study which assessed the performance of 96 ICU night shift nurses during the day and night shifts in a mixed medical-surgical ICU in the Netherlands. We determined chronotype and assessed sleeping behaviour for each nurse prior to starting shift work and before free days. The level of sleepiness and fatigue of nurses during the day and night shifts was determined, as was the effect of these conditions on psychomotor vigilance and mathematical problem-solving.

RESULTS

The majority of ICU nurses had a preference for early activity (morning chronotype). Compared to their counterparts (i.e. evening chronotypes), they were more likely to nap before commencing night shifts and more likely to have young children living at home. Despite increased sleepiness and fatigue during night shifts, no effect on psychomotor vigilance was observed during night shifts. Problem-solving accuracy remained high during night shifts, at the cost of productivity.

CONCLUSIONS

Most of the ICU night shift nurses assessed here appeared to have adapted well to night shift work, despite the high percentage of morning chronotypes, possibly due to their 8-h shift duration. Parental responsibilities may, however, influence shift work tolerance.

Are there high-risk groups among physicians that are more vulnerable to on-call work?

BACKGROUND

Work done in the emergency departments is one stressful aspect of physicians' work. Numerous previous studies have highlighted the stressfulness of on-call work and especially of night on call. In addition, previous studies suggest that there may be individual differences in adjusting to changes in circadian rhythms and on-call work.

OBJECTIVE

The objective of this study was to examine whether physicians' on-call work is associated with perceived work-related stress factors and job resources and whether there are groups that are more vulnerable to on-call work according to sex, age, and specialization status.

METHODS

This was a cross-sectional questionnaire study among 3230 Finnish physicians (61.5% women). The analyses were conducted using analyses of covariance adjusted for sex, age, specialization status, and employment sector.

RESULTS

Physicians with on-call duties had more time pressure and stress related to team work and patient information systems compared with those who did not have on-call duties. In addition, they had less job control opportunities and experienced organization as less fair and team climate as worse. Older physicians and specialists seemed to be especially vulnerable to on-call work regarding stress factors, whereas younger and specialist trainees seemed vulnerable to on-call work regarding job resources.

CONCLUSIONS

Focusing on team issues and resources is important for younger physicians and trainees having on-call duties, whereas for older and specialists, attention should be focused on actual work load and time pressure.

Morbidity, mortality, and health care costs for patients undergoing spine surgery following the ACGME resident duty-hour reform

Object

The Accreditation Council for Graduate Medical Education (ACGME) implemented resident duty-hour restrictions on July 1, 2003, in concern for patient and resident safety. Whereas studies have shown that duty-hour restrictions have increased resident quality of life, there have been mixed results with respect to patient outcomes. In this study, the authors have evaluated the effect of duty-hour restrictions on morbidity, mortality, length of stay (LOS), and charges in patients who underwent spine surgery.

Methods

The Nationwide Inpatient Sample was used to evaluate the effect of duty-hour restrictions on complications, mortality, LOS, and charges by comparing the prereform (2000–2002) and postreform (2005–2008) periods. Outcomes were compared between nonteaching and teaching hospitals using a difference-in-differences (DID) method.

Results

A total of 693,058 patients were included in the study. The overall complication rate was 8.6%, with patients in the postreform era having a significantly higher rate than those in the pre–duty-hour restriction era (8.7% vs 8.4%, p < 0.0001). Examination of hospital teaching status revealed complication rates to decrease in nonteaching hospitals (8.2% vs 7.6%, p < 0.0001) while increasing in teaching institutions (8.6% vs 9.6%, p < 0.0001) in the duty-hour reform era. The DID analysis to compare the magnitude in change between teaching and nonteaching institutions revealed that teaching institutions to had a significantly greater increase in complications during the postreform era (p = 0.0002). The overall mortality rate was 0.37%, with no significant difference between the pre– and post–duty-hour eras (0.39% vs 0.36%, p = 0.12). However, the mortality rate significantly decreased in nonteaching hospitals in the postreform era (0.30% vs 0.23%, p = 0.0008), while remaining the same in teaching institutions (0.46% vs 0.46%, p = 0.75). The DID analysis to compare the changes in mortality between groups revealed that the difference between the effects approached significance (p = 0.069). The mean LOS for all patients was 4.2 days, with hospital stay decreasing in nonteaching hospitals (3.7 vs 3.5 days, p < 0.0001) while significantly increasing in teaching institutions (4.7 vs 4.8 days, p < 0.0001). The DID analysis did not demonstrate the magnitude of change for each group to differ significantly (p = 0.26). Total patient charges were seen to rise significantly in the post–duty-hour reform era, increasing from $40,000 in the prereform era to $69,000 in the postreform era. The DID analysis did not reveal a significant difference between the changes in charges between teaching and nonteaching hospitals (p = 0.55).

Conclusions

The implementation of duty-hour restrictions was associated with an increased risk of postoperative complications for patients undergoing spine surgery. Therefore, contrary to its intended purpose, duty-hour reform may have resulted in worse patient outcomes. Additional studies are needed to evaluate strategies to mitigate these effects and assist in the development of future health care policy.

Worse outcomes for patients undergoing brain tumor and cerebrovascular procedures following the ACGME resident duty-hour restrictions

OBJECT

On July 1, 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented duty-hour restrictions for resident physicians due to concerns for patient and resident safety. Though duty-hour restrictions have increased resident quality of life, studies have shown mixed results with respect to patient outcomes. In this study, the authors have evaluated the effect of duty-hour restrictions on morbidity, mortality, length of stay, and charges in patients who underwent brain tumor and cerebrovascular procedures.

METHODS

The Nationwide Inpatient Sample was used to evaluate the effect of duty-hour restrictions on complications, mortality, length of stay, and charges by comparing the pre-reform (2000-2002) and post-reform (2005-2008) periods. Outcomes were compared between nonteaching and teaching hospitals using a difference-in-differences (DID) method.

RESULTS

A total of 90,648 patients were included in the analysis. The overall complication rate was 11.7%, with the rates not significantly differing between the pre- and post-duty hour eras (p = 0.26). Examination of hospital teaching status revealed that complication rates decreased in nonteaching hospitals (12.1% vs 10.4%, p = 0.0004) and remained stable in teaching institutions (11.8% vs 11.9%, p = 0.73) in the post-reform era. Multivariate analysis demonstrated a significantly higher complication risk in teaching institutions (OR 1.33 [95% CI 1.11-1.59], p = 0.0022), with no significant change in nonteaching hospitals (OR 1.11 [95% CI 0.91-1.37], p = 0.31). A DID analysis to compare the magnitude in change between teaching and nonteaching institutions revealed that teaching hospitals had a significantly greater increase in complications during the post-reform era than nonteaching hospitals (p = 0.040). The overall mortality rate was 3.0%, with a significant decrease occurring in the post-reform era in both nonteaching (5.0% vs 3.2%, p < 0.0001) and teaching (3.2% vs 2.3%, p < 0.0001) hospitals. DID analysis to compare the changes in mortality between groups did not reveal a significant difference (p = 0.40). The mean length of stay for all patients was 8.7 days, with hospital stay decreasing from 9.2 days to 8.3 days in the post-reform era (p < 0.0001). The DID analysis revealed a greater length of stay decrease in nonteaching hospitals than teaching institutions, which approached significance (p = 0.055). Patient charges significantly increased in the post-reform era for all patients, increasing from $70,900 to $96,100 (p < 0.0001). The DID analysis did not reveal a significant difference between the changes in charges between teaching and nonteaching hospitals (p = 0.17).

CONCLUSIONS

The implementation of duty-hour restrictions correlated with an increased risk of postoperative complications for patients undergoing brain tumor and cerebrovascular neurosurgical procedures. Duty-hour reform may therefore be associated with worse patient outcomes, contrary to its intended purpose. Due to the critical condition of many neurosurgical patients, this patient population is most sensitive and likely to be negatively affected by proposed future increased restrictions.

On-call work and physicians' well-being: testing the potential mediators

BACKGROUND

On-call duties have been rated to be among the most stressful aspects of physicians' work. On-call work has been associated, for example, with medical errors, injuries and lower well-being. Thus, because it is not possible to remove on-call duties, measures to decrease the negative ramifications of on-call work are needed.

AIMS

To examine whether working on-call would predict psychological distress, job satisfaction and work ability in a 4-year follow-up and whether sleeping problems or work interference with family (WIF) would act as mechanisms in these associations.

METHODS

Questionnaires in 2006 and 2010 among physicians in Finland. The mediation analyses were conducted using methods suggested by Preacher and Hayes to examine direct and indirect effects with multiple mediators.

RESULTS

There were 1541 respondents (60% women) of whom 52% had on-call duties. Sleeping problems and WIF acted as mechanisms in the association of existence of on-call duties with high distress, low job satisfaction and low work ability. On-call work was associated with higher levels of sleeping problems and WIF, and the number of active on-call hours was associated with higher levels of WIF, but not with sleeping problems.

CONCLUSIONS

According to our results, one way to attenuate on-call work's negative ramifications is to make it easier for on-call physicians to connect work and family lives and develop work arrangements to promote better sleep and protected sleep time.

Self-perceived sleepiness in emergency training physicians: prevalence and relationship with quality of life

Introduction

Sleep deprivation among training physicians is of growing concern; training physicians are susceptible due to their prolonged work hours and rotating work schedules. The aim of this study was to determine the prevalence of self-perceived sleepiness in emergency training physicians, and to establish a relationship between self-perceived sleepiness, and quality of life.

Methods

Prospective survey in Ibn Sina University hospital Center in Morocco from January to April 2011 was conducted. Questionnaires pertaining to socio-demographic, general, and sleep characteristics were completed by training physician who ensured emergency service during the month preceding the survey. They completed the Epworth sleepiness scale (ESS) which assessed the self-perceived sleepiness, and the EuroQol-5 dimensions (EQ-5D) scale which assessed the general quality of life.

Results

Total 81 subjects (49 men and 32 women) were enrolled with mean age of 26.1 ± 3.4 years. No sleepiness was found in 24.7% (n = 20), excessive sleepiness 39.5% (n = 32), and severe sleepiness in 35.8% (n = 29) of training physicians. After adjusting for multiple confounding variables, four independent variables were associated with poorer quality of life index in training physician; unmarried (ß −0.2, 95% CI −0.36 to −0.02; P = 0.02), no physic exercise (ß −0.2, 95% CI −0.39 to 0.006; P = 0.04), shift-off sleep hour less than 6 hours (ß −0.13, 95% CI −0.24 to −0.02; P = 0.01), and severe sleep deprivation(ß −0.2, 95% CI −0.38 to −0.2; P = 0.02).

Conclusion

Nearly two third of training physicians had suffered from sleepiness. There is an association between poor quality of life and severe sleepiness in unmarried physicians, sleeping less than 6 hours in shift-off day, and doing no physical activity.

The fatigued anesthesiologist: A threat to patient safety?

Universally, anesthesiologists are expected to be knowledgeable, astutely responding to clinical challenges while maintaining a prolonged vigilance for administration of safe anesthesia and critical care. A fatigued anesthesiologist is the consequence of cumulative acuity, manifesting as decreased motor and cognitive powers. This results in impaired judgement, late and inadequate responses to clinical changes, poor communication and inadequate record keeping. With rising expectations and increased medico-legal claims, anesthesiologists work round the clock to provide efficient and timely services, but are the "sleep provider" in a sleep debt them self? Is it the right time to promptly address these issues so that we prevent silent perpetuation of problems pertinent to anesthesiologist's health and the profession. The implications of sleep debt on patient safety are profound and preventive strategies are quintessential. Anesthesiology governing bodies must ensure requisite laws to prevent the adverse outcomes of sleep debt before patient care is compromised.

After-hours on-call: the effect on paediatricians' spouses and families

AIM

The after-hours or on-call component of a paediatrician's work has implications for their spouse and family. Little is known about the specifics and extent of this impact. We aimed to understand the potential positive and negative impacts of this important aspect of a paediatrician's work.

METHODS

The spouses (nine female and one male) of 10 practising paediatricians, who are providing care in a variety of hospital settings within New Zealand, were interviewed using an open-questioning technique. Interviews were analysed by a qualitative line-by-line thematic method in order to categorise the perceived impact of their spouses' on-call work on themselves and their families.

RESULTS

Participants reported multiple effects of after-hours on-call on themselves, their paediatrician partners and their families. Negative themes included sleep deprivation, restrictions on life-style and living location (specifically home proximity to hospital), spousal sacrifice, intimacy and communication challenges, and diminished quality time with children. Positive themes highlighted professional rewards, financial security and adaptability. Themes were consistent across age, length of relationship, spousal occupation and the presence of children. The intensity of these impacts for our participants appeared to vary depending on the degree of marital support and frequency of on-call.

CONCLUSION

After-hours on-call has a generally negative impact on paediatricians' spouses and families.

Increased error rates in preliminary reports issued by radiology residents working more than 10 consecutive hours overnight

RATIONALE AND OBJECTIVES

To determine if the rate of major discrepancies between resident preliminary reports and faculty final reports increases during the final hours of consecutive 12-hour overnight call shifts.

MATERIALS AND METHODS

Institutional review board exemption status was obtained for this study. All overnight radiology reports interpreted by residents on-call between January 2010 and June 2010 were reviewed by board-certified faculty and categorized as major discrepancies if they contained a change in interpretation with the potential to impact patient management or outcome. Initial determination of a major discrepancy was at the discretion of individual faculty radiologists based on this general definition. Studies categorized as major discrepancies were secondarily reviewed by the residency program director (M.H.S.) to ensure consistent application of the major discrepancy designation. Multiple variables associated with each report were collected and analyzed, including the time of preliminary interpretation, time into shift study was interpreted, volume of studies interpreted during each shift, day of the week, patient location (inpatient or emergency department), block of shift (2-hour blocks for 12-hour shifts), imaging modality, patient age and gender, resident identification, and faculty identification. Univariate risk factor analysis was performed to determine the optimal data format of each variable (ie, continuous versus categorical). A multivariate logistic regression model was then constructed to account for confounding between variables and identify independent risk factors for major discrepancies.

RESULTS

We analyzed 8062 preliminary resident reports with 79 major discrepancies (1.0%). There was a statistically significant increase in major discrepancy rate during the final 2 hours of consecutive 12-hour call shifts. Multivariate analysis confirmed that interpretation during the last 2 hours of 12-hour call shifts (odds ratio (OR) 1.94, 95% confidence interval (CI) 1.18-3.21), cross-sectional imaging modality (OR 5.38, 95% CI 3.22-8.98), and inpatient location (OR 1.81, 95% CI 1.02-3.20) were independent risk factors for major discrepancy.

CONCLUSIONS

In a single academic medical center, major discrepancies in resident preliminary reports increased significantly during the final 2 hours of consecutive 12-hour overnight call shifts. This finding could be related to either fatigue or circadian desynchronization. Discrimination of these two potential etiologies requires additional investigation as major discrepancies in resident reports have the potential to negatively impact patient care/outcome. Cross-sectional imaging modalities including computed tomography and ultrasound (versus conventional radiography), as well as inpatient location (versus Emergency Department location), were also associated with significantly higher major discrepancy rates.

Sleep deprivation in resident physicians, work hour limitations, and related outcomes: a systematic review of the literature

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, demonstrating 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.

How post-call resident doctors perform, feel and are perceived in out-patient clinics

CONTEXT

 Recently, in the U.S.A., the Accreditation Council for Graduate Medical Education guidelines limited residents' consecutive duty to 24 hours. In Europe, the European Working Time Directive limits the average working week to 48 hours.

OBJECTIVES

This study aimed to examine the performance of post-call residents in out-patient interviews using subjective and objective measures and to assess residents' subjective feelings.

METHODS

 We conducted a cross-sectional analysis of a systematic sample of 170 paediatric primary care consultations conducted during 117 clinic sessions served by 47 residents at a teaching hospital, including 34 consultations conducted during 23 sessions by 20 post-call residents. Interviews were audiotaped and quantitatively analysed using the Roter Interactional Analysis System (RIAS). Residents and patients' parents gave subjective appraisals of the visits using short questionnaires. Major covariates are resident gender and the timing of the clinic.

RESULTS

Results did not show significant differences between post-call residents and their peers who had left the hospital on time in most components of the out-patient interview. Subtle yet probably important differences emerged with findings that post-call residents were significantly less likely to ask a parent to repeat what she had just said, and parents seeing post-call residents were more likely to request the resident to repeat what he or she had just said and to check if the resident understood what they had said. Post-call residents were rated by objective coders as having better attitudes than their left-on-time counterparts, yet subjectively felt less satisfied and more fatigued. Female post-call residents felt less competent, less productive and less energetic; male post-call residents felt more challenged, more demoralised and busier.

CONCLUSIONS

The changes in activating and partnering talk that occur in post-call residents are consistent with findings concerning sleep deprivation and speech. Female and male residents tended to attribute their post-call performance to different factors. Setting limits on working hours might help to avoid potential negative impacts on post-call resident feelings, and the impact of working hours on resident performance warrants further exploration.

One night of sleep deprivation affects reaction time, but not interference or facilitation in a Stroop task

The Stroop color-naming task is one of the most widely studied tasks involving the inhibition of a prepotent response, regarded as an executive function. Several studies have examined performance on versions of the Stroop task under conditions of acute sleep deprivation. Though these studies revealed effects on Stroop performance, the results often do not differentiate between general effects of sleep deprivation on performance and effects specifically on interference in the Stroop task. To examine the effect of prolonged wakefulness on performance on the Stroop task, we studied participants in a 40-h "constant routine" protocol during which they remained awake in constant conditions and performed a Stroop color-naming task every two hours. We found that reaction time was slowest when the color and word did not match (incongruent), fastest when the color and word did match (congruent), and intermediate when participants named the color of the non-word stimulus (neutral). Performance on all three trial types degraded significantly as a function of time awake. Extended wakefulness did not significantly change the additional time needed to respond when the color and word did not match (Stroop interference), nor did it change the amount of facilitation when color and word matched. These results indicate that one night of sleep deprivation influences performance on the Stroop task by an overall increase in response time, but does not appear to impact the underlying processes of interference or facilitation. The results suggest that the degree to which an "executive function" is affected by sleep deprivation may depend on the particular executive function studied and the degree to which it is subserved by the prefrontal cortex.

Alerting, orienting and executive control: the effects of sleep deprivation on attentional networks

Sleep deprivation alters attentional functions like vigilance or tonic alerting (i.e., sustaining an alert state over a period of time). However, the effects of sleep loss on both orienting and executive control are still not clear, and no study has assessed whether sleep deprivation might affect the relationships among these three attentional systems. In order to investigate the efficiency of the three attentional networks--alerting, orienting and executive control--within a single task, we used the Attention Network Test (ANT). Eighteen right-handed male participants took part in the experiment, which took place on two consecutive days. On the first day, each participant performed a 20 min training session of the ANT. On the second day, participants remained awake for 24 h during which time the ANT was performed once at 5:00 p.m. and once at 4:00 a.m. Results showed an overall slowing of reaction times in the nocturnal session, indicating a strong decrease in vigilance. Furthermore, sleep deprivation did affect attentional orienting and executive control. Results are consistent with the hypothesis that the tonic component of alerting interacts with both attentional orienting and executive functions.

Sleep deprivation: implications for obstetric practice in the United States

Recent advances in basic science have expanded our understanding of the function of sleep and of the effects of sleep deprivation on human cognitive and psychomotor performance. In addition, a growing volume of data documents potential detrimental effects of sleep deprivation on medical practice. Such data have special implications for a specialty in which sleep deprivation is sometimes the norm. A review of this evidence suggests the pressing need for a reassessment of individual and small group obstetric practice, particularly as it relates to labor and delivery care; the current model of care in which each woman is delivered by the same provider who delivers prenatal care is generally not tenable in a culture increasingly focused on patient safety.

Recovery of cognitive performance and fatigue after one night of sleep deprivation

OBJECTIVES

The aim of this study was to investigate how subjective sleepiness, mood states, simple and high-order cognitive performance change after one night of sleep deprivation (SD) and recover to after 7 h normal recovery sleep opportunity during three recovery days.

METHODS

Ten healthy subjects participated in this study. We measured their subjective sleepiness, mood states and their performances of 2 simple tasks and 4 high-order cognitive tasks twice a day for 5 days, on the baseline day, post-vigil day and 3 recovery days after SD. This study was conducted considering each participant's motivation for task, learning effect and diurnal variation of performance.

RESULTS

The performances of simple tasks such as addition or short-term memory were not reduced after SD and were the poorest on the baseline day, and improved gradually; however the high-order cognitive performances were at their lowest on the post-vigil day and needed 2 recovery sleep opportunities to return to the baseline level. Fatigue and confusion in mood states and subjective sleepiness were also at their lowest after SD. Subjective sleepiness nearly recovered to the baseline level on the 1st recovery day, but fatigue and confusion reached the baseline levels on the 2nd recovery day.

CONCLUSION

These results suggest that cognitive deterioration and the recovery process may differ between simple task performance and high-order cognitive task performance, which needed 2 ordinary sleep opportunities to recover to the baseline level, and the change of subjective mood states were also different for each mood.

The 80-hour workweek restriction: How are OB/GYN resident procedure numbers affected?

OBJECTIVE

To evaluate the surgical caseload in a military obstetrics and gynecology residency program, prior to and after implementation of an 80-hour workweek.

METHODS

A retrospective cohort study evaluating data submitted to the Accreditation Council for Graduate Medical Education (ACGME) for cumulative resident procedures in obstetrics and gynecology for the years before (July 2001-June 2002) and after (July 2002-June 2003) 80-hour workweek implementation. Total obstetric and gynecology procedures were examined using both the Student's paired t-test and a two-way mixed factor analysis of variance.

RESULTS

Between July 2001 and June 2002 there were 822 gynecological cases and 3958 deliveries done by 17 OB/GYN residents; these were compared with 827 cases and 3504 deliveries done by 18 OB/GYN residents between July 2002 and June 2003 (p=0.189). The total numbers of obstetric and gynecology cases pre- and post-80-hour workweek intervention were similar when evaluated by month (July through June of 2001/2 vs. 2002/3; p=0.908). There was a significantly greater number of obstetrics cases compared with gynecological cases (p < 0.001) in the pre- vs. post-80-hour workweek groups; the number of gynecological cases remained constant in the post-80-hour workweek group while the obstetric numbers dropped (p=0.001).

CONCLUSION

The 80-hour workweek restriction resulted in similar total numbers of obstetrics and gynecology cases, although the total number of obstetric cases per resident declined after implementation.

Sleep deprivation alters pupillary reactivity to emotional stimuli in healthy young adults

The aim of this pilot study was to quantify the impact of sleep deprivation on psychophysiological reactivity to emotional stimuli. Following an adaptation night of sleep in the lab, healthy young adults were randomly assigned to either one night of total sleep deprivation or to a normal sleep control condition. The next afternoon, responses to positive, negative, and neutral picture stimuli were examined with pupillography, an indicator of cognitive and affective information processing. Only the sleep-deprived group displayed significantly larger pupil diameter while viewing negative pictures compared to positive or neutral pictures. The sleep-deprived group also showed anticipatory pupillary reactivity during blocks of negative pictures. These data suggest that sleep deprivation is associated with increased reactions to negative emotional information. Such responses may have important implications for psychiatric disorders, which may be triggered or characterized by sleep disturbances.

Relationships between affect, vigilance, and sleepiness following sleep deprivation

This pilot study examined the relationships between the effects of sleep deprivation on subjective and objective measures of sleepiness and affect, and psychomotor vigilance performance. Following an adaptation night in the laboratory, healthy young adults were randomly assigned to either a night of total sleep deprivation (SD group; n = 15) or to a night of normal sleep (non-SD group; n = 14) under controlled laboratory conditions. The following day, subjective reports of mood and sleepiness, objective sleepiness (Multiple Sleep Latency Test and spontaneous oscillations in pupil diameter, PUI), affective reactivity/regulation (pupil dilation responses to emotional pictures), and psychomotor vigilance performance (PVT) were measured. Sleep deprivation had a significant impact on all three domains (affect, sleepiness, and vigilance), with significant group differences for eight of the nine outcome measures. Exploratory factor analyses performed across the entire sample and within the SD group alone revealed that the outcomes clustered on three orthogonal dimensions reflecting the method of measurement: physiological measures of sleepiness and affective reactivity/regulation, subjective measures of sleepiness and mood, and vigilance performance. Sleepiness and affective responses to sleep deprivation were associated (although separately for objective and subjective measures). PVT performance was also independent of the sleepiness and affect outcomes. These findings suggest that objective and subjective measures represent distinct entities that should not be assumed to be equivalent. By including affective outcomes in experimental sleep deprivation research, the impact of sleep loss on affective function and their relationship to other neurobehavioral domains can be assessed.

Work environment and mental health status assessed by the general health questionnaire in female Japanese doctors

The number of female doctors in Japan has been increasing, but the relationship between their work environment and their mental health is not clear. This study aimed to determine factors in the work environment influencing mental health status among female doctors. We mailed an anonymous survey questionnaire to 587 female doctors, and 367 (62.5%) responded. The survey included questions about age, marital status, work-related information including their specialty, affiliated medical facility, position, type of employment, working time, and night duty. The thirty-item version of the General Health Questionnaire (GHQ-30) was used to examine psychological distress. For the purposes of analysis, subjects with a GHQ-30 score greater than or equal to eight were considered to have psychological distress. The mean age of the subjects was 45.1 yr (SD 15.1). A total of 152 [corrected] (41.6% [corrected]) of subjects met criteria for having psychological distress. Bivariate analysis showed that age (p=0.0009), marital status (p=0.0038), medical facility (p=0.0476), position (p=0.0180), working time (p=0.0337), and working at night (p<0.0001) were associated with the GHQ-30 score. Multiple logistic regression analysis showed that younger age (p=0.0030), engaging in night duty (p=0.0049), and being divorced (p=0.0093) were independently associated with psychological distress. These results suggest that work environment factors, particularly night duty, play important roles in modulating psychological distress among female doctors.

Impact of duty hours restrictions on quality of care and clinical outcomes

BACKGROUND

In July 2003, the Accreditation Council for Graduate Medical Education instituted residency duty-hours requirements in response to growing concerns regarding clinician fatigue and the incidence of medical errors. These changes, which limited maximum continuous hours worked and total hours per week, often resulted in increased discontinuity of care. The objective of this study was to assess the impact of the duty-hours restrictions on quality of care and outcomes of patients with acute coronary syndrome.

METHODS

We performed a retrospective analysis of 1003 consecutive patients with acute coronary syndrome admitted to the University of Michigan Hospital between July 2002 and June 2004. Patients were stratified by hospital admission during academic year 2002-2003 (pre-duty-hours changes, n=572) and academic year 2003-2004 (post-duty-hours changes, n=431). Main outcome measures included differences in adherence to quality indicators, length of stay, and in-hospital and 6-month adverse events.

RESULTS

Post-duty-hours changes, there was an increase in the usage of beta-blockers (85.8% vs 93.8%, P <.001), angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (65.7% vs 71.8%, P=.046), and statins (76.2% vs 84.0%, P=.002) at time of discharge. Length of stay decreased from 3.1 days to 2.8 days, P=.002. There was no difference in in-hospital mortality (4.2% vs 2.8%, P=.23). Six-month mortality (8.0% vs 3.8%, P=.007) and risk-adjusted 6-month mortality (odds ratio 0.53, 95% confidence interval, 0.28-0.99, P=.05) decreased after the duty-hours changes.

CONCLUSIONS

Implementation of the Accreditation Council for Graduate Medical Education residency duty-hours restrictions on an academic inpatient cardiology service was associated with improved quality of care and efficiency in patients admitted with acute coronary syndrome. In addition, improved efficiency did not adversely impact patient outcomes, including mortality.