COMMENTARY

Fixing the Resident Burnout Crisis Starts With Sleep

Kunal Sindhu, MD

Disclosures

June 21, 2019

Recent years have brought an increasing awareness of the prevalence of burnout among US physicians. This is actually a positive development, because only by recognizing the true scope of the problem can we, as medical professionals, begin to fix it. And we must fix it. Burnout in US medicine has serious consequences. These physicians experience a lower quality of life and are at risk for depression and suicide. They are also more likely to commit medical errors, jeopardizing patient safety.

Resident physicians are particularly vulnerable to burnout. Not only do they work long hours in grueling jobs that require spending excessive amounts of time interacting with electronic medical records, they also lack control over their schedules. Interns, who have the least amount of power to shape their working conditions, report the least satisfaction with their lifestyles.

As a result, resident physicians—and especially interns—do not sleep enough. A study in the Journal of General Internal Medicine found that mean nightly sleep time dropped 14.4% during the intern year, from 7.6 to 6.5 hours. A separate study in Sleep found that interns and residents averaged 6.93 hours and 7.18 hours of nightly sleep, respectively. On-call nights were particularly brutal: The study found that interns slept just 2.19 hours each night.

Although the problem is worse in some specialties than others, sleep deprivation is an unfortunate hallmark of medical training in America. A study in the Journal of Graduate Medical Education found that surgery interns were, unsurprisingly, the worst off; they slept only 40.8 hours per week, or 5.8 hours per day, on average. Internal medicine interns hardly fared better, sleeping only 43.9 hours per week, or 6.3 hours per day, on average.

These findings are alarming. Sleep is essential to maintaining human life, and sleep deprivation has profound consequences. In the short term, sleep deprivation augments the stress response, adversely affects mood, and reduces one's quality of life. In the long term, it disrupts metabolism, raising the risk for such chronic ailments as dyslipidemia, hypertension, and cardiovascular disease. It also negatively affects physician performance. Residents who work longer shifts make more significant medical errors. In fact, senior surgical attendings who sleep less than 6 hours the night before surgery are 170% more likely to make a serious error.

This status quo in US medicine is dangerous. As physicians, we are taught to advise our patients to pursue activities that promote health. Among other things, we advise them to eat well, exercise regularly, and generally take care of themselves. However, we are often blocked by our medical institutions from following our own advice. Hospitals often offer us poor food choices, so we do not always eat well. We work exhausting jobs, and thus cannot exercise consistently. We work long hours, and we do not sleep enough. That's a shame.

Most US medical institutions appear to be responding to the burnout crisis by launching and promoting wellness initiatives. The effectiveness of these programs is as of yet unclear, and they largely do not address the underlying structural factors that are driving the crisis. A better approach would be for medical institutions to start by implementing programs to ensure that their residents sleep more. Few, if any, steps that medical institutions can take would have as profound an effect on resident well-being.

Fundamentally, addressing this lack of sleep will involve strengthening the enforcement of duty-hour limits and further reducing the maximum length of individual shifts. These changes will admittedly be challenging to implement in an era in which some physicians are already suggesting that residents can work longer hours. This would also require that the Accreditation Council for Graduate Medical Education ensure that all residency programs faithfully follow duty-hour restrictions, an area in which it has not had great success thus far. In fact, substantial evidence suggests that some residency programs, especially those in surgical fields, do not always adhere to existing duty-hour limits.

Making sure that residents sleep more will not solve the burnout crisis among residents. However, the benefits of more sleep—less stress, better mood, improved physical health, and fewer medical errors—are so great that US medical institutions have an obligation to do more. Residents deserve better.

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