More education is needed to increase awareness of effective strategies and countermeasures to cope with sleep loss, says lead researcher.

In a new study, sleep researchers from Case Western Reserve University School of Medicine and colleagues report sleep loss and fatigue affect medical residents in several ways, including learning, job performance and personal relationships.

In addition, the study says 84 percent of the residents studied fall into a range calling for clinical intervention for sleep problems, based on a self-reporting scale measuring their likelihood of falling asleep.

The research paper, called "The Effects of Sleep Loss and Fatigue on Resident-Physicians: A Multi-Institutional Mixed-Method Study," appears in a special theme issue on medical residents in the May Academic Medicine.

Using a combination of focus groups and a questionnaire, the researchers asked 149 residents in six medical specialties from five U.S. academic health centers about how sleep loss and fatigue affect their work and lives.

Lead author Klara K. Papp, Ph.D., says, "Our findings show that sleep loss and fatigue affects residents in all six of the specialties and at all five academic medical centers studied. This is of concern because residency training is such an important stage in the professional development of physicians."

"Unfortunately, the strategies residents describe adopting to cope with the effects of sleep loss and fatigue are by trial-and-error. More education is needed to increase awareness of effective strategies and countermeasures. Secondly, we need to change the prevailing attitudes among those medical educators who believe that extended periods of sleep deprivation contribute positively to residents' medical education and to patient care," says Papp, an assistant professor of medical education at the Case School of Medicine in the Department of Medicine at University Hospitals of Cleveland and the Louis Stokes Cleveland Department of Veterans Affairs Medical Center.

Among the findings:

-- Residents report adverse effects of sleep loss and fatigue on their abilities to learn, either in short-term or long-term memory of material.

-- Learning from reading, lectures, conferences and other structured learning opportunities are affected. Residents' motivation to learn is also affected.

-- Twenty of 22 focus groups note sleep loss and fatigue adversely affect their higher-order thinking skills (cognitive abilities and complex thinking). This category of responses includes comments pertaining to patient diagnoses, medical decision-making, and complex thought processes.

-- Twenty-one of the 22 focus groups describe themselves as inattentive and abrupt in their relationships and interactions with patients and family members. Residents also have less patience with patients' families.

-- Eighteen of the 22 focus groups speak specifically of treating patients as objects, rather than caring for them as individuals.

-- Residents also say their relationships with other hospital staff members are negatively affected, and they feel a loss of empathy or concern for patients.

-- Eighteen of 22 focus groups have frequent concerns about medical errors occurring due to potential effects of sleep loss and fatigue. Most frequently cited examples pertain to entering information into the patient record, prescribing medications, and either writing incorrect dosages or prescribing for the wrong patient.

-- They find themselves "cutting corners" or "taking the easy way out."

-- Sleep and fatigue have negative effects on interpersonal relationships, the ability to manage tasks of daily life, and physical and emotional health.

-- They believe their driving ability is impaired.

-- For those with spouses (46 percent of the participants are married), sleep deprivation adds to the stress of their lives and also undermines a primary source of emotional support. Those who are single believe personal relationships are put on hold during residency.

According to the questionnaire filled out, four out of five residents score in the range of sleepiness for which clinical intervention is usually required (125 participants, or 84 percent). Only two participants (one percent) score in the "desirable" range, and 22 (15 percent) score in the "mild sleepiness" range.

On average, residents respond that they had a high to moderate chance of dozing in six of the eight situations encountered in daily life, such as sitting and reading, or riding as a passenger in a car for an hour, as measured on a scale called the Epworth Sleepiness Scale.

Other findings:

-- A total of 133 (89 percent) disagree with the statement "My thinking is unaffected by sleep loss or fatigue."

-- A total of 124 (85 percent) do not agree that "My work is unaffected by sleep loss and fatigue."

-- Ninety-five (64 percent) residents either strongly agree or agree that "Sleep loss and fatigue have major impact on my personal life."

Papp adds, "Although residents were very worried about sleep loss and fatigue on their decision-making, on errors in prescription writing and placing incorrect medical orders, the reported actual incidents that would raise patient safety concerns were rare. The team approach, which is common in academic health centers, and the systems' checks in place may avert many serious errors."

Other researchers in the study are from Brown Medical School; Case Department of Sociology; Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey; University of Kentucky; and University of Michigan Medical School. The study was funded in part by a grant from the National Heart, Lung and Blood Institute.

The data in this study were gathered in 2001 and 2002. Effective July 1, 2003, the Accreditation Council for Graduate Medical Education (ACGME) approved the common program and institutional standards for resident duty hours including an 80-hour weekly limit, rest periods, and limits on continuous duty hours. In addition, hospitals are more aware of the effects of fatigue on residents and monitor residents' hours to safeguard against the issues raised by this study.

About Case Western Reserve University

Case is among the nation's leading research institutions. Founded in 1826 and shaped by the unique merger of the Case Institute of Technology and Western Reserve University, Case is distinguished by its strengths in education, research, service, and experiential learning. Located in Cleveland, Case offers nationally recognized programs in the Arts and Sciences, Dentistry, Engineering, Law, Management, Medicine, Nursing, and Social Sciences. The Commission on Presidential Debates selected Case to host the U.S. vice presidential debate on October 5, 2004.

About the Case Western Reserve University School of Medicine

Founded in 1843, the Case Western Reserve University School of Medicine is the largest medical research institution in Ohio and 16th largest among the nation's medical schools for research funding from the National Institutes of Health. Eleven Nobel Laureates have been affiliated with the school.

The School of Medicine is recognized throughout the international medical community for outstanding achievements in teaching. In 2002, it became only the third medical school in history to receive the best review possible from the national body responsible for accrediting the nation's medical schools.

It ranks in the top 25 among U.S. research-oriented medical schools in the U.S. News and World Report guide to graduate education. Annually, the School of Medicine trains more than 600 M.D. and M.D./Ph.D. students. Case's ground-breaking medical education program gives students clinical experience early in their training, teaches students through an innovative organ-based system, and fosters a professional and collegial atmosphere in which students are given considerable opportunity to pursue their special interests in biomedical science and clinical medicine.

Case is affiliated with University Hospitals of Cleveland, MetroHealth Medical Center, the Louis Stokes Cleveland Department of Veterans Affairs Medical Center, and the Cleveland Clinic Foundation, with which it will open the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University this year.

Contact: George Stamatis
Case Western Reserve University