I am about to enter internal medicine rotation/ residency with 28 hours shift with no or minimal sleep. How can I maintain my concentration and performance in such sleep-deprived and heavy workload environment?
Sleeping issue during internal medicine rotation
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- Feb 23, 2010
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Coffee PRN. Nap whenever possible. While possible, it is unlikely that your IM 28hr call will have no opportunity for you to catch a couple hours of sleep.
- Dec 28, 2010
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Is this an issue you've had issues with in the past or are you just being proactive/neurotic about it?
If the latter, every IM resident has gotten through this and I would not worry about it to the extent that this becomes a self-fulfilling prophecy. Take it day by day, there will be times where you need to be very alert (presentations, collecting history) etc. and there will be times where you will be allowed to get short sleeping breaks. Coffee certainly helps in the moment, but for some it can heighten anxiety or create a false sense of confidence which heightens the possibility of errors so be careful and don't use in excess. Different coping strategies work for different people and you'll undoubtedly find your own.
If this is an issue you've had in the past, you're obligated to meet with your counselor to discuss this. That may seem intimidating because at this point you don't want to limit yourself, but arrangements will be made discretely and may not even be that big of a deal. Options/Policies will differ by institution so the only way to know it to set up a meeting.
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Call is how often? 1:4? For a one month rotation that’s 7 calls? Get sleep before and after...and rarely , unless you aren’t efficient, will you be busy the whole 28 hours...go take a nap during your down time.
- Dec 28, 2010
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Part of the struggle is that my support system does not include a physician to coach me through clinical reasoning. I do have advisors who I plan on using to help support my transition elsewhere, but they're definitely not going to have the time to coach me just to help. Does anyone know of any physician coaching services to improve in areas such as clinical reasoning?
Huh? You’re in residency. You’re surrounded by attendings and seniors. Seek out advice from those you click with.
- Feb 23, 2010
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Either
A: You're responding to someone I have ignored so I don't have context
B: I'm completely missing where this comment came from
C: You are also the op but forgot to switch accounts before responding.
Edit: just realized that you have been posting extensively in a related but separate thread. I'm assuming that you responded here by accident as your comment here is otherwise something of a non sequitur.
I remember doing 28 hour q3 in the MICU as an intern. It was dangerous. I had time to sleep but wasn’t the best call sleeper. I was pretty delirious by the time the rotation ended. But it did end.
I don't sleep well on my 28 hour calls generally.
Sometimes (rare to occasional) I don't have any time to sleep due to codes/bouncebacks/crashing pts/etc
Ideally I would be lying down for some number of hours (3-6) and falling asleep
I could see a program with both admission caps AND no code responsibilities having consistent sleep while on call. But generally for medicine programs it's got to be spotty at best
Overall the long calls at my program just suck. Ooof
Sometimes (rare to occasional) I don't have any time to sleep due to codes/bouncebacks/crashing pts/etc
Ideally I would be lying down for some number of hours (3-6) and falling asleep
I could see a program with both admission caps AND no code responsibilities having consistent sleep while on call. But generally for medicine programs it's got to be spotty at best
Overall the long calls at my program just suck. Ooof
So far I've had 3 call days, each roughly 24 hours, and for each one I've gotten at most 20 minutes of sleeping done. Not because I can't sleep, I can sleep anywhere, but because it's been that freaking busy. Mistakes happen, but at some point I have to pass that responsibility to the system in place.
Is there any data to show that 24 hour shifts in residency actually do anything to improve (1) the quality of physician it produces at time of graduation, and (2) the quality of care a patient receives. Seems like at this point it's being done for the sake of tradition and at the potential peril of patients and physicians alike.
Eh having seen the way medical errors get covered up, I don't know how much I trust those measures.
Would also like to see physician morbidity accounted for with the human toll being measured.
It's a complicated trade off whichever way you look at it.
Would also like to see physician morbidity accounted for with the human toll being measured.
It's a complicated trade off whichever way you look at it.
Quite an interesting read. Thanks for sharing this. There is some good correspondence to that study on the NEJM website.
Also:
There are actually a few studies looking at work hour variations, and generally they show that shorter shifts are either neutral or lead to more errors due to handoffs. The PICU one is the most recent one.
Quantifying the 'quality' of a physician is going to be challenging at baseline (what measure do you use? Board scores are notoriously unreliable, patient satisfaction scores don't necessarily mean safe/effective care, etc, etc), so I'm not sure I know of any studies that look at that.
I would say that you should be careful about when you take your coffee/caffeine. Remember that caffeine will take about 30 minutes to start working and last for about 3ish hours. Also remember that you may be more or less sensitive. If you don’t like straight coffee, then consider caffeine pills. So many sugary drinks have a bunch of other garbage in them. Your health usually takes a hit during this time, no need to add to it. Don’t ingest caffeine in the last couple hours before you go home. Also, don’t be afraid to take a nap in the hospital before going home. A should bag with a change of cloths helps with this.
I had a couple 24 hours shifts a month while on wards (24 Hours of ED call plus rounding the next day). The most I stayed was 32 hours when I was solo in one of the ICU’s. I slept through morning report once (my intern said I probably was attending to a patient issue . . . .lol), and I dosed off in front of my apartment once.
It’s a season. Be careful, and you’ll get through it. I’d strongly consider living close by.
I had a couple 24 hours shifts a month while on wards (24 Hours of ED call plus rounding the next day). The most I stayed was 32 hours when I was solo in one of the ICU’s. I slept through morning report once (my intern said I probably was attending to a patient issue . . . .lol), and I dosed off in front of my apartment once.
It’s a season. Be careful, and you’ll get through it. I’d strongly consider living close by.
It's not just for the sake of tradition. It's also done so hospital administrators can cash those fat checks on the backs of residents.
This is what it says:
"There was wide variability among sites, however; errors were lower during intervention schedules than during control schedules at one site, rates were similar during the two schedules at two sites, and rates were higher during intervention schedules than during control schedules at three sites. In a secondary analysis that was adjusted for the number of patients per resident physician as a potential confounder, intervention schedules were no longer associated with an increase in errors. "
Those studies are inadequate because they don't measure mental health outcomes, morbidity, and even mortality among the providers in each group.
Honestly I could be way off, but I'm conflicted over the issue of resident hours. On one hand I would love not to have shifts extend beyond 12 hours, on the other hand, I don't want residency programs to grow and pump out more residents and saturate the market.
- Jun 14, 2004
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Which is somewhat related to the paradox that exists related to NPs/PAs. I suspect the Venn diagram of people who want reduced work hours and are up in arms about NP/PAs overlaps significantly. But it's a zero sum game, and the shifts have to be covered by someone. You could hire more residents, but people should be careful what they wish for in that regard. Just go over and look at the thread in the EM forum regarding job prospects. Oversaturation isn't pretty.
- Mar 13, 2012
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The creation of a night-float service solves a lot of this. As it stands right now at our institution multiple services have either 24-28 hr shifts or they have 12-16 hr shifts, depending on the program. The only reason some have the longer shifts is because the residents have basically decided that they'd prefer not to have more call when not on the inpatient service or they'd prefer shorter nightfloat (e.g. 4-5 days a week rather than 6), so they are doing the 28s. Personally, I think its sadistic. Sleep is an essential and directly impacts your quality of life.
Right now psychiatry has a solid night-float system, but it means residents are doing 4-6 weeks of continuous night float (6 days a week, 11-12 hr shifts), which sucks, but at least you're sleeping (albeit on a different more lonely schedule). They are debating changing it to be more like IM night float. They want to have 2 residents on doing 16s and once weekly 24s, alternating every other day for 8 weeks, and the goal was stated as decreasing call when on other rotations. Personally that sounds so much worse that I don't even understand how they're considering it.
I've done enough 24/28s to know that they suck, and I never want to experience them again. 12-16s, yeah I can do those any day of the week.
This is what night float is for. I've done both and night float is, by far, better and more educational and safer in my view. With a night float schedule and some weekend call (and you can extend weekend call to 16s or 8s), there's no need for anyone to work 24 hours and all shifts will still be covered.
Another option is to do a moonlighting service for overnights/weekend coverage if you can't hire hospitalists for overnights (usually NPs). A friend of mine said his FM program used to have this for PGY 3s and attendings where you could sign up in the beginning of the year for specific overnight or extended shifts and get paid for it as a moonlighter (they were usually holidays or school vacation weeks). The point is there are ways to get coverage besides forcing residents to work 30 hours. Don't forget there are tons of hospitals without residents or hospitals who don't have residents for every service. They manage.
My previous residency had a great night float system. We worked hard in inpatient service and had a very large census for a FM program, but no one worked more than 11 hour shifts unless you were unlucky that day and had a late admission and had to stay to finish the note. 7a-6p. Night float team worked 6p-7a and stayed on 2 weeks but had both weekends off. All PGYs did a total of 13 weeks of night float during residency. I'm sure we were a cash cow for the hospital given the number of daily admissions we did, but it worked well for keeping a good work-life balance while getting great training. And in my opinion it diminished risk to both patient and resident safety.
As a devil's advocate - my program did night float which was awesome - nights were fun and you were free from the tedium of rounding and meetings, but we also didn't get the experience of doing a 30 hour call and learning how to function in that mindset/sleeplessness. Thankfully we did q4 30's (28's, whatever is allowed now) in the ICU. Why am I saying thankfully?
They sucked. But now as an attending I have an incredibly lucrative moonlighting gig where I cover a small hospital from Friday at 7am thru Monday at 7am. That's right party people - 72h strait as solo physician coverage. I get paid absolute bank, and honestly it's still better than the shifts in the ICU which prepared me to be able to handle it and learn how to sleep when on call - as well as what's important enough to go in for at 2am and what can wait until the morning.
So do they suck? Absolutely. Are they a valuable learning experience that will better prepare you for your future career? Absolutely. And feel free to disagree with that, but you'll never convince me that learning how to competently manage patients at hour 24 of sleep deprivation is going to do you a disservice long term.
They sucked. But now as an attending I have an incredibly lucrative moonlighting gig where I cover a small hospital from Friday at 7am thru Monday at 7am. That's right party people - 72h strait as solo physician coverage. I get paid absolute bank, and honestly it's still better than the shifts in the ICU which prepared me to be able to handle it and learn how to sleep when on call - as well as what's important enough to go in for at 2am and what can wait until the morning.
So do they suck? Absolutely. Are they a valuable learning experience that will better prepare you for your future career? Absolutely. And feel free to disagree with that, but you'll never convince me that learning how to competently manage patients at hour 24 of sleep deprivation is going to do you a disservice long term.
- Jul 28, 2004
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This exactly.
In addition, golden weekends aren't usually a thing with NF systems. I got more burnt out with only 1 day off per week than I did q4 30h shifts but 1 whole weekend off every month.
Edit: and admittedly this is a somewhat rare thing, but my wife was in residency when I was and with a night float system we once went 3 weeks without actually seeing each other at all.
In theory that sounds good, but what happens if for any number of reasons you cannot get much, if any, sleep working that many hours. As a patient I don't want that doctor coming anywhere near me if he/she walks in to my room looking like death. I don't want them making medical decisions for me or having anything to do with my care if they aren't well rested and in their best and sharpest frame of mind. Patients are owed that. You (and every physician) are prone to the same fatigue and poor clinical reasoning as anyone else would be with sleep deprivation. This notion in medicine that dismissing the need for sleep as we render complex medical care is both absurd and incongruous with our understanding of how the brain and sleep work, and in 25 years I'm sure this will be viewed as barbaric as it should be. Pt safety should always be first (and docs too for that matter), and lack of sleep is a pretty darn good way to increase risk of errors being made regardless if you're a resident or an attending. There are dozens of occupations out there where work hours are restricted due to the inherent risk to the public that comes with sleep deprivation. Having a medical license doesn't exclude us from those same vulnerabilities.
Edit: stepping off my soapbox now.
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Exactly. Would anyone want to fly in an airplane with a pilot who was working a 72 hour straight shift where they got an hour or two of sleep between flights? or even a 24 hour one?
Look, and I get it, but where I live there legitimately is often not an alternative. So you can either get a sleep deprived me or you can get nothing. That pneumonia you have? Yep, you'll need to get life flighted down to the closest center, enjoy the $25,000 bill for the flight. Cellulitis? Airplanes on the way. Oh, you'd prefer ground transport? Sorry, we don't have a crew that can make the 12 hour round trip.
I'll also add that if the purpose and/or justification of working 30 hour shifts as a resident is to prepare those residents to work those kind of extended, sleep deprived hours as an attending then perhaps we need to be asking why an attending should ever be expected to work that long. And if he/she is doing it voluntarily to make the big bucks (at the risk of making poor medical decisions when they are fatigued) then perhaps that individual should figure out how to make that work on their own after graduation.
I may be missing the boat here, but would it be safe to say that most residency programs are going to be a lot busier and have a lot higher acuity than the little communities where the need for extended hours is due to no other choice, thus increasing the chances of making a critical error? This is assuming that most of the smaller community hospitals where help is scarce are going to transfer out their sicker patients to tertiary care centers. I understand that this does not apply across the board.
I also realize I'm never going to convince someone who doesn't think there is value to learning how to work sleep deprived that there is a benefit in doing so. It's like anti-vaxxers (or now anti-maskers) - the opinion is set and often fixed.
Think of it this way. You get married. You have a kid. That kid doesn't sleep through the night, so you don't sleep through the night. There will be nights you'll spend up in an ER or up with a vomiting baby. Do you call in for those shifts because you've been awake for 24h and can't work the next day? And where do you draw the "sleep deprived" line? Lord knows I would argue I want someone who has had a full 8 hours over someone with a broken 6 because they're up with a baby.
What happens if at some point insomnia comes for you - do you go on disability because you physically can't fall asleep until 3 o'clock in the morning?
These examples seem ridiculous, I get it. But this is what you're arguing for.
Think of it this way. You get married. You have a kid. That kid doesn't sleep through the night, so you don't sleep through the night. There will be nights you'll spend up in an ER or up with a vomiting baby. Do you call in for those shifts because you've been awake for 24h and can't work the next day? And where do you draw the "sleep deprived" line? Lord knows I would argue I want someone who has had a full 8 hours over someone with a broken 6 because they're up with a baby.
What happens if at some point insomnia comes for you - do you go on disability because you physically can't fall asleep until 3 o'clock in the morning?
These examples seem ridiculous, I get it. But this is what you're arguing for.
- Mar 13, 2012
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I think the issue is that as far as my night shifts are concerned, it's not a question of a doc with 6 hrs vs. 8 hrs (honestly 6 hrs is more the norm anyway, especially with 16s), its the difference between 6-8 hrs and 0-2 hrs. Night services are busy, at least where I'm training.
I've done plenty of 28s. You know what it taught me? That I don't trust myself or anyone else to make good judgement with < 3 hrs of sleep a night. There is also very little learning that happens, because quite frankly I rarely remember much from the night anyway after sleeping during post-call. There's pretty good evidence in sleep medicine that having < 3 continuous hours of sleep correlates to a clinically significant impairment (usually assessed as reaction time and driving).
Also, I love how you compared people who don't see the value in sleep deprivation in medical training to anti-vaxxers or anti-maskers, as if its a-scientific to have that view.
If you want to work the way you do, by all means, have at it, but there's nothing that says it's necessary to do that in medical training, but there's some good reasons for it not to be that way. Its not like not doing a 28 in training precludes you from doing it as an attending.
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I said nothing about the impact on residents. The question was about patient safety. These studies all looked at patient safety and there aren't differences. I agree that they aren't looking at the right outcomes, but what works for me individually may not work well for someone else.
And, as others have mentioned, there are other factors as well. I know some of my classmates got better sleep in the hospital on call than they did at home with a new(ish) baby. YMMV.
Someone once made the analogy with driving while drunk. People start to think their drunk driving is better, because it's their impaired judgement as measured by their impaired judgement. In reality, performance suffers.
People subjectively may feel they "get used to" operating under certain conditions, but I doubt they are actually improving in any real sense.
I doubt "practice" with sleep deprivation makes you any better at it than practicing driving drunk. You just normalize it and find ways to adapt (increase following distance, slow down) but whatever.
People subjectively may feel they "get used to" operating under certain conditions, but I doubt they are actually improving in any real sense.
I doubt "practice" with sleep deprivation makes you any better at it than practicing driving drunk. You just normalize it and find ways to adapt (increase following distance, slow down) but whatever.
I don't know that there's evidence practicing while sleep deprived makes practicing while sleep deprived better. The last thing I looked at came out of the military and did not suggest that it did.
It seems like you're saying that because you *might* be able to function with sleep deprivation then everybody should be able to as well. We are all in different places in life and what we have going on outside the hospital can and will influence our performance on the inside. So the resident who has a new baby/sick kid/whatever pulls a 28 hour shift, falls asleep in the call room from exhaustion, misses a page, and suddenly they're the terrible resident who didnt show up to the MI and now has a bad eval and a worse reputation. Life's not fair but this whole issue seems to confer a lot of risk without much benefit.
That can be said about literally everything and should not be the basis of policy. If you have a baby and can't sleep at home, go sleep somewhere else. No one's stopping you from sleeping in the call room. But what we know - as doctors - is that sleep deprivation is real. We tell our patients to protect their sleep. We even prescribe sleep aids to help them do that. Then we turn around and make policies that are inconsistent with normal sleep. We're hypocrites.
That's a choice though. You can choose to do it on your own whether or not your residency made you do it. But residents are vulnerable and should not be made to do these shifts. Explaining it as a good thing because it allowed you to moonlight isn't a good enough reason in my opinion. Also, I don't think it should even be an argument of competently managing patients after 24 hours of sleep deprivation because it simply shouldn't be done.
Did you really just compare us to anti-vaxxers and anti-maskers? Because I'd argue that you're the anti-vaxxer and anti-masker in this argument since the science is on this side of that line. The evidence suggests that sleep deprivation DOES impair you. You can't change the evidence because it suits your skills or pocketbook.
I never understand residents who don’t like the night float system
The only reasoning I can come up with is that.... they’ve never experienced the night float system....
It’s eons better
Doctors work long hours and overnight for very practical reasons. Typically workforce or money. When I’m on call, I likely worked the day before and work the day after. It will be 8 am one day to 5 pm the next day or so. It is rare to get less than 5 hours of sleep I’d say. But what else would my practice do? Hire someone else to do nights? Less money. Do weeks of nights as an attending? Less money and less productivity compared to day time work.
It’s a practical choice docs make, but let’s not fool ourselves into thinking it is healthy though.
It’s a practical choice docs make, but let’s not fool ourselves into thinking it is healthy though.
Really? Weeks on end without seeing my spouse or interacting with anybody outside of the hospital? And never having more than a single day off during the entire time to fully recharge and decompress.
You can't see why some people would prefer being able to have dinner and see my spouse 5-6 days a week and having golden weekends to visit the rest of my family and take hiking trips with my dogs?
Nope. I much preferred the rotations with call over the rotations with night float in residency. I understand that some people hate the call nights and don't have family around. However, I am surprised that you cannot understand that some residents are much happier under each system and night float isn't a perfect panacea.
By that argument, we shouldn't have night float at all. After all, it's not 'normal' to sleep during the day. But medicine during the night looks different than medicine during the day. Decisions are made based on available resources, for better or worse. That experience is important. Doesn't make it normal to work nights.
You seem to think we're on different sides, and I don't think we are. Sleep deprivation is an issue, and we certainly shouldn't force people to work in unsafe situations. But if Resident A functions better on a 28 hour call every 4 (or whatever days) and Resident B functions better working a week of nights every month, whose 'truth' should we follow? Which policy is 'right'? Neither lead to great sleep outcomes, but, again, doing medicine at night is an important learning experience. You're trying to balance two competing interests. Not to mention the competing interest of 'days off'... when you can get a true day off working 24s vs a 24 hour period off by working a night float system.
In my residency, we changed how shifts worked on weekends multiple times. My intern year, we had 16 hour shifts on the weekends--one person on days, and one person on nights, with the night person staying to round the following morning. Both were on days during the week. My second year, we did 24 hour shifts on Saturdays with an adjusted rounding schedule (so we were out at 24 hours). My third year, one of the chiefs hated 24s, so banned them across the board and made some weekend shifts 12 hours and others 16 (depending on whether or not you had to round post night shift). My chief year, we reinstated 24s for certain teams but ran into more issues with duty hours.
This all isn't to say that we shouldn't try to make things better, but often people are working within the confines of the resources available to them.
- Jun 14, 2004
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This is an important point. The idea that night floats are a panacea begs the question "Are night shifts healthy?" There's data to suggest they aren't. So which one is "least bad"?
The Impact of Shift Work on Sleep, Alertness and Performance in Healthcare Workers
The argument is over sleep deprivation. You're not necessarily sleep deprived working a night float schedule. People do it all the time in other jobs like grocery stores, gas stations, and truck drivers. You notice none of those folks work 24-hour shifts? You also notice hospitals don't generally require their attendings to do 24s? They get away with it with residents because residents have no choice but to do what they're told.
It also doesn't make it dangerous to work nights.
I'd argue that we should follow the science and as far as I know, there is no legit scientific evidence that sleep deprivation allows you to work better in a high-stress, high-risk work environment. In fact, the studies say exactly the opposite.
Shift work like night float doesn't lead to the same personal outcomes as persistent sleep deprivation.
The "day off" after a 24 is spent sleeping and/or in a sleep-deprived haze.
I'm not understanding this statement. You mean the hospital is working within the confines of its resources?
I just skimmed it, but it's based on an n of 35 and it seems to be rotating night float schedules. Agree that when you start night float, it takes a day or two to acclimate and also agree that it isn't great, but I don't believe there are inherent risks as there are in persistent 24 hour shifts.
What are you talking about? That giant block from right when you wake up in the early afternoon to 6-8 at night you couldn’t see anyone? Couldn’t have dinner then? Seriously?
Literally can have dinner every single night..
Also, youre peds trained: you weren’t sleeping a few hours for a good bunch of those nights in residency, allowing for an even larger chuck mentioned above? I find that hard to believe
I’ve pulled thirty two 28hr calls in the 4 months of my surgery intern year so far. They can be brutal but I usually can get 1-3 hours of sleep unless something crazy goes down.
I check vitals and I/Os q4 hrs unless someone is more acute. So I make sure I’m up at 8p, 12a, 4a.
I usually PM round myself at 9 and see all my pts and check in with the nurses. This lets me answer their would be pages and then I can usually grab a 30min to 1.5hr nap between 10:30 and midnight. Wake up, check vitals and I/Os, follow up on pressing issues and then head back to the call room for what ever naps I can get in between pages, checking on labs, sup’ing lytes, following up to dos, and 4a when I print the list and recheck numbers before sign out.
I check vitals and I/Os q4 hrs unless someone is more acute. So I make sure I’m up at 8p, 12a, 4a.
I usually PM round myself at 9 and see all my pts and check in with the nurses. This lets me answer their would be pages and then I can usually grab a 30min to 1.5hr nap between 10:30 and midnight. Wake up, check vitals and I/Os, follow up on pressing issues and then head back to the call room for what ever naps I can get in between pages, checking on labs, sup’ing lytes, following up to dos, and 4a when I print the list and recheck numbers before sign out.
Our night float started at 5pm and my husband (and friends) didn't get home from work until after then. So no, we didn't ever have dinner together when I was on night float. Did your night float really not start until 8pm at night? Yes, I often got some sleep on night float, didn't make me hate it any less!
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