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Wednesday, May 01, 2013

Sleep No More: Sleep Deprivation, Doctors, and Error or Is Sleep the Next Frontier for Public Health?

How often do you hear your students or friends or colleagues talk about operating on very little sleep for work or family reasons? In my case it is often, and depending on the setting it is sometimes stated as a complaint and sometimes as a brag (the latter especially among my friends who work for large law firms or consulting firms). To sleep 7-8 hours is becoming a “luxury” or perhaps in some eyes a waste – here I think of the adage “I will sleep when I am dead” expresses that those who need sleep are “missing out” or “wusses.” My impression, anecdotal to be sure, is that our sleep patterns are getting worse not better and that many of these bad habits (among lawyers) are learned during law school.

One profession that has dealt with these issues at the regulatory level is medicine. In July 2011, the Accreditation Council for Graduate Medical Education (ACGME) – the entity Responsible for the accreditation of post-MD medical training programs within the United States – implemented new rules that limit interns to 16 hours of work in a row, but continue to allow 2nd-year and higher resident physicians to work for up to 28 consecutive hours. In a new article with sleep medicine expert doctors Charles A. Czeisler and Christopher P. Landrigan that just came out in the Journal of Law, Medicine, and Ethics, we examine how to make these work hour rules actually work.

As we discuss in the introduction to the article 

Over the past decade, a series of studies have found that physicians-in-training who work extended shifts (>16 hours) are at increased risk of experiencing motor vehicle crashes, needlestick injuries, and medical errors. In response to public concerns and a request from Congress, the Institute of Medicine (IOM) conducted an inquiry into the issue and concluded in 2009 that resident physicians should not work for more than 16 consecutive hours without sleep. They further recommended that the Centers for Medicare & Medicaid Services (CMS) and the Joint Commission work with the Accreditation Council for Graduate Medical Education (ACGME) to ensure effective enforcement of new work hour standards. The IOM’s concerns with enforcement stem from well-documented non-compliance with the ACGME’s 2003 work hour rules, and the ACGME’s history of non-enforcement. In a nationwide cohort study, 84% of interns were found to violate the ACGME’s 2003 standards in the year following their introduction.

Whether the ACGME's 2011 work hour limits went too far or did not go far enough has been hotly debated. In this article, we do not seek to re-open the debate about whether these standards get matters exactly right. Instead, we wish to address the issue of effective enforcement. That is, now that new work hour limits have been established, and given that the ACGME has been unable to enforce work hour limits effectively on its own, what is the best way to make sure the new limits are followed in order to reduce harm to residents, patients, and others due to sleep-deprived residents? We focus on three possible national approaches to the problem, one rooted in funding, one rooted in disclosure, and one rooted in tort law. I would love reactions to our proposals in the paper, but wanted to float the more general idea in this space.

 Obesity is a good example of something that through concerted action moved from the periphery to safely within the confines of public health thinking and even public health law. Is it time to do the same for sleep? Should we stop valorizing sleeping very little in our society? Should we be thinking about corporate and public policies directed to improving sleep pattern? What might that look like? One thought I have is about encouraging telecommuting to reduce commuting time, sleep rooms in offices? Of course, on the parenting sleeplessness sides many of the solutions are social support.  What about what we tell and model for our students? I try to impart to my students that extra hours spent studying well into the night will have diminishing marginal returns, but who knows if that message is imparted. I also worry that with the number of journals, moot courts, clubs, etc, we encourage our students to join at law school that we are enablers of sleeping too little and perpetuating the “superman” myth (and I do wonder about the gendered component here)... Real men don’t sleep. And then they perform badly at their jobs and get into car crashes….

- I. Glenn Cohen

Posted by Ivan Cohen on May 1, 2013 at 12:30 PM in Article Spotlight, Corporate, Science, Teaching Law | Permalink


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I wish I could sleep more than I do (I fall asleep rather late and simply wake up quite early in the morning, unable to continue sleeping: mild insomnia I suppose). However, I do take a nap at midday whenever possible (most of the time) and am surprised when folks make extravagant inferences or somewhat disparaging remarks upon learning of my nap routine. I have to tell them my doctor thinks it's perfectly fine (and in my case, necessary) and remind them that in some societies this is not uncommon. I try to discourage my students from partying until the wee hours of the morning but, alas, it seems, to little effect. I also inform them that if they're depending on more than one or two cups of strong coffee (or the equivalent thereof) to keep awake at night to study, it's probably doing more harm than good (along the lines of the diminishing marginal returns phenomenon).

My wife has told me about the sleep habits of resident interns at the hospital where she works and they indeed do frighten me!

Posted by: Patrick S. O'Donnell | May 1, 2013 1:06:43 PM

Civil and military aviation are both good examples of functional sleep deprivation risk mitigation. The general standard is based on a 12 hour work/rest model, with some exceptions. In the brief-fly-debrief rhythm of aviation, rest, nutrition, and stress of the aircrew are specifically addressed in the briefing portion prior to getting airborne.
As a current Naval Aviator and aspiring physician, I've been shocked to learn about the cavalier - even aggressive - attitude towards sleep in the medical field. Lives are on the line in both fields, although I contend that a physician seldom puts his own life at risk when he's tired.

Posted by: Tom Cunningham | May 3, 2013 6:49:35 PM

I am a professor of medicine and a past director of an ACGME accredited fellowship.

So the ACGME can't enforce the rules it has made and is now looking for help? Does that not lead anyone to ask the following question, "why then make the rule in the first place?" Every military person understands that you never give an order that you know in advance won't be obeyed. The ACGME had to know that these rules weren't going to be obeyed: indeed, having read them, and the guidelines, and the books and papers that talk about administering the rules, it's darned near impossible to obey them in the best of circumstances. Add to the mix the lack of funding for new residents and for new health professionals (hospitalists, nurse practitioners, etc) to pick up the work that residents now can't do, and the rules have to bend. It's reality.

There is also the understanding that no matter what is done for residents, fellows and students, there is one group that will NEVER have duty hour limitations: attending physicians, either on faculty or in private practice. Try and enforce that one.

Mr. Cunningham notes the aviation experience. He's correct, and I'm not going to deny the need for proper rest in medicine (some of my own colleagues are pioneers in exactly this area of work). I'm agreeable to wanting residents to be properly rested.

But what I see here is the typical 'progressive' model: make a rule that can't be enforced, and then become progressively more coercive in forcing people to follow the rule. As each new rule, law, code, etc proves unable to solve the problem, simply layer on another rule.

I've seen other areas of law and society do this. It never works. Why would you think it will work this time?

Posted by: Steve White | May 3, 2013 8:40:28 PM

Getting the government involved in our sleep--sounds creepy just saying it, not to mention it will likely make the problem (assuming there is one) even worse.

Posted by: David Hogberg | May 4, 2013 8:22:04 AM

Thanks to all for the comments. Tom I think the aviation example is a good analogy. David, we are not talking about the government monitoring your sleep directly as you will see when you read the paper. We are talking largely about the ways in which institutions violate work hour rules, like the ones set by ACGME, aimed at public safety and using funding and tort law to try to deter them from doing so. Government can also play a more constructive role, like encouraging telecommuting and doing other things aimed at improving sleep by reducing things (like long commutes) that get in the way.

Posted by: I. Glenn Cohen | May 4, 2013 12:54:00 PM

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