Peter Wehrwein

Naps for young doctors

Doctors-in-training should be encouraged to do some on-the-job napping, according to the organization that sets the standards for residency programs around the country.

The Accreditation Council for Graduate Medical Education (ACGME) issued new standards yesterday that came out in favor of a well-timed snooze. The guidelines, which are scheduled to go into effect next year, say this:

Programs must encourage residents to use alertness management strategies in the context of patient care responsibilities. Strategic napping, especially after 16 hours of continuous duty and between the hours of 10:00 p.m. and 8:00 a.m., is strongly encouraged.

Medical residency is the training that follows graduation from medical school. Traditionally, residents at American hospitals were expected to work marathon hours—often overnight and a couple of days in a row. These long shifts were seen as a way to get new doctors thoroughly steeped in medicine and necessary for mastery of the complexities of a medical specialty. The grueling apprenticeship is a feature of many professions. Perhaps it is the 10,000-hour rule coming into play.

And, not so incidentally, making medical residency an endurance-slash-sleep-deprivation contest also supplied hospitals with cadres of young, eager doctors who were paid relatively low salaries.

But whether overworked (and undersupervised) residents might be endangering patients became a front-page issue after the Libby Zion case. Then research done at Harvard and elsewhere started to show, in a systematic way, connections between the sleep-deprived residents, medical errors, and patient safety. Rules were changed to limit hours, require a certain amount of time off between shifts, and improve supervision.

There’s some question whether it is honored in the breach, but now residents are limited to working 80 hours a week on average. That is still a heckuva a lot of hours but far fewer than “good old days,”  which were actually quite bad—and unsafe—in a lot of ways.

The Institute of Medicine (IOM) published a report on resident training two years ago. According to an article published in The New England Journal of Medicine yesterday, the ACGME standards published yesterday followed the IOM’s lead in most respects but parted company when it came to the important issue of preventing errors by sleep-deprived residents. Here is how the The  New England Journal of Medicine report summarized the difference:

The IOM recommended that resident shifts longer than 16 hours include an uninterrupted 5-hour sleep period. The ACGME task force concluded that such a long sleep period was unworkable, instead recommending “strategic napping” during long shifts.

It’s pretty remarkable that an organization like the ACGME has endorsed napping, albeit carefully qualified as being of the strategic sort.

But napping is collecting endorsements these days.

The National Sleep Foundation says that “while naps do not necessarily make up for inadequate or poor quality nighttime sleep, a short nap of 20-30 minutes can help to improve mood, alertness, and performance.”

Studies of nightshift workers have shown that their performance improves if they grab a “prophylactic nap” before they start work. Other studies show that the “operational nap” of just  20 minutes during a nightshift improves performance at the end of the shift, although you have to be careful about sleep inertia—that groggy feeling that lingers once you wake up from a nap.

Robert Stickgold, a prominent Harvard sleep researcher, says in some cases, a nap can provide as much benefit as a full night of sleep.

Not many businesses have truly embraced the workplace nap. But the nap-as-productivity-booster has its advocates.  (Better the short nap than those multihour energy drinks with all that caffeine, provided you can get the boss to agree first.)

There’s even some discussion that pilots ought to be allowed to doze off for short periods—and that they do so anyway on long trips.

If you want to read more about naps, we published a piece about them in the Harvard Health Letter last year. And our our brother publication, the Harvard Men’s Health Watch, published a piece two years ago.

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Comments:

  1. baby cots

    They should really have a nap.. Dont abuse your body!

  2. Eric Weathersby

    Obviously when a young resident works a continuous shift with out sleep or a nap, errors are inevitable so napping is an alternative to medical error and patient safety and should be embraced. However if that is not an option for some employers there is a new energy drink that does not have caffeine and is not spiked with sugar it is called Drink ACT. Drink ACT energy drinks works in minutes and lasts for hours.it is spike with essential vitamins and minerals that we need but rarely get. It will give doctors and interns alike that needed boost without the “crash”. But nothing will replace a good night sleep!
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  3. April

    I think they should get naps. Take advantage when you can because you don’t know when you’ll be able to or would have to be up longer than planned. Wise words and take advantage of the time when you can. It’s very demanding job.

  4. Allen Harp

    Sorry, but the thought that we are “shortchanging our trainees by limiting their hours” reiks more of a fraternity hazing that quality training. Yes a practicing physician must be prepared for the worst and we certainly want all the experience for them possible. But the approach of taking 4 years of work hours and forcing them into a 1 to 2 year framework always has been a recipe for disaster. “We are endangering the American public, by training doctors who don’t have enough experience.” Well, we certainly aren’t going to train experienced, seasoned doctors are we? This sounds more like “I had to survive it so they should too”.

    Lying in the ER waiting for help…I prefer to have the yawn of a resident just waking from a power nap than from a frazzled young man or woman at their mental worst from sleep deprivation. Where did these neanderthal concepts originate from to begin with?

  5. Atanu Goswami

    Very dicey and like a two edged sword long duty hours is a subject for debate. Long hours does not necessarily mean good training. It is a reflection of inadequateness of workforce. However in some ways long duty hours do help. The longer u are in duty the more u learn and that is how a resident progresses. We do 24 hour shifts but try to catch a nap whenever possible.

  6. Owen Marcus

    Naps are good for everyone. They improve everything, including the quality of life.

  7. Richard Weiss

    residents are expected to work 80 hour weeks is double the amount of the american work force. this is common sense.after working more than 12 hours fatigue and exhaustion diminish the mentation of anyone. i find it disingenuous that ACGME will not do the studies required.
    will it be a rct randomized trial, meta-analysis, obsevational studies and all with statistical analysis,look for bias, errors in internal validity.

    the sleep issue continues with no organization willing to design a study. Why? Why is the sleep dilemma continue? it seems that ACGME is stonewalling everyone and this becomes a political dragnet with the seemliness of the health care bill.

  8. Fred Dennis

    I disagree with Eric. Naps are for Emergency Docs. As a Residency Trained practicing Emergency Physician for over 20 years, having to work shift work is part of the job. And most sites don’t schedule blocks of nights then blocks of days. Naps keep me at peak performance. If my natural schedule is to be awake from 0600 to 2200, then working 1800 to 0200 or all of a sudden working a night shift can result in decreased performance at the end of the sift.
    Most of us nap before going in for our first night shift. Many of us nap before working a late evening shift, not because we have nothing better to do, but rather over the years we’ve learned how to help shift our “body clocks” and maintain optimal performance.
    On the other hand there is something to be said about experiencing extremes of stress during your Residency so that you learn you limits in a setting with backup.

  9. Ana Jeronimo

    If we need trainees to stay awake working for 48h in a row to get practice and training, that is the proof of the failure in every training program in Medicine. No doctor in Europe needs that intensive training to get expertise and we sure have good doctors in Europe… How can anyone learn something after a 24 hours shift with no sleep? That is the perfect excuse to take away the responsability from specialists, and to keep a cheap labour working force. I´m surprised how Americans accept that, how can they accept their relatives to be treated by unsupervised and inexperient doctors that are kept awake and working for such long hours… in a country where legal conflits are so intense because of much less important issues.

  10. Eric Cohen

    Naps are for babies.

    We are shortchanging our trainees by limiting their hours.
    We are endangering the American public, by training doctors who don’t have enough experience.