165worked a traditional schedule made 36% more serious medical errors than interns
who were in the intervention group, despite no significant difference in patient acu-
ity. The majority of these errors were medication related, but the rate of diagnostic
errors was 5.6 times that of the intervention group. Interestingly, the rate of proce-
dural errors was low and similar between the two groups.
Other studies confirm that sleep deprivation does have a measurable effect on
psychomotor ability of surgical residents. Grantcharov et al. demonstrated that a
typical night on call (with little to no sleep) resulted in a significantly longer time
to complete laparoscopic tasks, more task errors, and unnecessary movements than
in a rested state [ 9 ]. Similar results have been reported by other authors using lapa-
roscopic simulators and other modalities. Studies also suggest that one night of
sleep deprivation (less than 3 hours of sleep in a 24-hour shift) creates a psychomo-
tor impairment that equivalents to being legally intoxicated [ 10 ]. Various studies
have both corroborated and refuted the assertation that sleep deprivation impairs
surgical ability [ 11 – 13 ]. To quote Dr. Thomas McCall’s perspective on resident
fatigue, “Common sense suggest resident’s abilities are impaired by fatigue. Few
would choose to ride in a car driven by a resident coming off a 36-hour shift” [ 14 ].
The effects of fatigue on resident well-being have been extensively studied. In
the early work by Friedman et al., interns scored significantly less in areas of sur-
gency (exhibiting high levels of positive affect), vigor, elation, egotism, and social
affection when fatigued as opposed to rested. Not surprisingly, fatigue left them
feeling more sadness [ 6 ]. In a review of studies that examined the effects of sleep
deprivation and fatigue on resident physicians, Samkoff and Jaques outlined the
findings from numerous studies that included manual dexterity, vigilance, and mood
[ 15 ]. It has been noted that sleep deprivation can lead to more sadness and less
social affection in resident physicians. Additionally, sleep deprivation led to psy-
chological problems such as memory defects, depersonalization, irritability, diffi-
culty in thinking, depression, etc. Other studies have noted that resident physicians
have high rates of major depression and episodes of clinical depression. Even after
only 6 months of residency, interns have worse moods as manifested by increased
rates of anger, tension, confusion, depression, and fatigue. Even a single night of
sleep loss has been shown to increase mood issues, depression, anxiety, and demo-
tivation in residents. Extended work hours can also have deleterious physical conse-
quences for resident physicians as well. It has been shown that fatigued residents are
more likely to sustain needle stick injuries and significantly more likely to be
involved in motor vehicle accidents [ 16 , 17 ].
To thoroughly explore the issues of how duty hours have impacted surgical edu-
cation, we aim to discuss the historical events that have catalyzed the changes in
resident physician work hours in the United States and how that event led to policy
changes that affected resident education. Then we aim explore attitudes of training
programs outside of the United States for purposes of comparison. We will then
review some contemporary data that supports a more flexible approach to the issue
of duty hours in the surgery and how this impacts patient care and resident
satisfaction.
9 Resident Duty Hours in Surgical Education