Optimizing Resident Physician Schedules for Better Sleep and Patient Care

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• Resident Physician Schedule Challenges
• Sleep Needs Research for Medical Residents
• Patient Care Coverage and Supervision Balance
• Four-Day Rotation Model for Residency Training
• Barriers to Testing New Resident Schedules
• Decline in Teaching Time for Medical Residents
• Full Transcript

Resident Physician Schedule Challenges

Modern medical residency programs face significant scheduling challenges. Dr. Marshall Wolf, MD, explains that medical boards often create rules "in a data-free zone." These regulations can lead to poorly structured training programs. Dr. Anton Titov, MD, explores how to help young doctors thrive under these constraints. The tension exists between sleep requirements, patient coverage, and educational needs.

Sleep Needs Research for Medical Residents

Research reveals crucial insights about resident sleep requirements. Dr. Marshall Wolf, MD, cites literature showing two hours of sleep may suffice for non-call days. However, the "fireman effect" changes this equation dramatically. When expecting potential emergency calls, residents need at least four hours of sleep. Dr. Wolf's program implemented this minimum sleep protection. This approach ensured residents could perform effectively the next day.

Patient Care Coverage and Supervision Balance

Patient safety depends on proper supervision and adequate coverage. Dr. Marshall Wolf, MD, warns that some modern schedules reduce teaching opportunities. Residents need time to discuss cases with experienced physicians. Sleep-deprived physicians face serious risks beyond medical errors. Dr. Marshall Wolf, MD, notes they are twice as likely to have car accidents when sent home exhausted.

Four-Day Rotation Model for Residency Training

Dr. Marshall Wolf, MD, developed an innovative four-day rotation schedule. This model addresses multiple residency training challenges simultaneously:

• Day 1: Admitting day from 7:00 AM to 10:00 PM, with protected sleep in-hospital
• Day 2: Regular hospital duties from 7:00 AM to 5:00 PM
• Day 3: Continued patient care from 7:00 AM to 5:00 PM
• Day 4: Complete off-duty day with no hospital responsibilities

This schedule covers the critical first three days of most hospital admissions. It maintains weekly hours under 80 while eliminating unprotected overnight shifts.

Barriers to Testing New Resident Schedules

Medical boards often resist innovative scheduling approaches. Dr. Marshall Wolf, MD, prepared a comprehensive study of his four-day model. The research would measure sleep quality, patient outcomes, and staff satisfaction. Despite this rigorous approach, the medical board refused permission for testing. Dr. Wolf expresses frustration with this evidence-free decision-making in medicine.

Decline in Teaching Time for Medical Residents

Modern residency structures have dramatically reduced teaching time. Dr. Marshall Wolf, MD, reveals shocking data about resident activities. Trainees spend approximately five hours daily on computer work. They only spend about 1.5 hours in direct patient contact. This imbalance leaves residents "too busy to be taught." Dr. Anton Titov, MD, discusses the need for solutions that restore educational opportunities while maintaining patient care standards.

Full Transcript

Dr. Anton Titov, MD: In modern medicine, what is the best schedule for physicians in training? How do we make sure that young doctors are both happy and perform their best?

Dr. Marshall Wolf, MD: I have a lot of problems about schedules. Part of it is the medical boards. They tell training programs what they should and shouldn't do in terms of schedules. Medical bureaucrats often do that in a data-free zone. They haven't studied the situation.

So they set up training programs that don't make sense, at least in my mind.

I'll go back to the resident's sleep business. What we were trying to find out was how many hours of sleep a young physician needs so that a trainee physician performs well the next day. There was data in the literature, and the data was quite interesting.

It turned out two hours of sleep was enough for trainee physicians to perform well the next day — unless they were on call. It is what's called a "fireman effect." You may get two hours of sleep and not be called; that is enough. But if there is a chance you will be called in an emergency, like a fireman, then you need four hours of sleep.

We redesigned a training program so that even when people were not supposed to be on call, they would get at least four hours of sleep. That should be enough to let them perform well the next day.

It is interesting — and a tribute to the young people I trained and their energy level — that they often arrived on an every-fourth-night schedule sleep-deprived from their joyous activities on their nights off. They weren't getting enough sleep at that time.

In terms of the schedule, I am concerned about the new schedules for two reasons. First, they leave young physicians with poor coverage. You would like a young physician to get some sleep, but a trainee physician should also have a chance to discuss the patient with a more experienced resident or staff physician. Some of the new programs don't do that.

Second, some schedules send people home when they are sleep-deprived. We know that sleep-deprived physicians are twice as likely to have a car accident.

It was interesting — when my youngest son was an intern and I saw what he was going through, by that time I had stopped running our medical residency program. I came up with a new schedule for our program that I thought would deal with a lot of these issues.

The medical board refused to let us try the schedule for residents that I designed, even though we were going to measure the effect on sleep, clinical outcomes, patient satisfaction, and nursing satisfaction. We were prepared to do a definitive study, but the medical board would not let us do it.

I am a little discouraged. They are now beginning to look at some of these issues, but in a less restricted way than they should. It bothers me that people who made their career doing research and testing hypotheses, in the field of medical residency scheduling, make declarative statements and don't test them.

What I wanted to do on a four-day schedule was this: On the first day, you come to the hospital at 7 AM — that is your admitting day. You admit patients until 10 PM, then get to bed at midnight and sleep in the hospital. You didn't go home.

On the next day, you'd spend 7 AM to 5 PM in the hospital. On the third day, the same — 7 AM to 5 PM. On the fourth day, you would be completely off and not come to the hospital.

The length of stay in American hospitals now averages about three days. If trainee physicians are there for the first three days, they are there when most of the exciting things happen. They see their patient's illness and therapy evolve.

But the total hours were less than the 80 hours then suggested. There were no nights without protected sleep time. I thought it was a terrific schedule, but they would not let us test it.

Dr. Anton Titov, MD: Do you think it is possible to test it somewhere?

Dr. Marshall Wolf, MD: They are beginning to do some of those things here. But I thought we should test this schedule for residents in our training program. It bothered me because I had many wonderful ideas to make our program better.

I would ask the young people who were training with me: "What's broken? How do you fix it?" Then we would discuss the new suggestions and try them. We always kept track of whether the experiment worked. About half to two-thirds of the time it worked; a third of the time it didn't, even though we were sure it would.

It bothers me that the people looking at hours for house staff don't have the same rigorous approach to testing what they suggest. Whether a proposed schedule actually makes things better for trainee physicians is not always assessed.

Another thing I worry about with the new training schedules is that young physicians don't have quite enough time to be taught. The workday is so busy. Especially now, trainee physicians spend a lot of time on their computers.

I was shocked to learn that several studies show residents spend about five hours per day on a computer and only 1.5 hours per day face-to-face with patients. They are so busy that they don't have time to be taught. We have to figure out how to address this. I am thinking about it, but I don't have a solution.

Dr. Anton Titov, MD: How do we balance sleep and work schedules for medical and surgical residents in the intense environment of a modern academic hospital?

Dr. Marshall Wolf, MD: That's the question.