What happens on call doesn’t stay on call. The effects of in-house call on acute care surgeons’ sleep and burnout: Results of the Surgeon Performance (SuPer) trial.
Jamie Coleman*1, Caitlin Robinson2, William von Hippel4, Kristen Holmes4, Samuel Pearson4, Ryan Lawless2, Alan Hubbard3, Mitchell Cohen2
1Surgery, University of Louisville, Louisville, KY; 2Surgery, University of Colorado, Aurora, CO; 3Biostatistics, University of California Berkeley, Berkeley, CA; 4Psychology, University of Queensland, Brisbane, Queensland, Australia
Objective: Acute care surgeons (ACS) frequently participate in practice models that require in-house call (IHC), which leads to disrupted sleep and high levels of stress and burnout. Chronic sleep disruption has ill-effects including depressed mood, decreased performance and an increased risk of inflammatory health sequelae including myocardial infarction, stroke and cancer. We sought to quantify sleep through the use of continuous wearable physiological devices to assess the effects of IHC on sleep patterns and burnout among ACS.
Methods: Physiological and survey data of 209 ACS with trauma call responsibilities from 91 level I and II trauma centers were collected over six months. Participants continuously wore a physiological tracking device and responded to daily electronic surveys. Comprehensive work, demographic, and personal health data were collected at the time of enrollment. Daily surveys captured work and life events as well as feelings of restfulness and burnout. The Maslach Burnout Inventory (MBI) was administered at the beginning and end of the study period. For comparison a 10:1 non-surgeon cohort was matched by age and gender.
Results: Physiologic data were recorded for 34,135 days from 209 ACS (48.8% female; ages 31-73, mean 43 years). A total of 4,389 nights of IHC were recorded, with a mean of 3.3 nights of IHC per surgeon per month and mean length of 18.3 hours. Overall sleep duration, REM, and slow wave sleep were reduced when surgeons took IHC, when they operated or participated in a trauma activation, and after a particularly stressful case or bad outcome (p’s<.01) (Fig. 1). Feelings of moderate, very, or extreme burn out occurred 25.7% of days and feelings of being moderately, slightly, or not at all rested occurred 75.91% of days. The emotional exhaustion subscale of the MBI revealed 38% of ACS met criteria for burnout. Decreased amount of time since the last IHC, reduced sleep duration, being on call, and having a bad outcome all contribute to greater feelings of daily burnout (p’s<.001). Decreased time since last call also exacerbates the negative effect of IHC on burnout (p<.01), such that IHC has a larger effect on burnout when time since the last IHC is reduced.
Conclusions: ACS exhibit lower quality and reduced amount of sleep as compared to an age-matched population. These effects were stronger when surgeons operated, participated in a trauma activation or had a bad outcome while on call. Furthermore, reduced sleep and decreased time since the last call led to increased feelings of daily burnout, accumulating in emotional exhaustion as measured on the MBI. These data indicate physiological markers of sleep are strongly predictive of burnout. A reevaluation of IHC requirements and patterns as well as identification of countermeasures to restore homeostatic wellness in ACS is essential to protect and optimize our workforce.
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