To sleep or not to sleep: How residents make decisions post-call

Residents are using “trade-off” approaches—in which they barter crucial sleep hours for personal time—to determine how to recover after overnight shifts, according to a recent study. Authors of the study identified two key behaviors among residents struggling to maintain work-life balance and decide the best way to spend their personal time. 

“Despite assumptions about how residents should be using their post-call, off-duty time, there is little research on how residents actually use this time and the reasoning underpinning their activities,” according to authors of the study, which was recently published in Academic Medicine. “This study sought to understand residents’ nonclinical post-call activities when they leave the hospital, their decision-making processes, and their perspectives on the relationship between these activities and their well-being or recovery.”

The study took place from 2012 to 2014 at a Canadian medical school accredited by the Liaison Committee on Medical Education. The authors interviewed 24 residents across six surgical and non-surgical specialties about their post-call activities immediately following a 24-hour overnight shift, what motivates them to prioritize certain activities post-call and the personal impact these decisions have on residents’ recovery of sleep and self.

Based on an analysis of interview transcripts, study authors found that residents grapple with competing priorities and typically use “two trade-off orientations—being oriented toward maintaining a normal life or toward mitigating fatigue—when making decisions about how to use their post-call days. These orientations were not static; residents reported shifting their predominant orientation according to the situation and accrued experience,” the study authors wrote.

Residents who focused on “maintaining a normal life” restricted sleep to a few hours or sacrificed rest altogether to pursue activities “that permitted them to maintain what residents characterized as ‘normal human things’ involving their personal lives and relationships outside of the hospital,” according to the article.

Many residents said they wished to “break [the] cycle” of solely working and sleeping between rotations to explore activities that improved their connections with loved ones and personal lives.  While certain residents in the study said that forfeiting precious hours of sleep was challenging, some of the key activities they prioritized over sleep post-call included:

• Connecting with family and friends. Many residents cited a desire to connect with loved ones during personal hours due to concerns that unpredictable work schedules wouldn’t allow them to see close family and friends at a later time.
• Completing important life errands. Residents expressed a desire to “keep their life order,” which motivated them to replace sleep with completing pressing life tasks, such as going to the bank, a dentist appointment and getting their car repaired during normal business hours. “As one resident reasoned, if it [were] not for post-call days, these services would be fairly inaccessible to residents,” according to the study.
• Productivity. Despite acknowledging the need to sleep, some residents said that they still choose to use their time post-call to complete duties—such as working out and buying groceries—to increase their sense of personal fulfillment and productivity.

While life activities emerged as priorities for some residents, others pursued sleep post-call to mitigate fatigue and recover from overnight shifts. These “trade-offs” typically occurred “in situations where recharging experiences, such as choosing to ‘crawl right into bed and sleep for as long as possible’ or engage in passive activities, took priority over tasks that required more energy expenditure, such as studying, socializing or attending to normal life,” according to authors of the study.

Some key trends study authors noted among these residents included:

• Substantial differences in sleep durations. “A few residents described wanting to sleep ‘for as long as possible’ while others deliberately restricted their daytime sleep with the intention of preserving their sleep-wake rhythm,” according to the study.
• A perceived need to justify why they’d like to sleep. “Anticipated criticism from colleagues further complicates residents’ trade-offs,” the study noted.
• Concerns about missing important opportunities. Many residents who prioritized their sleep still felt conflicted about “sacrificing valuable educational experiences by leaving the hospital and choosing to sleep or rest,” according to the study.

Authors of the study noted that these trends—among residents in both “trade-off” groups—addresses “the evidence gap involving residents’ nonclinical post-call activities” but also underscores the importance of re-evaluating how duty-hour restrictions impact residents' recovery processes post-call.

“These findings challenge the dominant viewpoint in the current-duty hours literature, which has maintained a singular focus on sleep as the only path to recovering from working long hours,” the study authors wrote. “Our study suggests that we must broaden the duty-hours discussion to include other recovery processes.”

Read the full study for additional observations.

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