Sleep loss and performance in residents and nonphysicians: A meta-analytic examination

Sleep

Volumn 28, Issue 11, 2005, Pages 1392-1402

  Philibert, Ingrid ^a  

^a Accreditation Council for Graduate Medical Education   (United States)

Author keywords

Cognitive performance; Meta analysis; Resident physicians; Sleep deprivation; Work hour limits

Indexed keywords

ARTICLE; COGNITION; HUMAN; LEARNING; MEMORY; META ANALYSIS; MOTOR PERFORMANCE; PHYSICIAN; PRIORITY JOURNAL; RESIDENT; SAFETY; SLEEP; SLEEP DEPRIVATION; STATISTICAL ANALYSIS; SYSTEMATIC REVIEW; TASK PERFORMANCE; WAKEFULNESS; WORK;

EID: 27644560608     PISSN: 01618105     EISSN: None     Source Type: Journal    
DOI: 10.1093/sleep/28.11.1392     Document Type: Article

References (142)

1. Friedman RC, Bigger JT, Kornfield DS. The intern and sleep loss. N Engl J Med 1971;285:201-3.
2. Dawson D, Reid K. Fatigue, alcohol and performance impairment. Nature 1997;88:235.
3. Lamond N, Dawson D. Quantifying the performance impairment associated with fatigue. J Sleep Res 1999;8:255-262.
4. Public Citizen. Petition to the Occupational Safety and Health Administration (OSHA), filed by Public Citizen, the American Medical Student Association and the Committee of Interns and Residents (CIR); Washinbton, DC; April 30, 2001.
5. 107th CONGRESS, 1st Session, H. R. 3236. The Patient and Physician Safety and Protection Act of 2001;Washington, DC, November 6, 2001.
6. Geer RT, Jobes DR, Tew JD, Stepsis LH. Incidence of automobile accidents involving anesthesia residents after on-call duty cycles. Anesthesiology 1997;87:A938.
7. Marcus CL, Loughlin GM. Effect of sleep deprivation on driving safety in housestaff. Sleep 1996;19:763-6.
8. Steele MT, Ma OJ, Watson WA, Thomas HA Jr, Muelleman RL. The occupational risk of motor vehicle collisions for emergency medicine residents. Acad Emerg Med 1999;6:1050-3.
9. Parks DK, Yetman RJ, McNeese MC, Burau K, Smolensky MH. Day-night pattern in accidental exposures to blood-borne pathogens among medical students and residents. Chronobiol Int. 2000;17:61-70.
10. Accreditation Council for Graduate Medical Education, Common program requirements for duty hours. Approved June 24, 2003. Available at: http://www.acgme.org/DutyHours/dutyHoursCommonPR.pdf. Accessed August 3, 2005.
11. Accreditation Council for Graduate Medical Education. Report of the ACGME Work Group on Resident Duty Hours, page 5. June 11, 2002. Available at: http://www.acgme.org/DutyHours/wkgroupreport611.pdf. Accessed August 3, 2005.
12. Association of American Medical Colleges. AAMC policy guidance on graduate medical education, September 2001. Available at: http://www.aamc.org/ patientcare/gmepolicy/start.htm. Accessed August 3, 2005.
13. Asch DA, Parker RM. The Libby Zion case. One step forward or two steps backward? N Engl J Med 1988;318:771-5.
14. Evans L. Regulatory and legislative attempts at limiting medical resident work hours. J Leg Med 2002;23:251-67.
15. Naitoh P. Sleep deprivation in human subjects: a reappraisal. Waking Sleeping 1976;1:53-60.
16. Leung L, Becker CE. Sleep-deprivation and house staff performance-Update 1984-1991. J Occup Med 1992;34:1153-60.
17. Samkoff JS, Jacques CHM. A review of studies concerning effects of sleep-deprivation and fatigue on residents' performance. Acad Med 1991;66:687-93.
18. Schmidt FL, Hunter JE, Urry VE. Statistical power in criterion-related validation studies. J Appl Psychol 1976;61:473-85.
19. Sedlmeier P, Gigerenzer G. Do studies of statistical power have an effect on the power of the studies? Psych Bull 1985;105:309-16.
20. Hedges LV. How hard is hard science, how soft is soft science: the empirical cumulativeness of research. Am Psychol 1987;42:443-55.
21. Hunter, JE, Schmidt FL. Methods of Meta-analysis. Newbury Park, CA: Sage Publications; 1990.
22. Schwartz AJ, Black ER, Goldstein MG, et al: Levels and causes of stress among residents. J Med Educ 1987;62:744-753.
23. Asken MJ, Raham DC: Resident performance and sleep deprivation: a review. J Med Educ 1983;58:382-388.
24. Garcia EE: Sleep deprivation in physician training. NY State J Med 1987;87:637-638.
25. Page L. Long work weeks typical for residents-survey. Am Med News, February 5, 1988, pp 10-12.
26. Lingenfelser T, Kaschel R, Weber A, Zaiser-Kaschel H, Jakober B, Kuper J. Young hospital doctors after night duty - their task-specific cognitive status and emotional condition. Med Educ. 1994;28:566-572.
27. Browne BJ, VanSusteren T, Onsager DR, Simpson D, Salaymeh B, Condon RE. Influence of sleep-deprivation on learning among surgical house staff and medical students. Surgery. 1994;115:604-610.
28. Haynes DF, Schwedler M, Dyslin DC, Rice JC, Kerstein MD. Are postoperative complications related to resident sleep deprivation? South Med J. 1995;88:283-289
29. Grantcharov TP, Bardram L, Funch-Jensen P, Rosenberg J. Laparoscopic performance after one night on call in a surgical department: prospective study. BMJ. 2001;323:1222-3.
30. Taffinder NJ, McManus IC, Gul Y, et al. Effect of sleep deprivation on surgeons' dexterity on laparoscopy simulator. Lancet. 1998;352:1191.
31. Aya AGM, Mangin R, Robert C, Ferrer JM, Eledjam JJ. Increased risk of unintentional dural puncture in night-time obstetric epidural anesthesia. Can J Anaesth. 1999;46:665-69.
32. Storer JS, Floyd HH, Gill WL, et al. Effects of sleep deprivation on cognitive ability and skills of paediatric residents. Acad Med 1989;64:29-32.
33. Ben-Aroya Z, Segal D, Hadar A, et al. Effect of Ob/Gyn residents' fatigue and training level on the accuracy of fetal weight estimation. Fetal Diagn Ther 2002;177-81.
34. Smith-Coggins R, Rosekind MR, Hurd S, Buccino KR. Relationship of day versus night sleep to physician performance and mood. Ann Emerg Med 1994;24:928-34.
35. Denisco RA, Drummond JN, Gravenstein JS. The effect of fatigue on the performance of a simulated anesthetic monitoring task. J Clin Monit 1987;3:22-4.
36. Bertram DA. Characteristics of shifts and second-year resident performance in an emergency department. NY State J Med 1988;88:10-4.
37. Koslowsky M, Babkoff H. Meta-analysis of the relationship between total sleep deprivation and performance. Chronobiol Int 1992;9:132-6.
38. Pilcher JJ, Huffcutt AI. Effects of sleep deprivation on performance: A meta-analysis. Sleep 1996;19:318-26.
39. Weinger MB, Ancoli-Israel S. Sleep deprivation and clinical performance. JAMA 2002;287:955-57.
40. Veasey S, Rosen R, Barzansky B, Rosen I, Owens J. Sleep loss and fatigue in residency training: a reappraisal. JAMA 2002;288:1116-24.
41. Lockley SW, Cronin JW, Evans EE, et al. Harvard Work Hours, Health and Safety Group. Effect of reducing interns' weekly work hours on sleep and attentional failures. N Engl J Med 2004;351:1829-37.
42. Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med 2004;351:1838-48.
43. Gottlieb DJ, Parenti CM, Peterson CA, Lofgren RP. Effect of a change in house staff work schedule on resource utilization and patient care. Arch Intern Med 1991;151:2065-70.
44. Van Dongen HPA, Maislin G, Mullington JM, Dinges DF. The cumulative cost of additional wakefulness: dose-response effects on neurobehavioral functions and sleep physiology from chronic sleep restriction and total sleep deprivation. Sleep 2003;26:117-26.
45. Carskadon M, Dement WC. Cumulative effects of sleep restriction on daytime sleepiness. Psychophysiology 1981;18:107-13.
46. Baldwin DC Jr, Daugherty SR. Sleep Deprivation and fatigue in residency training: results of a national survey of first- and second-year residents. Sleep 2004;27:217-23.
47. Jewett ME, Dijk DJ, Kronauer RE, Dinges DF. Dose-response relationship between sleep duration and human psychomotor vigilance and subjective alertness. Sleep 1999;22:171-9.
48. Blagrove AU, Blagrove, M, Alexander, C, Home, JA. The effects of chronic sleep reduction on the performance of cognitive tasks sensitive to sleep-deprivation. Appl Cogn Psychol 1995;9:21-40.
49. Dinges D, Maislin G, Van Dongen H. Chronic sleep restriction: relation of sleep structure to daytime sleepiness and performance. Sleep 2001;24:A28.
50. Webb WB, Agnew HW. The effects of a chronic limitation of sleep length. Psychophysiology 1974;11:265-74.
51. Dinges DF, Pack F, Williams K et al. Cumulative sleepiness, mood disturbance, and psychomotor vigilance performance decrements during a week of sleep restricted to 4-5 hours per night. Sleep 1997;20:267-77.
52. Papp KK, Stoller EP, Sage P, et al. The effects of sleep loss and fatigue on resident physicians: a multi- institutional, mixed-method survey. Acad Med 2004;79:394-406.
53. Howard SK, Gaba DM, Rosekind MR, Zarcone VP. The risks and implications of excessive daytime sleepiness in resident physicians. Acad Med 2002;77:1019-25.
54. Bird CM, Papadopoulou K, Ricciardelli P, Rossor MN, Cipolotti L. Test-retest reliability, practice effects and reliable change indices for the recognition memory test. Br J Clin Psychol 2003;42:407-25.
55. Rawlings DB, Crewe NM. Test-retest practice effects and test score changes of the WAIS-R in recovering traumatically brain-injured survivors. Clin Neuropsychol 1992;6:415-30.
56. Connor A, Franzen M, Sharp B. Effects of practice and differential instructions on Stroop performance. Int J Clin Neuropsychol 1988;10:1-4.
57. Klose KJ, Wallace-Barnhill GL, Craythorne NWB. Performance test results for anesthesia residents over a five-day week including on-call duty. Anesthesiology 1985;63:A485.
58. Caldwell JA, Ramspott S. Effects of task duration on sensitivity to sleep deprivation using the multi-attribute task battery. Behav Res Meth Instrum Comp 1998;30:651-60.
59. Van Dongen HP, Baynard MD, Nosker GS, Dinges DF. Repeated exposure to total sleep deprivation: Substantial trait differences in performance impairment among subjects. Sleep 2002;25:121-123.
60. Aeschbach D, Sher L, Postolache TT, Matthews JR, Jackson MA, Wehr TA. A longer biological night in long sleepers than in short sleepers. J Clin Endocrinol Metab 2003;88:26-30.
61. Van Dongen HP, Maislin G, Dinges DF. Dealing with inter-individual differences in the temporal dynamics of fatigue and performance: importance and techniques. Aviat Space Environ Med 2004;75:A147-54.
62. Anderson CM, Maislin G, Van Dongen HP, et al. Effect of chronically reduced nocturnal sleep, with and without daytime naps, on neurobehavioral performance. Sleep 2000;23:A74.
63. Angus RG, Heslegrave RJ. Effects of sleep loss on sustained cognitive performance during a command and control simulation. Behav Res Meth Instrum Comput 1985;17:55-67.
64. Beaumont M, Batejat D, Pierard C, et al. Slow-release caffeine and prolonged (64-h) continuous wakefulness: effects on vigilance and cognitive performance. J Sleep Res 2001;10:265-276.
65. Belenky G, Wesensten NJ, Thorne DR, et al. Patterns of performance degradation and restoration during sleep restriction and subsequent recovery: a sleep dose-response study. J Sleep Res 2003;121-12.
66. Bonnet MH. The effect of varying prophylactic naps on performance, alertness and mood throughout a 52-hour continuous operation. Sleep 1991;14:307-15.
67. Bonnet MH, Gomez S, Wirth O, Arand DL. The use of caffeine vs prophylactic naps in sustained performance. Sleep 1995;18:97-104.
68. Caldwell JA, LeDuc PA. Gender influences on performance, mood and recovery sleep in fatigued aviators. Ergonomics 1998;41:1757-71.
69. Casagrande M, Violani C, Curcio G, Bertini M. Assessing vigilance through a brief pencil and paper letter cancellation task (LCT): Effects of one night of sleep deprivation and of the time of day. Ergonomics 1997;40:613-30.
70. Deaconson TF, O'Hair DP, Levy MF, Lee MBF, Schueneman AL, Condon RE. Sleep-deprivation and resident performance. JAMA 1988;260:1721-7.
71. DeGennaro L, Ferrara M, Curcio G, Bertini M. Visual search performance across 40 h of continuous wakefulness: Measures of speed and accuracy and relation with oculomotor performance. Physiol Behav 2001;74:197-204.
72. Doran SM, Van Dongen HPA, Dinges DF. Sustained attention performance during sleep deprivation: Evidence of state instability. Arch Ital Biol 2001;139:253-67.
73. Dorrian J, Lamond N, Dawson D. The ability to self-monitor performance when fatigued. J Sleep Res 2000;9:137-44.
74. Drummond SPA, Brown GG, Stricker JL, Buxton, RB, Wong, EC, Gillin JC. Sleep deprivation-induced reduction in cortical functional response to serial subtraction. Neuroreport 1999;10:3745-8.
75. Drummond SPA, Gillin JC, Brown GG. Increased cerebral response during a divided attention task following sleep deprivation. J Sleep Res 2001;10:85-92.
76. Eastridge BJ, Hamilton EC, O'Keefe GE, et al. Effect of sleep deprivation on the performance of simulated laparoscopic surgical skill. Am J Surg 2003;186:169-74.
77. Engel W, Seine R, Powell V, D'Alessandri R. Clinical performance of interns after being on-call. South Med J 1987;80:761-763.
78. Fluck E, File SE, Springett J. et al. Does the sedation resulting from sleep deprivation and lorazepam cause similar cognitive deficits? Pharmacol Biochem Behav 1998;59:909-15.
79. Forest G, Godbout R. Effects of sleep deprivation on performance and EEG spectral analysis in young adults. Brain Cogn 2000;43:195-200.
80. Gillberg M, Kecklund G, Axelsson J, Akerstadt T. Counteracting sleepiness with a short nap. J Sleep Res 1994;3:90.
81. Gottlieb DJ, Peterson CA, Parenti CM, Lofgren RP. Effect of a night float system on housestaff neuropsychological function. J Gen Intern Med 1993;8:146-8.
82. Harrison Y, Hoerne JA. One night of sleep loss impairs innovative thinking and flexible decision making. Organ Behav Hum Decis Process 1999;78:128-45.
83. Harrison Y, Home JA. Sleep loss and temporal memory. Q J Exp Psychol A 2000;53:271-9.
84. Hart RP, Buchsbaum DG, Wade JB, Hamer RM, Kwentus JA. Effect of sleep deprivation on first-year residents' response times, memory, and mood. J Med Educ 1987;52:940-2.
85. Hawkins MR, Vichick DA, Silsby HD, Kruzich DJ, Butler R. Sleep deprivation and performance of house officers. J Med Educ 1985;60:530-5.
86. Heuer H, Spijkers W, Kiesswetter E, Schmidtke V. Effects of sleep loss, time of day, and extended mental work on implicit and explicit learning of sequences. J Experiment Psychol Appl 1998;4:139-62.
87. Hockey GRJ, Wastell DG, Sauer J. Effects of sleep deprivation and user interface on complex performance: a multilevel analysis of compensatory control. Hum Fact 1998;40:233-53.
88. Home JA. Sleep loss and "divergent thinking" ability. Sleep 1988;11:528-36.
89. Howard SK, Gaba DM, Smith BE, et al. Simulation study of rested versus sleep-deprived anesthesiologists. Anesthesiology 2003;98:1345-55.
90. Jacques CH, Lynch JC, Samkoff JS. The effects of sleep loss on cognitive performance of resident physicians. J Fam Pract 1990;30:223-9.
91. Jaskowski P, Wlodarczyk D. Effect of sleep deficit, knowledge of results, and stimulus quality on reaction time and response force. Percept Mot Skills 1997;84:563-72.
92. Kannan S, Malhotra SK, Bajaj A, Pershad D, Chari P. Sleep deprivation in anaesthetists: Effect on cognitive functions. Neurol India 1997;45:250-2.
93. Kim DJ, Lee HP, Kim MS, et al. The effect of total sleep deprivation on cognitive functions in normal adult male subjects. Int J Neurosci 2001;109:127-37.
94. Linde L, Edland A, Bergstrom M. Auditory attention and multiattribute decision-making during a 33 h sleep-deprivation period: mean performance and between-subject dispersions. Ergonomics 1999;42:696-713.
95. McCarthy ME, Waters WF. Decreased attentional responsivity during sleep deprivation: Orienting response latency, amplitude, and habituation. Sleep 1997;20:115-23.
96. Mak SK, Spurgeon P. The effects of acute sleep deprivation on performance of medical residents in a regional hospital: prospective study. Hong Kong Med J 2004;10:14-20.
97. Manly T, Lewis GH, Robertson IH, Watson PC, Datta AK. Coffee in the cornflakes: time-of-day as a modulator of executive response control. Neuropsychologia 2002;40:1-6.
98. Matsumoto Y, Mishima K, Satoh K, Shimizu T, Hishikawa Y Physical activity increases the dissociation between subjective sleepiness and objective performance levels during extended wakefulness in human. Neurosci Lett 2002;326:133-6.
99. Neri DF, Wiegmann D, Shappell SA, McCardie A, McKay DL. The effects of tyrosine on cognitive performance during extended wakefulness. Aviat Space Environ Med 1995;66:313-9.
100. Pigeau R, Naitoh P, Buguet A, McCann C. Modafinil, d-amphetamine and placebo during 64 hours of sustained mental work. Effects on mood, fatigue, cognitive performance and body temperature. J Sleep Res 1995;4:212-28.
101. Pilcher JJ, Walters AS. How sleep deprivation affects psychological variables related to college students' cognitive performance. J Am Coll Health 1997;45:121-6.
102. Polzella DJ. Effects of sleep deprivation on short-term recognition memory. J Exp Psychol Hum Learn Mem 1975;104:194-200.
103. Reznick RK, Folse JR. The effects of sleep-deprivation on performance of surgical residents. Am J Surg 1987;154:520-5.
104. Richardson GS, Wyatt JK, Sullivan JP, et al. Objective assessment of sleep and alertness in medical house staff and the impact of protected time for sleep. Sleep 1996;19:718-26.
105. Robbins J, Gottlieb F. Sleep deprivation and cognitive testing in internal medicine house staff. West J Med 1990;12:82-86.
106. Steyvers FJ. The influence of sleep deprivation and knowledge of results on perceptual encoding. Acta Psychol 1987;66:173-87.
107. Stone MD Doyle J, Bosch RJ, Bothe A, Steele G. Effect of resident call status on ABSITE performance. Surgery 2000;128:465-71.
108. Thomas M, Sing H, Belenky G et al. Neural basis of alertness and cognitive performance impairments during sleepiness. I. Effects of 24 h of sleep deprivation on waking human regional brain activity. J Sleep Res 2000;9:335-52.
109. Webb WB. A further analysis of age and sleep deprivation effects. Psychophysiology 1985;22:156-61.
110. Wesensten NJ, Belenky G, Kautz MA, Thorne DR, Reichardt RM, Balkin TJ. Maintaining alertness and performance during sleep deprivation: modafinil versus caffeine. Psychopharmacology 2002;159:238-47.
111. Wimmer F, Hoffmann RF, Bonato RA, Moffitt AR. The effects of sleep-deprivation on divergent thinking and attention processes. J Sleep Res 1992;1:223-30.
112. Wright KP, Badia P, Myers BL, Plenzler SC. Combination of bright light and caffeine as a countermeasure for impaired alertness and performance during extended sleep deprivation. J Sleep Res 1997;6:526-35.
113. Selden CR. Current Bibliographies in Medicine 92-13: Meta-Analysis; January 1980 through December 1992. Bethesda: National Library of Medicine; 1992.
114. Schmidt FL, Hunter J. The validity and utility of selection methods in personnel psychology. Practical and theoretical implications of 85 years of research findings. Psychol Bull 1998;124:262-74.
115. DerSimonian R, Laird N. Metal-analysis in clinical trials. Controlled Clin Trials 1986;7:177-88.
116. Hedges LV, Vevea JL. Fixed and random-effects models in meta-analysis. Psychological Methods, 1998;3:486-77.
117. Hall SM, Brannick MT. Comparison of two random-effects methods of meta-analysis. J Appl Psychol 2002;87:377-89.
118. Morris SB, DeShon RP. Combining effect size estimates in meta-analysis with repeated measures and independent-group designs. Psych Methods 2002;7:105-25.
119. Schmidt FL, Hunter J. Development of a general solution to the problem of validity generalization. J Appl Psychol 1977;62:529-40.
120. FirthCozens J, Greenhalgh J. Doctors' perceptions of the links between stress and lowered clinical care. Soc Sci Med 1997;44:1017-22.
121. Geer R, Jobes D, Gilfor J, Traber K, Dinges D. Reduced psychomotor vigilance in anesthesia residents after 24-hour call. Anesthesiology 1995;83:A1008.
122. Weinger MB. Vigilance, boredom, and sleepiness. J Clin Monit Comput 1999;15:549-52.
123. Weinger MB, Herndon OW, Gaba DM. The effect of electronic record keeping and transesophageal echocardiography on task distribution, workload, and vigilance during cardiac anesthesia. Anesthesiology 1997;87:144-55.
124. Aronson S, Cook R. Vigilance-a main component of clinical quality. Anesthesiology 1998;88:1122-4.
125. Durnford S. Junior hospital doctors: tired and tested. BMJ 1988;297:931-2.
126. Whang EE, Perez A, Ito H, Mello MM, Ashley SW, Zinner MJ. Work hours reform: perceptions and desires of contemporary surgical residents. J Am Coll Surg 2003;197:624-30.
127. Fischer, JE. Continuity of care: a casualty of the 80-hour work week. Acad Med 2004;79:381-3.
128. Underwood W, Boyd AJ, Fletcher KE, Lypson ML. Executive Committee of the American College of Surgeons-Candidate Associate Society. Viewpoints from generation X: a survey of candidate and associate viewpoints on resident duty-hour regulations. J Am Coll Surg 2004;198:989-93.
129. Egger M, Smith GD. Meta-analysis. Bias in location and selection of studies. BMJ 1998;316:61-6.
130. Akerstedt T, Landstrom U. Work place countermeasures of night shift fatigue. Int J Industrial Ergonomics 1998;21:167-78.
131. Dula DJ, Dula NL, Hamrick C, Wood GC. The effect of working serial night shifts on the cognitive functioning of emergency physicians. Ann Emerg Med 2001;38:152-5.
132. Schwartz RJ, Dubrow TJ, Rosso SE. Guidelines for surgical residents. Surgery 1992;127:778-82.
133. Baldwin DC Jr, Daugherty SR, Tsai R, Scotti MJ A national survey of residents' self-reported work hours: thinking beyond specialty. J Acad Med 2003;78:1154-63.
134. ACGME, Resident Survey, Data from February/March 2004, reported in "The ACGME's Approach to Limit Resident Duty Hours 12 Months After Implementation: A Summary of Achievements, page 2 and Exhibit 1." Available at: http://www.acgme.org/acWebsite/dutyHours/dh_dutyhoursummary2003-04.pdf. Accessed August 3, 2005
135. Wu W, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? JAMA 1991;265:2089-94.
136. Fletcher KE, Davis SQ, Underwood W, Mangrulkar RS, McMahon LF Jr, Saint S. Systematic review: effects of resident work hours on patient safety. Ann Intern Med 2004;141:851-7.
137. Howard DL, Silber JH, Jobes DR. Do regulations limiting residents' work hours affect patient mortality? J Gen Intern Med. 2004;19:1-7.
138. Reason JT. Human Error. New York: Cambridge University Press; 1990.
139. Arnstein F. Catalogue of human error. Br J Anaesth 1997;79:645-56.
140. Ihse I, Haglund U. The Swedish 40-hour work week: how does it affect surgical care. Surgery 2003;134:17-8.
141. Petersen LA, Brennan TA, O'Neil AC, Cook EF, Lee TH. Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med 1994;121:866-72.
142. Buysse DJ, Barzansky B, Dinges D, et al. Sleep, fatigue, and medical training: setting an agenda for optimal learning and patient care. Sleep 2003;26:218-25.