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Sleep quality and health related problems of shift work among resident physicians: a cross-sectional study
Journal Pre-proof Sleep Quality and Health Related Problems of Shift Work Among Resident Physicians: A Cross-sectional Study Roa'a Jaradat, PharmD, MS, Amro Lahlouh, MD, MS, Mohamed Mustafa, MD PII:
S1389-9457(19)31645-4
DOI:
https://doi.org/10.1016/j.sleep.2019.11.1258
Reference:
SLEEP 4252
To appear in:
Sleep Medicine
Received Date: 29 June 2019 Revised Date:
4 November 2019
Accepted Date: 27 November 2019
Please cite this article as: Jaradat R'a, Lahlouh A, Mustafa M, Sleep Quality and Health Related Problems of Shift Work Among Resident Physicians: A Cross-sectional Study, Sleep Medicine, https:// doi.org/10.1016/j.sleep.2019.11.1258. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier B.V.
Sleep Quality and Health Related Problems of Shift Work Among Resident Physicians: A Cross-sectional Study 1
2
Roa'a Jaradat, PharmD, MS *, Amro Lahlouh, MD, MS , Mohamed Mustafa, MD 1
2
Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan 2 Department of Neurology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan *Corresponding Author Roa'a Waleed Jaradat Faculty of Pharmacy Department of Clinical Pharmacy Jordan University of Science and Technology Irbid, 21110, Jordan Tel: +962795642705 E-mail: [email protected]
Abstract Objectives: Shift work is defined as any irregular work schedule that extends beyond the usual 9 am to 5 pm time frame. Evidence from outside medicine suggests that it may be related to detrimental health outcomes. Our objective from this study is to evaluate sleep quality, health risks, and chronic diseases among post-graduate resident physicians who work on rotating shifts at a large tertiary health care center. Study design: A self-reported questionnaire-based cross-sectional study. Methods: Sleep quality was assessed by Pittsburgh Sleep Quality Index (PSQI) while anxiety and depression were estimated through the four-item patient health questionnaire for anxiety and depression (PHQ-4). Associations between sleep quality and the following: Gender, PHQ-4 stage, year of residency, number of oncalls per month and subjective fatigue; memory impairment; and lack of concentration was investigated. Results: A total of 201 resident physicians participated in the study (60.7% males, median; IQR age: 27 years [26-29]). More than one third of subjects were smokers, 41.3% were overweight, and 16.4% were obese. The majority (90%) reported poor sleep quality, 38.3% mild PHQ-4, 21.4% moderate PHQ-4, and 18.9% severe PHQ-4. Residents having 6 on-calls or more per month had significantly poorer sleep quality (p: 0.03), as well as higher anxiety and depression scores compared to their counterparts. Poor sleep quality was markedly associated with moderate PHQ-4, subjective fatigue, and lack of concentration (p: 0.026, 0.004 and 0.001, respectively). Subjective difficulty with concentration was reported in 86.6% of resident physicians and was significantly higher as the number of on-calls per month is 3 or more. Most residents report subjective fatigue (92.5%) while subjective memory impairment was prevalent in 68.7%. Irritable bowel syndrome was the most prevalent chronic disorder (13%), followed by heartburn or gastrointestinal ulcers and disc prolapse(6% and 3.5%, respectively). Conclusions: Resident physicians have considerable risk for developing severe diseases. Our findings suggest that several modifications should be undertaken to enhance work facilities, limit working hours, and raise awareness among postgraduate resident physicians.
Keywords: Shift work; residents; sleep quality; health; anxiety; on-calls.
1. Introduction: A shift worker is anyone who pursues an irregular work schedule, whether they work on rotating shifts, regular night shifts, or just outside the usual working hours between 9 a.m. and 5 p.m. 1-3. While shift work promotes productivity and sustains 24-hours services, epidemiological studies have proposed that it can be detrimental on different health aspects. These include vascular events, type-2 diabetes, stroke, cancer, and obesity 2-5. Diabetes was more associated with rotating shift than night-shift as reported by one meta-analysis 5. A study in Denmark revealed that the work environment can affect incidence of cardiovascular disease which can be decreased by approximately 20% if stressful working conditions, passive smoking, and shift work were not present 6. Unfortunately, results were often inconsistent or controversial partly owing to variable population, methods, and definitions of outcomes and shift work 3. In addition, all studies were stemmed from industry so they may not be necessarily applicable to health practitioners. Moreover, shift workers are more subjected to sleep loss, difficulties with sleep onset, drowsy driving and accidents, difficulties with concentration, and excessive caffeine intake than day time workers 4,7. These factors collectively can foster the development of obesity thus various metabolic disorders as well as disturbances in neurocognitive performance, mood and behavior 8-10. Thus, substantial errors could arise while residents are making decisions regarding treatment plans or diagnosis. Shift work can affect health primarily through two mechanisms; first, the life style which would be disturbed given the irregular work pattern, and secondly is the pathophysiology. Regarding life style, workers are usually strained due to job and social stress. They might find it harder to establish regular exercise, healthy diet as they may be prone to eat fast food or large infrequent meals, or maintain good quality of life 3,11. Pathophysiology is mainly related to disruption of circadian rhythm and increased oxidative stress 3,12,13. Circadian rhythm is an endogenous process that regulates cell cycle and metabolism on the whole organism level. It drives persistent and periodic biological cycles over the 24-hours to co-ordinate various physiological and behavioral activities 14. Circadian misalignment can affect the development of various metabolic disorders, disease severity, treatment effectiveness, and survival 14,15 . Circadian dysregulations are implicated in sleep and mood disorders, sepsis, obstructive lung diseases, and cancer 15. Furthermore, a cross-sectional study suggests that night shift work suppresses melatonin levels considerably and causes decreased repair of oxidative DNA lesions, suggesting a role for oxidative stress 16. Health risks among physician residents have not been studied before. Partial sleep deprivation, which is most commonly encountered during the residents' oncalls, have more deleterious effect on human functioning than acute or chronic total sleep deprivation 17. One study revealed that a round 87% of physicians experienced acute sleep loss after the end of on-call shifts and that consequently caused a significant reduction in daytime alertness 8. Out of 334 residents, 36.8% exhibited poor sleep quality as defined by Pittsburgh Sleep Quality Index (PSQI) in one study 18. Another study showed that more than one third of the resident doctors suffered from excessive daytime sleepiness which was negatively correlated with the 36-item short-form health survey (SF-36) 19. Few small-scale studies have found associations between resident shift work and poor sleep quality, excessive daytime sleepiness,
and quality of life 18-21. Residents with poor sleep quality has been shown to report higher weight gain, abnormal waist circumference, and higher levels of Ghrelin "the hunger hormone" while those who report excessive daytime sleepiness had less concentrations of Leptin "the satiety hormone" in one study 22. Number of hours of additional work per week was positively correlated with consumption of high-carbs diet among residents while negatively correlated with healthy eating habits 22. These factors collectively can foster the development of obesity thus various metabolic disorders. Shift work is expanding globally and its impact on health has become a focus both for researchers and employers. Our project aims to investigate how shift work can affect sleep quality as well as anxiety and depression. Additionally, we estimated the prevalence of smoking, caffeine intake, obesity and overweigh as long well as chronic health problems among resident physicians in a tertiary care center in Jordan. Several predictors of poor sleep quality were assessed too.
2. Methods: 2.1. Study design This was a cross-sectional, questionnaire-based, observational study conducted between the period from January to March 2019 on post-graduate resident physicians at King Abdullah University Hospital (KAUH), a large teaching hospital at the North of Jordan. The local institutional review board committee at Jordan University of Science and Technology and KAUH approved this project (digital proposal number 812-2018). 2.2. Study sample The study subjects comprised of postgraduate physicians commencing their residency program at KAUH who had spent at least 6 months in residency, and are able to give an informed consent for participation in the survey. Residents with diagnosed sleep disorders were excluded. Residency program in KAUH constitutes 46 years of full time commitment. Frequency of on-call shifts vary between different specialties and across different year levels within the same specialty. Dermatology and pathology have no on-call shifts. The on-call shift starts at 4 p.m. at the end of a normal working day until the next morning (8 a.m.) of another working day, in other words, the on-call physician works continuously for 32 hours. Physicians were recruited from different specialties, including internal medicine, general surgery, pediatrics, neurology, ophthalmology, psychiatry, obstetrics and gynecology, urology, pathology, radiology, orthopedics, family medicine, neurosurgery, and dermatology. 2.3. Sample size calculation and sampling The estimated number of post-graduate physicians who were commencing their residency program at the time of the study was around 400 doctors. Only two studies evaluated the prevalence of poor sleep quality among resident physicians which were 36.8% and 39.3% 18,20. Accordingly, we calculated the minimum required sample size using version 3 of OpenEpi online calculator assuming the following parameters: The hypothesized prevalence (P) = 39.3%, margin of error (d) = 0.05, confidence interval (CI) = 95%, and design effect (DEEF) = 1 for random sampling; and power set for 80% 23. The calculated sample size was 192 physicians. Our sample size was 201. The study participants were recruited randomly considering the eligibility criteria. 2.4. Questionnaire design After investigating throughout literature review, draft questionnaire was developed and reviewed by a panel of experts of specialist physicians. Then, a pilot study was implemented on 20 physicians so that the questionnaire can be modified based on their feedback. The findings from those respondents were not included in data analysis. A self-administrated questionnaire was developed based on literature review, PSQI, and the four-item patient health questionnaire for anxiety and depression (PHQ-4). It consisted of 25 questions which were divided into four sections. The first section
contains ten questions aimed to identify the physician's gender, age, specialty, year of residency, number of on-call shifts per month, smoking status, caffeine intake (including coffee, tea, and caffeinated beverages), weight, height, and presence of any health problems. The second section (eleventh to thirteenth questions) was directed into subjective assessment of the occurrence of memory problems, lack of concentration, and fatigue over the last month. The third part was devoted to assess PSQI score which assesses sleep quality. Finally, the fourth section covers four questions regarding PHQ-4 score which evaluates depression and anxiety. 2.5. Key measures Assessment of sleep quality was done using the Pittsburgh Sleep Quality Index (PSQI), which is a self-rated questionnaire composed of 19 items subsequently classified into 7 components: subjective sleep quality, sleep onset latency (time taken for the transition from full wakefulness to sleep), sleep duration, habitual sleep efficiency (i.e., the percentage of time in bed that one is asleep), sleep disturbances, use of sleeping medication, and daytime dysfunction during the past month. Each component is weighted from 0 to 3, generating one global score ranging from 0 to 21. Poor sleep quality is indicated by total score of 5 or greater, while good sleep quality is indicated by a score of less than 5 24. Depression and Anxiety were assessed using: The four-item patient health questionnaire for anxiety and depression (PHQ-4) which is a valid brief tool for detecting both anxiety and depressive disorders. It's consisted of four questions, each with four possible answers weighted from 0-3. Total score is calculated by summing all the scores together. Then, they are rated as normal (0-2), mild (3-5), moderate (6-8), and severe (9-12). Moreover, a total score ≥3 for the first 2 items suggests anxiety while score of ≥3 for the last 2 questions suggests depression 25. 2.6. Statistical Analysis All variables are categorical data except age. They are described by frequency and proportion (%). Age is described as median±IQR. Univariate and multivariable analysis of the associations between sleep quality (poor, adequate) and each of the following: Gender, PHQ-4 stage, year of residency, number of on-calls per month and subjective fatigue; memory impairment; and lack of concentration was implemented using binary logistic regression. Furthermore, univariate and multivariable ordinal logistic regression were implemented to assess the relationship between same factors and PHQ-4 stage. Statistical significance was set at a two-sided p value of less than 0.05. Statistical analysis was performed using SPSS (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp.).
3. Results: A total of 201 postgraduate residents gave consent for participation in this survey. The majority was at the age between 26 and 29 years old. Males constituted 60.7% of the sample. Table 1 represents general characteristics of study subjects. 3.1. Subjective fatigue, problems with memory, and concentration difficulty More than two thirds of residents reported that they had fatigue (68.7%). Most participants stated that they suffered from frequent episodes of memory loss (92.5%) and 86.6% reported lack of concentration throughout the previous month. Subjective lack of concentration was significantly associated to number of on-calls per month (p: 0.016, χ2 test). Logistic regression confirmed this association for 3 or more oncalls per month (p values: 0.03, 0.005, and 0.004 for 3-4, 5-6, and more than 6 on-calls/month, respectively). 3.2. Prevalence of major risk factors for health problems More than one third of residents were smokers and only 19.9% did not, or occasionally, consume caffeinated drinks. The majority were overweight (41.3%) while 16.4% were obese (Table 1). 3.3. Sleep quality (PSQI) A total of 181 residents (90%) reported having poor sleep quality. Dermatology, psychiatry, and neurosurgery residents tend to have the highest rates of adequate sleep, while all residents of pediatrics, ophthalmology, general surgery, orthopedics, and radiology had poor sleep quality (Fig.1). Poor sleep quality was associated significantly with subjective fatigue and concentration difficulty (p: 0.004 and 0.001, Table 2). Moreover, poor sleep quality increased subjective memory problems but not to a significant degree (p: 0.06). High frequency of oncalls per month (more than 6) was significantly associated with poor sleep quality (p: 0.03). Fifth year of study was associated significantly with poor sleep quality too (p: 0.015). Sleep quality and PHQ-4 was significantly related (p: 0.003, χ2 test) as well as depression and anxiety as sole parameters (p: 0.004 and 0.006, respectively). Univariate regression analysis demonstrated significant associationbetween poor sleep quality with moderate PHQ-4 stage (p: 0.026). However, multivariable regression revealed that there were no significant predictors of PSQI (Table 2). 3.4. Anxiety and depression (PHQ-4) Males reported significantly lower PHQ-4 scores (OR: 0.56, 95% CI:0.33-0.94, p value: 0.03). Subjective memory problems, lack of concentration, and fatigue were all significantly associated with almost all mild to severe PHQ-4 scores as shown in
Table 3. Number of on-calls per month was positively associated with PHQ-4 stages (OR: 1.46, 95% CI: 1.17-1.81, p value: 0.001). Current year of residency is negatively associated with PHQ-4 (OR: 0.74, 95% CI: 0.62-0.89, p value: 0.001). After multivariable regression adjustment, all associations remained significant except for subjective lack of concentration and year of residency (Table 3). Residents of ophthalmology and gynecology reported highest rates of severe PHQ-4 (40%), while all dermatology residents reported normal PHQ-4 (Fig. 2). Psychiatry and ears, nose, and throat (ENT) residents reported normal and mild PHQ-4 scores. 3.5. Prevalence of chronic diseases among resident physicians Irritable bowel syndrome was the most prevalent chronic disorder among resident doctors (13%), followed by heartburns or gastrointestinal ulcers and disc prolapse (6% and 3.5%, respectively) as illustrated in Fig. 3.
4. Discussion: Cases of sudden death are alarmingly increasing among resident physicians in Jordan despite their young age. The Jordan Medical Association recently spoke about the increased numbers of mortality cases among physicians in their working field which reflect the devastating conditions and stressful working environment. Shift work is known to impose several health risks. This was not fully elucidated among postgraduate resident physicians. We conducted this study to estimate sleep quality and prevalence of health risk factors, anxiety, depression, and chronic health issues. We also investigated the relationship between the number of on-calls per month and sleep quality as well as anxiety and depression as measured by PSQI and PHQ-4, respectively. Significant number of residents was smokers (35.3%) and about 60% were overweight or obese. Overweight, obesity, and smoking are known contributors to death as they predispose to coronary heart disease, cerebrovascular disease, and cancer 26,27. Smoking is the leading cause of death, alongside with poor diet and physical inactivity, as it causes 18.1% of deaths annually in the United States 28 . Body mass index of 25 or more is associated with hypertension and hyperlipidemia 29. Overweight and obesity leads to increased mortality rates in nonsmokers 30. This association was greater among younger subjects 31. When combined, obese smokers are at strikingly high risk of mortality compared to nonobese nonsmoker counterparts 32. Considerable efforts must be directed toward lifestyle modification and health related practices of resident doctors since they are more prone to consume fast food during on-calls and usually have no sufficient time for regular exercise. Poor sleep quality was highly prevalent among residents (90%). This warrants considerable attention as poor sleep quality can promote coronary heart disease 33. Residents with high frequent on-calls per month were at higher risk of poor sleep reflecting the significance of limiting working hours and number of on-calls per month. Residents at fifth year level appear to have poorer sleep quality although number of on-calls decreases as the level increase, this might be as a result of the stress accompany graduation and board examinations. Moreover, poor sleep quality was significantly associated with anxiety, depression, and moderate to severe PHQ-4 score. Odds of asthma, cardiac disease, back problems, ulcer, migraine headache and eyesight difficulties were significantly higher as the severity of anxiety and depression increases 34. These disorders were found among our study's participants. Furthermore, these psychiatric disorders can contribute to physical, cognitive, and functional disability and even death 35. Co-occurring anxiety with depression leads to worse outcomes 36. Females reported higher scores of PHQ-4 than males. Number of on-calls per month was also significantly associated with anxiety and depression. Relative to other groups, six or more on-calls per month were significantly associated with more reported mild, moderate, and severe anxiety and depression PHQ-4 score. We assessed subjective responses to fatigue, memory impairment, and difficulty with concentration. At least two thirds of residents stated having the triple. These parameters are essentially integrated in the decision making process regarding diagnosis and therapeutic plans. Major medical errors can be arisen. Subjective fatigue and lack of concentration were significantly associated with poor sleep quality and mild-severe PHQ-4 whereas subjective memory impairment was significantly associated with moderate-severe PHQ-4. Residents who commence 3 or
more on-calls per month had significantly higher rates of reporting lack of concentration supporting the view that limiting working hours is a must. Irritable bowel syndrome was the most common chronic disorder among resident physicians. It's known to coexist with depression and anxiety 37,38. Heartburns or ulcers were prevalent in 6% of our sample. Heartburns was associated with anxiety, depression, occupational stress, and low quality of life in one study 39. Ulcers can be related to stress as well 40. Spinal disc herniation or disc prolapse can develop as a result of extreme frontal bending, hard work, smoking, or BMI of 26 or more as reported in previous studies 41-43. Disc prolapse results in back pain than can extend to lower limbs, and my lead to functional disability 44. To our knowledge, this study is the first to examine the relationship between number of on-calls per month and PSQI and PHQ-4 scores. Furthermore, the prevalence of smoking, caffeine consumption, and body mass index among resident physicians was not assessed before. Although cross-sectional design is best to assess prevalence, observational designs cannot imply causality. We cannot conclude that shift work is the sole contributor to health risk factors or chronic health problems, other genetic and environmental factors might play a role too. Collectively, smoking; overweight; obesity; poor sleep quality; high PHQ-4 scores; fatigue; memory impairment; and lack of concentration can have a major role contributing to morbidity and mortality as well as interfering with the delivery of optimal diagnostic and therapeutic plans which will be adversely reflected in the health of the whole community. The significance of this study should be reflected in the rules of the Ministry of Health by limiting working hours, changing on-calls schedule, increasing medical workforce, improving sleep places to promote better sleep hygiene, offering free times for taking naps, and providing stress-relieving activities. Experimental studies that evaluate the effect of work hour restrictions on physicians’ health, safety, and patient outcomes are mandatory. 5. Acknowledgments This project was supported by the Jordan University of Science and Technology (grant number 20190051). 6. Disclosure Statement Authors declare that they have no financial/personal interest or belief that could affect the results of this study.
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Tables
Table 1: Personal characteristics of study sample (n=201) n (%) Characteristic 27 (26-29) Age (median ± IQR) Gender 122 (60.7) Male 79 (39.3) Female Number of oncalls/month 17 (8.4) No oncalls 5 (2.5) 1-2 22 (10.9) 3-4 60 (29.9) 5-6 97 (48.3) >6 Current year of residency 82 (40.8) 1st 34 (16.9) 2nd 28 (13.9) 3rd 42 (20.9) 4th 14 (7) 5th 1 (0.5) 6th 138 (68.7) Subjective loss of memory 186 (92.5) Subjective fatigue 174 (86.6) Subjective lack of concentration Smoking status 122 (60.7) never smoked 71 (35.3) smoker 8 (4) ex-smoker Caffiene intake 40 (19.9) never or occasionally drink 115 (57.2) 1-2 cups/day 35 (17.4) 3-4 cups/day 11 (5.5) 5 or more cups/day BMI (kg/m2) 3 (1.5) Underweight (<18.5) 82 (40.8) Normal weight (18.5-24.9) 83 (41.3) Overweight (25-29.9) 33 (16.4) Obese (>=30) Sleep quality (PSQI) 20 (9.95) Adequate 181 (90.05) Poor PHQ-4 43 (21.4) Normal 77 (38.3) Mild 43 (21.4) Moderate 38 (18.9) Severe BMI, body mass index; IQR, interquartile range.
Table 2: Univariate and multivariable binary logistic regression of predictors for sleep quality (PSQI). Univariate Multivariable Factor p value Odds 95% CI p Odds 95% CI ratio value ratio Gender ref ref ref Female 0.14 2 (0.8-5.15) Male 0.004* 5.7 (1.720.24 2.78 (0.51Subjective fatigue 18.85) 14.98) 0.06 2.42 (0.95Subjective memory 6.14) problems 0.001* 5.68 (2.060.12 2.8 (0.77Subjective lack of 15.65) 10.14) concentration PHQ-4 0.006* 17.59 (2.310.15 9.92 (0.43Anxiety 134.15) 227.8) 0.004* 20.08 (2.630.09 11.24 (0.69Depression 153.18) 182.9) PHQ-4 ref ref ref Normal 0.26 1.77 (0.660.38 0.57 (0.16Mild 4.78) 2.03) 0.026* 11.12 (1.340.27 0.1 (0.002Moderate 92.15) 5.95) 0.998 NPC 0.1 NPC Severe Number of oncalls/month ref ref ref no oncalls 0.87 1.23 (0.110.49 3.16 (0.121-2 14.42) 81.91) 0.43 1.95 (0.370.46 2.29 (0.253-4 10.2) 20.82) 0.16 2.77 (0.680.38 2.11 (0.45-6 11.26) 11.16) 0.03* 4.67 (1.160.28 2.64 (0.46More than 6
18.78) Year of residency First Second
ref 0.6
15.31)
ref 0.67
ref (0.150.83 0.82 (0.142.98) 4.83) 0.42 0.54 (0.120.85 0.85 (0.14-5) Third 2.43) 0.27 0.48 (0.130.81 0.82 (0.16Fourth 1.76) 4.16) 0.015* 0.16 (0.040.26 0.33 (0.05Fifth 0.71) 2.28) 1 NPC 1 NPC Sixth PHQ-4, The four-item patient health questionnaire for anxiety and depression; PSQI, Pittsburgh Sleep Quality Index; ref, reference group. * p value < 0.05
Table 3: Univariate and multivariable ordinal logistic regression of predictors for PHQ-4. Univariate Multivariable Factor p value Odds 95% CI p value Odds 95% CI ratio ratio 0.03* 0.56 (0.330.02* 0.52 (0.29Gender 0.94) 0.89) <0.001* 11.66 (3.520.004* 6.64 (1.82Subjective fatigue 38.67) 24.22) 0.001* 3.67 (1.710.52 1.33 (0.56Subjective lack of 7.98) 3.14) concentration <0.001* 4.49 (2.52-8) <0.001* 3.61 (1.94Subjective 6.75) memory problems 0.001* 1.46 (1.170.009* 1.42 (1.09Number of on1.81) 1.84) calls/ month 0.001* 0.74 (0.620.26 0.89 (0.72Year of residency 0.89) 1.09) NA, no available data (number of subjects=0); NPC, not possible to calculate; PHQ-4, The four-item patient health questionnaire for anxiety and depression; ref, reference group. * p value < 0.05
Figures
Family medicine (14) Emergency medicine (10) Anesthesia (8) Radiology (7) Orthopedics (9) Pathology (7) Neurology (15) Dermatology (3) Psychiatry (6) Neurosurgery (3) Urology (8) Ophthalmology (10) ENT (7) Obs and Gyne (10) Pediatrics (9) General surgery (35) Internal medicine (40) 100%
90%
80%
70%
60%
50%
40%
Good sleep quality
30%
20%
10%
0%
Poor sleep quality
Fig. 1. Distribution of quality of sleep across different specialties (frequency).
ENT, ears nose throat; obs and gyne, obstetrics and gynaecology.
100 90 80 70 60 50 40 30 20 10 0
Normal PHQ-4
Mild PHQ-4
Moderate PHQ-4
Severe PHQ-4
Fig. 2. Distribution of PHQ-4 stages across different specialties (frequency). ENT, ears nose throat; obs and gyne, obstetrics and gynaecology.
Anxiety disorder Cardiac disease Depression Asthma Hypertension Diabetes Migraine Disc prolapse Heart burn or GI ulcers IBS 14
12
10
8
6
4
2
0
Fig. 3. Prevalence of chronic diseases among post-graduate medical residents (percentage). IBS, irritable bowel disease.
• • • • •
More than one third (35.3%) of resident physicians were smokers The majority (90%) of residents reported poor sleep quality Poor sleep quality was markedly associated with moderate PHQ-4, subjective fatigue, and lack of concentration Subjective difficulty with concentration was reported in 86.6% of resident physicians and was significantly higher when the number of on-calls per month is 3 or more Irritable bowel syndrome was the most prevalent chronic disorder (13%), followed by heartburn or gastrointestinal ulcers and disc prolapse
S1389-9457(19)31645-4
DOI:
https://doi.org/10.1016/j.sleep.2019.11.1258
Reference:
SLEEP 4252
To appear in:
Sleep Medicine
Received Date: 29 June 2019 Revised Date:
4 November 2019
Accepted Date: 27 November 2019
Please cite this article as: Jaradat R'a, Lahlouh A, Mustafa M, Sleep Quality and Health Related Problems of Shift Work Among Resident Physicians: A Cross-sectional Study, Sleep Medicine, https:// doi.org/10.1016/j.sleep.2019.11.1258. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier B.V.
Sleep Quality and Health Related Problems of Shift Work Among Resident Physicians: A Cross-sectional Study 1
2
Roa'a Jaradat, PharmD, MS *, Amro Lahlouh, MD, MS , Mohamed Mustafa, MD 1
2
Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan 2 Department of Neurology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan *Corresponding Author Roa'a Waleed Jaradat Faculty of Pharmacy Department of Clinical Pharmacy Jordan University of Science and Technology Irbid, 21110, Jordan Tel: +962795642705 E-mail: [email protected]
Abstract Objectives: Shift work is defined as any irregular work schedule that extends beyond the usual 9 am to 5 pm time frame. Evidence from outside medicine suggests that it may be related to detrimental health outcomes. Our objective from this study is to evaluate sleep quality, health risks, and chronic diseases among post-graduate resident physicians who work on rotating shifts at a large tertiary health care center. Study design: A self-reported questionnaire-based cross-sectional study. Methods: Sleep quality was assessed by Pittsburgh Sleep Quality Index (PSQI) while anxiety and depression were estimated through the four-item patient health questionnaire for anxiety and depression (PHQ-4). Associations between sleep quality and the following: Gender, PHQ-4 stage, year of residency, number of oncalls per month and subjective fatigue; memory impairment; and lack of concentration was investigated. Results: A total of 201 resident physicians participated in the study (60.7% males, median; IQR age: 27 years [26-29]). More than one third of subjects were smokers, 41.3% were overweight, and 16.4% were obese. The majority (90%) reported poor sleep quality, 38.3% mild PHQ-4, 21.4% moderate PHQ-4, and 18.9% severe PHQ-4. Residents having 6 on-calls or more per month had significantly poorer sleep quality (p: 0.03), as well as higher anxiety and depression scores compared to their counterparts. Poor sleep quality was markedly associated with moderate PHQ-4, subjective fatigue, and lack of concentration (p: 0.026, 0.004 and 0.001, respectively). Subjective difficulty with concentration was reported in 86.6% of resident physicians and was significantly higher as the number of on-calls per month is 3 or more. Most residents report subjective fatigue (92.5%) while subjective memory impairment was prevalent in 68.7%. Irritable bowel syndrome was the most prevalent chronic disorder (13%), followed by heartburn or gastrointestinal ulcers and disc prolapse(6% and 3.5%, respectively). Conclusions: Resident physicians have considerable risk for developing severe diseases. Our findings suggest that several modifications should be undertaken to enhance work facilities, limit working hours, and raise awareness among postgraduate resident physicians.
Keywords: Shift work; residents; sleep quality; health; anxiety; on-calls.
1. Introduction: A shift worker is anyone who pursues an irregular work schedule, whether they work on rotating shifts, regular night shifts, or just outside the usual working hours between 9 a.m. and 5 p.m. 1-3. While shift work promotes productivity and sustains 24-hours services, epidemiological studies have proposed that it can be detrimental on different health aspects. These include vascular events, type-2 diabetes, stroke, cancer, and obesity 2-5. Diabetes was more associated with rotating shift than night-shift as reported by one meta-analysis 5. A study in Denmark revealed that the work environment can affect incidence of cardiovascular disease which can be decreased by approximately 20% if stressful working conditions, passive smoking, and shift work were not present 6. Unfortunately, results were often inconsistent or controversial partly owing to variable population, methods, and definitions of outcomes and shift work 3. In addition, all studies were stemmed from industry so they may not be necessarily applicable to health practitioners. Moreover, shift workers are more subjected to sleep loss, difficulties with sleep onset, drowsy driving and accidents, difficulties with concentration, and excessive caffeine intake than day time workers 4,7. These factors collectively can foster the development of obesity thus various metabolic disorders as well as disturbances in neurocognitive performance, mood and behavior 8-10. Thus, substantial errors could arise while residents are making decisions regarding treatment plans or diagnosis. Shift work can affect health primarily through two mechanisms; first, the life style which would be disturbed given the irregular work pattern, and secondly is the pathophysiology. Regarding life style, workers are usually strained due to job and social stress. They might find it harder to establish regular exercise, healthy diet as they may be prone to eat fast food or large infrequent meals, or maintain good quality of life 3,11. Pathophysiology is mainly related to disruption of circadian rhythm and increased oxidative stress 3,12,13. Circadian rhythm is an endogenous process that regulates cell cycle and metabolism on the whole organism level. It drives persistent and periodic biological cycles over the 24-hours to co-ordinate various physiological and behavioral activities 14. Circadian misalignment can affect the development of various metabolic disorders, disease severity, treatment effectiveness, and survival 14,15 . Circadian dysregulations are implicated in sleep and mood disorders, sepsis, obstructive lung diseases, and cancer 15. Furthermore, a cross-sectional study suggests that night shift work suppresses melatonin levels considerably and causes decreased repair of oxidative DNA lesions, suggesting a role for oxidative stress 16. Health risks among physician residents have not been studied before. Partial sleep deprivation, which is most commonly encountered during the residents' oncalls, have more deleterious effect on human functioning than acute or chronic total sleep deprivation 17. One study revealed that a round 87% of physicians experienced acute sleep loss after the end of on-call shifts and that consequently caused a significant reduction in daytime alertness 8. Out of 334 residents, 36.8% exhibited poor sleep quality as defined by Pittsburgh Sleep Quality Index (PSQI) in one study 18. Another study showed that more than one third of the resident doctors suffered from excessive daytime sleepiness which was negatively correlated with the 36-item short-form health survey (SF-36) 19. Few small-scale studies have found associations between resident shift work and poor sleep quality, excessive daytime sleepiness,
and quality of life 18-21. Residents with poor sleep quality has been shown to report higher weight gain, abnormal waist circumference, and higher levels of Ghrelin "the hunger hormone" while those who report excessive daytime sleepiness had less concentrations of Leptin "the satiety hormone" in one study 22. Number of hours of additional work per week was positively correlated with consumption of high-carbs diet among residents while negatively correlated with healthy eating habits 22. These factors collectively can foster the development of obesity thus various metabolic disorders. Shift work is expanding globally and its impact on health has become a focus both for researchers and employers. Our project aims to investigate how shift work can affect sleep quality as well as anxiety and depression. Additionally, we estimated the prevalence of smoking, caffeine intake, obesity and overweigh as long well as chronic health problems among resident physicians in a tertiary care center in Jordan. Several predictors of poor sleep quality were assessed too.
2. Methods: 2.1. Study design This was a cross-sectional, questionnaire-based, observational study conducted between the period from January to March 2019 on post-graduate resident physicians at King Abdullah University Hospital (KAUH), a large teaching hospital at the North of Jordan. The local institutional review board committee at Jordan University of Science and Technology and KAUH approved this project (digital proposal number 812-2018). 2.2. Study sample The study subjects comprised of postgraduate physicians commencing their residency program at KAUH who had spent at least 6 months in residency, and are able to give an informed consent for participation in the survey. Residents with diagnosed sleep disorders were excluded. Residency program in KAUH constitutes 46 years of full time commitment. Frequency of on-call shifts vary between different specialties and across different year levels within the same specialty. Dermatology and pathology have no on-call shifts. The on-call shift starts at 4 p.m. at the end of a normal working day until the next morning (8 a.m.) of another working day, in other words, the on-call physician works continuously for 32 hours. Physicians were recruited from different specialties, including internal medicine, general surgery, pediatrics, neurology, ophthalmology, psychiatry, obstetrics and gynecology, urology, pathology, radiology, orthopedics, family medicine, neurosurgery, and dermatology. 2.3. Sample size calculation and sampling The estimated number of post-graduate physicians who were commencing their residency program at the time of the study was around 400 doctors. Only two studies evaluated the prevalence of poor sleep quality among resident physicians which were 36.8% and 39.3% 18,20. Accordingly, we calculated the minimum required sample size using version 3 of OpenEpi online calculator assuming the following parameters: The hypothesized prevalence (P) = 39.3%, margin of error (d) = 0.05, confidence interval (CI) = 95%, and design effect (DEEF) = 1 for random sampling; and power set for 80% 23. The calculated sample size was 192 physicians. Our sample size was 201. The study participants were recruited randomly considering the eligibility criteria. 2.4. Questionnaire design After investigating throughout literature review, draft questionnaire was developed and reviewed by a panel of experts of specialist physicians. Then, a pilot study was implemented on 20 physicians so that the questionnaire can be modified based on their feedback. The findings from those respondents were not included in data analysis. A self-administrated questionnaire was developed based on literature review, PSQI, and the four-item patient health questionnaire for anxiety and depression (PHQ-4). It consisted of 25 questions which were divided into four sections. The first section
contains ten questions aimed to identify the physician's gender, age, specialty, year of residency, number of on-call shifts per month, smoking status, caffeine intake (including coffee, tea, and caffeinated beverages), weight, height, and presence of any health problems. The second section (eleventh to thirteenth questions) was directed into subjective assessment of the occurrence of memory problems, lack of concentration, and fatigue over the last month. The third part was devoted to assess PSQI score which assesses sleep quality. Finally, the fourth section covers four questions regarding PHQ-4 score which evaluates depression and anxiety. 2.5. Key measures Assessment of sleep quality was done using the Pittsburgh Sleep Quality Index (PSQI), which is a self-rated questionnaire composed of 19 items subsequently classified into 7 components: subjective sleep quality, sleep onset latency (time taken for the transition from full wakefulness to sleep), sleep duration, habitual sleep efficiency (i.e., the percentage of time in bed that one is asleep), sleep disturbances, use of sleeping medication, and daytime dysfunction during the past month. Each component is weighted from 0 to 3, generating one global score ranging from 0 to 21. Poor sleep quality is indicated by total score of 5 or greater, while good sleep quality is indicated by a score of less than 5 24. Depression and Anxiety were assessed using: The four-item patient health questionnaire for anxiety and depression (PHQ-4) which is a valid brief tool for detecting both anxiety and depressive disorders. It's consisted of four questions, each with four possible answers weighted from 0-3. Total score is calculated by summing all the scores together. Then, they are rated as normal (0-2), mild (3-5), moderate (6-8), and severe (9-12). Moreover, a total score ≥3 for the first 2 items suggests anxiety while score of ≥3 for the last 2 questions suggests depression 25. 2.6. Statistical Analysis All variables are categorical data except age. They are described by frequency and proportion (%). Age is described as median±IQR. Univariate and multivariable analysis of the associations between sleep quality (poor, adequate) and each of the following: Gender, PHQ-4 stage, year of residency, number of on-calls per month and subjective fatigue; memory impairment; and lack of concentration was implemented using binary logistic regression. Furthermore, univariate and multivariable ordinal logistic regression were implemented to assess the relationship between same factors and PHQ-4 stage. Statistical significance was set at a two-sided p value of less than 0.05. Statistical analysis was performed using SPSS (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp.).
3. Results: A total of 201 postgraduate residents gave consent for participation in this survey. The majority was at the age between 26 and 29 years old. Males constituted 60.7% of the sample. Table 1 represents general characteristics of study subjects. 3.1. Subjective fatigue, problems with memory, and concentration difficulty More than two thirds of residents reported that they had fatigue (68.7%). Most participants stated that they suffered from frequent episodes of memory loss (92.5%) and 86.6% reported lack of concentration throughout the previous month. Subjective lack of concentration was significantly associated to number of on-calls per month (p: 0.016, χ2 test). Logistic regression confirmed this association for 3 or more oncalls per month (p values: 0.03, 0.005, and 0.004 for 3-4, 5-6, and more than 6 on-calls/month, respectively). 3.2. Prevalence of major risk factors for health problems More than one third of residents were smokers and only 19.9% did not, or occasionally, consume caffeinated drinks. The majority were overweight (41.3%) while 16.4% were obese (Table 1). 3.3. Sleep quality (PSQI) A total of 181 residents (90%) reported having poor sleep quality. Dermatology, psychiatry, and neurosurgery residents tend to have the highest rates of adequate sleep, while all residents of pediatrics, ophthalmology, general surgery, orthopedics, and radiology had poor sleep quality (Fig.1). Poor sleep quality was associated significantly with subjective fatigue and concentration difficulty (p: 0.004 and 0.001, Table 2). Moreover, poor sleep quality increased subjective memory problems but not to a significant degree (p: 0.06). High frequency of oncalls per month (more than 6) was significantly associated with poor sleep quality (p: 0.03). Fifth year of study was associated significantly with poor sleep quality too (p: 0.015). Sleep quality and PHQ-4 was significantly related (p: 0.003, χ2 test) as well as depression and anxiety as sole parameters (p: 0.004 and 0.006, respectively). Univariate regression analysis demonstrated significant associationbetween poor sleep quality with moderate PHQ-4 stage (p: 0.026). However, multivariable regression revealed that there were no significant predictors of PSQI (Table 2). 3.4. Anxiety and depression (PHQ-4) Males reported significantly lower PHQ-4 scores (OR: 0.56, 95% CI:0.33-0.94, p value: 0.03). Subjective memory problems, lack of concentration, and fatigue were all significantly associated with almost all mild to severe PHQ-4 scores as shown in
Table 3. Number of on-calls per month was positively associated with PHQ-4 stages (OR: 1.46, 95% CI: 1.17-1.81, p value: 0.001). Current year of residency is negatively associated with PHQ-4 (OR: 0.74, 95% CI: 0.62-0.89, p value: 0.001). After multivariable regression adjustment, all associations remained significant except for subjective lack of concentration and year of residency (Table 3). Residents of ophthalmology and gynecology reported highest rates of severe PHQ-4 (40%), while all dermatology residents reported normal PHQ-4 (Fig. 2). Psychiatry and ears, nose, and throat (ENT) residents reported normal and mild PHQ-4 scores. 3.5. Prevalence of chronic diseases among resident physicians Irritable bowel syndrome was the most prevalent chronic disorder among resident doctors (13%), followed by heartburns or gastrointestinal ulcers and disc prolapse (6% and 3.5%, respectively) as illustrated in Fig. 3.
4. Discussion: Cases of sudden death are alarmingly increasing among resident physicians in Jordan despite their young age. The Jordan Medical Association recently spoke about the increased numbers of mortality cases among physicians in their working field which reflect the devastating conditions and stressful working environment. Shift work is known to impose several health risks. This was not fully elucidated among postgraduate resident physicians. We conducted this study to estimate sleep quality and prevalence of health risk factors, anxiety, depression, and chronic health issues. We also investigated the relationship between the number of on-calls per month and sleep quality as well as anxiety and depression as measured by PSQI and PHQ-4, respectively. Significant number of residents was smokers (35.3%) and about 60% were overweight or obese. Overweight, obesity, and smoking are known contributors to death as they predispose to coronary heart disease, cerebrovascular disease, and cancer 26,27. Smoking is the leading cause of death, alongside with poor diet and physical inactivity, as it causes 18.1% of deaths annually in the United States 28 . Body mass index of 25 or more is associated with hypertension and hyperlipidemia 29. Overweight and obesity leads to increased mortality rates in nonsmokers 30. This association was greater among younger subjects 31. When combined, obese smokers are at strikingly high risk of mortality compared to nonobese nonsmoker counterparts 32. Considerable efforts must be directed toward lifestyle modification and health related practices of resident doctors since they are more prone to consume fast food during on-calls and usually have no sufficient time for regular exercise. Poor sleep quality was highly prevalent among residents (90%). This warrants considerable attention as poor sleep quality can promote coronary heart disease 33. Residents with high frequent on-calls per month were at higher risk of poor sleep reflecting the significance of limiting working hours and number of on-calls per month. Residents at fifth year level appear to have poorer sleep quality although number of on-calls decreases as the level increase, this might be as a result of the stress accompany graduation and board examinations. Moreover, poor sleep quality was significantly associated with anxiety, depression, and moderate to severe PHQ-4 score. Odds of asthma, cardiac disease, back problems, ulcer, migraine headache and eyesight difficulties were significantly higher as the severity of anxiety and depression increases 34. These disorders were found among our study's participants. Furthermore, these psychiatric disorders can contribute to physical, cognitive, and functional disability and even death 35. Co-occurring anxiety with depression leads to worse outcomes 36. Females reported higher scores of PHQ-4 than males. Number of on-calls per month was also significantly associated with anxiety and depression. Relative to other groups, six or more on-calls per month were significantly associated with more reported mild, moderate, and severe anxiety and depression PHQ-4 score. We assessed subjective responses to fatigue, memory impairment, and difficulty with concentration. At least two thirds of residents stated having the triple. These parameters are essentially integrated in the decision making process regarding diagnosis and therapeutic plans. Major medical errors can be arisen. Subjective fatigue and lack of concentration were significantly associated with poor sleep quality and mild-severe PHQ-4 whereas subjective memory impairment was significantly associated with moderate-severe PHQ-4. Residents who commence 3 or
more on-calls per month had significantly higher rates of reporting lack of concentration supporting the view that limiting working hours is a must. Irritable bowel syndrome was the most common chronic disorder among resident physicians. It's known to coexist with depression and anxiety 37,38. Heartburns or ulcers were prevalent in 6% of our sample. Heartburns was associated with anxiety, depression, occupational stress, and low quality of life in one study 39. Ulcers can be related to stress as well 40. Spinal disc herniation or disc prolapse can develop as a result of extreme frontal bending, hard work, smoking, or BMI of 26 or more as reported in previous studies 41-43. Disc prolapse results in back pain than can extend to lower limbs, and my lead to functional disability 44. To our knowledge, this study is the first to examine the relationship between number of on-calls per month and PSQI and PHQ-4 scores. Furthermore, the prevalence of smoking, caffeine consumption, and body mass index among resident physicians was not assessed before. Although cross-sectional design is best to assess prevalence, observational designs cannot imply causality. We cannot conclude that shift work is the sole contributor to health risk factors or chronic health problems, other genetic and environmental factors might play a role too. Collectively, smoking; overweight; obesity; poor sleep quality; high PHQ-4 scores; fatigue; memory impairment; and lack of concentration can have a major role contributing to morbidity and mortality as well as interfering with the delivery of optimal diagnostic and therapeutic plans which will be adversely reflected in the health of the whole community. The significance of this study should be reflected in the rules of the Ministry of Health by limiting working hours, changing on-calls schedule, increasing medical workforce, improving sleep places to promote better sleep hygiene, offering free times for taking naps, and providing stress-relieving activities. Experimental studies that evaluate the effect of work hour restrictions on physicians’ health, safety, and patient outcomes are mandatory. 5. Acknowledgments This project was supported by the Jordan University of Science and Technology (grant number 20190051). 6. Disclosure Statement Authors declare that they have no financial/personal interest or belief that could affect the results of this study.
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Tables
Table 1: Personal characteristics of study sample (n=201) n (%) Characteristic 27 (26-29) Age (median ± IQR) Gender 122 (60.7) Male 79 (39.3) Female Number of oncalls/month 17 (8.4) No oncalls 5 (2.5) 1-2 22 (10.9) 3-4 60 (29.9) 5-6 97 (48.3) >6 Current year of residency 82 (40.8) 1st 34 (16.9) 2nd 28 (13.9) 3rd 42 (20.9) 4th 14 (7) 5th 1 (0.5) 6th 138 (68.7) Subjective loss of memory 186 (92.5) Subjective fatigue 174 (86.6) Subjective lack of concentration Smoking status 122 (60.7) never smoked 71 (35.3) smoker 8 (4) ex-smoker Caffiene intake 40 (19.9) never or occasionally drink 115 (57.2) 1-2 cups/day 35 (17.4) 3-4 cups/day 11 (5.5) 5 or more cups/day BMI (kg/m2) 3 (1.5) Underweight (<18.5) 82 (40.8) Normal weight (18.5-24.9) 83 (41.3) Overweight (25-29.9) 33 (16.4) Obese (>=30) Sleep quality (PSQI) 20 (9.95) Adequate 181 (90.05) Poor PHQ-4 43 (21.4) Normal 77 (38.3) Mild 43 (21.4) Moderate 38 (18.9) Severe BMI, body mass index; IQR, interquartile range.
Table 2: Univariate and multivariable binary logistic regression of predictors for sleep quality (PSQI). Univariate Multivariable Factor p value Odds 95% CI p Odds 95% CI ratio value ratio Gender ref ref ref Female 0.14 2 (0.8-5.15) Male 0.004* 5.7 (1.720.24 2.78 (0.51Subjective fatigue 18.85) 14.98) 0.06 2.42 (0.95Subjective memory 6.14) problems 0.001* 5.68 (2.060.12 2.8 (0.77Subjective lack of 15.65) 10.14) concentration PHQ-4 0.006* 17.59 (2.310.15 9.92 (0.43Anxiety 134.15) 227.8) 0.004* 20.08 (2.630.09 11.24 (0.69Depression 153.18) 182.9) PHQ-4 ref ref ref Normal 0.26 1.77 (0.660.38 0.57 (0.16Mild 4.78) 2.03) 0.026* 11.12 (1.340.27 0.1 (0.002Moderate 92.15) 5.95) 0.998 NPC 0.1 NPC Severe Number of oncalls/month ref ref ref no oncalls 0.87 1.23 (0.110.49 3.16 (0.121-2 14.42) 81.91) 0.43 1.95 (0.370.46 2.29 (0.253-4 10.2) 20.82) 0.16 2.77 (0.680.38 2.11 (0.45-6 11.26) 11.16) 0.03* 4.67 (1.160.28 2.64 (0.46More than 6
18.78) Year of residency First Second
ref 0.6
15.31)
ref 0.67
ref (0.150.83 0.82 (0.142.98) 4.83) 0.42 0.54 (0.120.85 0.85 (0.14-5) Third 2.43) 0.27 0.48 (0.130.81 0.82 (0.16Fourth 1.76) 4.16) 0.015* 0.16 (0.040.26 0.33 (0.05Fifth 0.71) 2.28) 1 NPC 1 NPC Sixth PHQ-4, The four-item patient health questionnaire for anxiety and depression; PSQI, Pittsburgh Sleep Quality Index; ref, reference group. * p value < 0.05
Table 3: Univariate and multivariable ordinal logistic regression of predictors for PHQ-4. Univariate Multivariable Factor p value Odds 95% CI p value Odds 95% CI ratio ratio 0.03* 0.56 (0.330.02* 0.52 (0.29Gender 0.94) 0.89) <0.001* 11.66 (3.520.004* 6.64 (1.82Subjective fatigue 38.67) 24.22) 0.001* 3.67 (1.710.52 1.33 (0.56Subjective lack of 7.98) 3.14) concentration <0.001* 4.49 (2.52-8) <0.001* 3.61 (1.94Subjective 6.75) memory problems 0.001* 1.46 (1.170.009* 1.42 (1.09Number of on1.81) 1.84) calls/ month 0.001* 0.74 (0.620.26 0.89 (0.72Year of residency 0.89) 1.09) NA, no available data (number of subjects=0); NPC, not possible to calculate; PHQ-4, The four-item patient health questionnaire for anxiety and depression; ref, reference group. * p value < 0.05
Figures
Family medicine (14) Emergency medicine (10) Anesthesia (8) Radiology (7) Orthopedics (9) Pathology (7) Neurology (15) Dermatology (3) Psychiatry (6) Neurosurgery (3) Urology (8) Ophthalmology (10) ENT (7) Obs and Gyne (10) Pediatrics (9) General surgery (35) Internal medicine (40) 100%
90%
80%
70%
60%
50%
40%
Good sleep quality
30%
20%
10%
0%
Poor sleep quality
Fig. 1. Distribution of quality of sleep across different specialties (frequency).
ENT, ears nose throat; obs and gyne, obstetrics and gynaecology.
100 90 80 70 60 50 40 30 20 10 0
Normal PHQ-4
Mild PHQ-4
Moderate PHQ-4
Severe PHQ-4
Fig. 2. Distribution of PHQ-4 stages across different specialties (frequency). ENT, ears nose throat; obs and gyne, obstetrics and gynaecology.
Anxiety disorder Cardiac disease Depression Asthma Hypertension Diabetes Migraine Disc prolapse Heart burn or GI ulcers IBS 14
12
10
8
6
4
2
0
Fig. 3. Prevalence of chronic diseases among post-graduate medical residents (percentage). IBS, irritable bowel disease.
• • • • •
More than one third (35.3%) of resident physicians were smokers The majority (90%) of residents reported poor sleep quality Poor sleep quality was markedly associated with moderate PHQ-4, subjective fatigue, and lack of concentration Subjective difficulty with concentration was reported in 86.6% of resident physicians and was significantly higher when the number of on-calls per month is 3 or more Irritable bowel syndrome was the most prevalent chronic disorder (13%), followed by heartburn or gastrointestinal ulcers and disc prolapse