Sleep Reform for Physicians: Part 2

Once I’d sent an email advocating for myself in the wake of extreme sleep deprivation on home call, I began having conversations with other fellows and early-career faculty members who trained at our institution. Did they have the same experience of severe sleep deprivation on home call that I experienced?

The answer was a resounding yes. One of my continuity clinic faculty who completed fellowship a few years prior said, “The call schedule here has always been particularly malignant, although I get the sense that the program leadership isn’t fully aware of how brutal home call really is.”

If the call burden had been a longstanding struggle for fellows, why hadn’t anyone tried to change it? It was frustrating to me that this problem persisted year after year. Even though I knew my actions might be futile, I knew I had to try.

I was unsure what would move the needle, but I was working in a data-driven field and surrounded by physicians who made practice changes for patients when the data was strong. So,  I started with data. After discussing the problem with our chief fellow and devising a strategy, over the ensuing months, I collected the following three pieces of data. In conjunction with the chief fellow, we presented it to our program leadership:

1. A log of every page and call I received during one week of home call. 

If the program leadership team wasn’t aware of the volume of call, then I figured the best way to show them was with data. 

During one week on call, from Friday at 5 p.m. until the following Friday at 7 a.m., I kept a notebook and pen with me. Each time I received a message from a nurse, a call from a patient, or a consult from the ER or hospital, I jotted down the nature of the page. It included every request for electrolytes, each communication from a nurse about a patient’s clinical status in the BMT, each accidental page when a service meant to call another team, and even “Thank you” text pages in the middle of the night when a clinician responded to a message from hours prior.

I then compiled this into an electronic document before sending it to program leadership. 

2. A one-page data sheet detailing the known harms of sleep deprivation. 

I conducted a literature search, sifting through countless articles and books about sleep loss. The data were new to me and completely striking, given the pervasiveness of sleep deprivation in my medical training. While I was aware of some of the information about cognitive function, medical errors, and patient safety, I didn’t know that sleep loss increased the risk for needle sticks and car accidents, or its toll on the mental and physical health of clinicians.

(This one-page sheet will be provided in Part 3 of this series.)

3. Data from a poll of other hematology oncology fellowship programs.

The question I kept coming back to was, “Is this volume of home call a normal experience in a hematology oncology fellowship? Are other programs doing it better?”

While I had previously interviewed at many programs across the Northeast and Midwest when applying to fellowship, and had asked some questions about their call schedules, I had little understanding of what the reality was for fellows across the country. 

I decided to conduct a poll. Some of my friends from residency were now hematology oncology fellows at other programs, and I had a small reach on social media. After a few months of reaching out through contacts and connecting with others, I was able to get a sample from 10 hematology-oncology fellows nationwide: Were fellows elsewhere covering BMT overnight as the first call? What did volumes and frequency look like? 

A clear pattern emerged. Many programs used nocturnist teams to cover BMT services overnight. While some programs had greater call burdens than others in terms of hospital and ER consults and patient calls, the volume overnight was much less than at our program. When presenting this data to our program leadership, we included a statement that reducing the call burden could strengthen our fellowship and even serve as a recruitment lever for incoming classes. 

When the program leadership received this data, they were surprised by the volume of call and the degree of exhaustion. After internal discussion and deliberation, they agreed that change was needed. Based on the poll of other fellowship programs, they agreed that the most impactful solution would be to shift primary BMT coverage overnight away from the fellows to a hospitalist model.

Over the ensuing months, the program leadership brought these requests to the hospital administrative team and began discussing staffing and budget. 

I soon graduated from the fellowship and took a role at the same institution; my previous fellowship program leaders became my colleagues. I also continued to teach and interact with fellows. The program leadership and chief fellow continued to champion this cause over time. While the funding was complicated and took time, the hospitalist service eventually took over primary coverage of the BMT, with in-house night coverage (primarily staffed by APPs).

Even with program leadership support to improve medical training, it takes time (often years), additional staffing, and money to implement these changes. We introduced this data, along with proposed solutions, in the spring of 2022, and it wasn’t until August of 2024 that these changes took effect. 

Now, fellows report that overnight calls have dropped dramatically, from 20+ pages a night to 1–2 on lighter nights and sometimes up to 5-7 on busy nights. It hasn’t eliminated sleep disruption, but it has substantially reduced the most severe sleep deprivation while maintaining a high level of education and training for fellows. 

I share this blueprint today with the hopes of empowering trainees who wish to advocate for sleep reform at their own programs and institutions.