Capsule Commentary on Zebrowski et al., So Tired: Predictive Utility
of Baseline Sleep Screening in a Longitudinal Observational Survey
Cohort of First-Year Residents
Lisa C. Martinez, MD FACP
Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA.
J Gen Intern Med 33(6):942
© Society of General Internal Medicine 2018
his study exploring incoming interns’ sleep dysfunction
and how it is impacted by intern year
comes at a time
when there is considerable focus on outcomes in residency
education, specifically, resident wellness and patient safety.
The investigators had previously reported sleep dysfunction in
and with this study investigated whether
these baseline characteristics evolve during internship. Fifty-
four percent of the 281 residents enrolled at study initiation
completed the year-long follow-up. The incoming residents
completed the Pittsburg Sleep Quality Index (PSQI) and the
Epworth Sleepiness Scale (ESS), along with demographic
information. This study was performed when interns’ schedule
was working under the 2011 work-hour restrictions. While the
ACGME has expanded the duty hours to now include 24 h
shifts, many programs have not incorporated this schedule, so
this may still be valid for many programs throughout the
The results of this investigation showed that interns gener-
ally have worsening scores in their ESS and PSQI, specifically
in daytime dysfunction, sleep disturbance, and change in
bedtime and wake time leading to decreased sleep duration,
regardless of their specialty. This offers insight into the possi-
ble effect internship has on sleep quality. This study, however,
did not address the effect that sleep dysfunction has on patient
outcomes or resident wellness. Previous studies have looked at
the effect of the 2011 duty-hour restrictions on medical errors
and depressive symptoms,
showing that despite no effect on
sleep duration, residents still reported concern of making a
serious medical error. In another study, the ESS did not show
any statistically significant effect on patient outcomes.
focus on ways to assess contributors to intern and resident
performance, it is important to assess whether these markers
have real and measurable effects on either patient or resident
For educators, this study promotes consideration of sleep
dysfunction in interns as they progress through their first year;
however, it does not address the real world implications of this
dysfunction. Continued research into the specific markers that
play a role in resident performance and outcomes needs to be
Corresponding Author: Lisa C. Martinez, MD FACP; Schmidt College
of Medicine Florida Atlantic University, Boca Raton, FL, USA
Compliance with ethical standards:
Conflict of interest: Theauthordeclaresthathe/shedoesnothavea
conflict of interest.
1. Zebrowski JP, Pulliam SJ, Denninger JW, Berkowitz LR.SoTired:
Predictive Utility of Baseline Sleep Screening in a Longitudinal Observa-
tional Survey Cohort of First-Year Residents. J Gen Intern Med. https://
2. Pulliam SJ, Weinstein DF, Malhotra A, Macklin EA, Berkowitz LR.
Baseline sleep dysfunction among matriculating interns. J Grad Med Educ.
3. Sen S, Kranzler HR, Didwania AK, et al. Effects of the 2011 Duty Hour
Reforms on Interns and Their Patients: A Prospective longitudinal Cohort
Study. JAMA Intern Med. 2013;173(8):658–662.
4. West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. Association
of resident fatigue and distress with perceived medical errors. JAMA.
Published online February 27, 2018