Night Float and the Struggle for Wellness in Medical Education

Dr James Agapoff and Dr Anandam Hilde discuss a quality improvement project to tackle the problem of sleep deprivation in trainees.

The resident’s weary eyes said it all. He was finishing a 24-hour shift of a 30-day Q3 rotation (where a 24 to 30-hour shift starts every 3rd day).

As a medical student waiting for morning sign-out, I remember thinking, ‘He doesn’t look very healthy.’

The attending arrived and the resident gave his sign-out to my team, indicating he still had a few notes to finish before heading home. The resident shuffled out of the room, and I turned to my team and said, “He doesn’t look too good.”

My resident smiled. “He’s just sleep-deprived and grumpy. There is no time to exercise or eat healthy on the Q3.”

I shook my head. “I think we need to do a better job at leading by example.”

“We are physicians. We are different,” said the attending.

Words escaped me. I felt like my attending’s words characterized a significant defect in medical education. Put plainly, physicians didn’t practice what they preached. I wondered, “Was I the only non-superhuman physician in training?”

To answer my question, I did what any good medical student would do—I went to the literature. There, I found a Harvard study of thirty-four residents on the Q3 schedule who underwent psychomotor vigilance testing following each 24 to 30-hour shift. They found that not only did the residents accumulate a sleep deficit but also a progressive deterioration in neurobehavioral performance [1].  Conclusion: physicians are not super-human.

I shared this article with my resident, who recommended that I “…keep it to myself.” A lack of courage, and a healthy amount of survival instinct, made me heed the advice, but I resolved to be an advocate for myself and other residents when I graduated.

I got my chance in my first post-graduate year (PGY) as a psychiatry resident.

In my program, all upper-level residents participated in call starting in their second post-graduate year. A call shift lasted approximately 28-30 hours, with the 12-hour ‘call’ occurring in the emergency department (ED). With approximately 12 to 15 upper level residents in any given year, the range in call shifts per resident each year ranged from 24 to 30. This did not sound fun or healthy to me.

Luckily, a PGY-3 resident, Ana Hilde, who was in position to be Chief Resident, agreed with my concerns. As part of a quality improvement (QI) project, Dr. Hilde polled the entire resident class to determine what program changes would improve resident wellness. 26% (5/19) of residents indicated night float and a change in the call system was critical to improving their wellness and reducing burnout. Their free text survey responses included statements like “Get rid of 24 hour shifts (I can’t think clearly enough due to post call fatigue…),” and “Night float to decrease call, which makes my brain slow.” Based on these results, we set about the task of convincing the faculty and program administrators that we could offer a better coverage system for the wellbeing of the residents and patients alike.

What we proposed was a night float system consisting of 5, 12-hour shifts, with variable rotation lengths depending on PGY level. For weekends, a call system would remain in place; however, residents would never work the day before or after a rotation. Additionally, shifts would be staggered to include a PGY-1 resident who could assist the ED resident in the evening and the night float resident for part of the night when patient volume was highest.

Using the scientific literature as a support, we wrote up our proposal to the Program Director and Chair of the Department of Psychiatry, and I volunteered to be the first upper-level resident to test out this new system. The system went into place July 1st 2015, and was an immediate success.

Night float created several immediate advantages over the previous call system. For the first time, the night shift resident could establish a continuity of care with patients on the consult-liaison service and inpatient unit. This allowed for more efficient and effective care of complex patients. Working with the same resident or group of residents over successive days allowed nurses, emergency room physicians, and attendings to give better feedback and resident evaluations. Night float also offered a valuable opportunity for one-on-one mentorship between PGY-1s and their resident supervisor. This created a natural bridge to the PGY-2 year, where residents would begin solo weekend calls.

I have no data to support my belief that night float significantly improved patient care and patient outcomes, but if the data of the Harvard study is true, then night float residents experienced far less errors in patient care than residents working a Q3 rotation or standard call schedule. I’m happy to report that after 5 years, night float in my residency program is still in place, and neither I nor the residents who came after me ever had to ever perform a 24-hour shift at our primary hospital site.

During the white coat ceremony at the beginning of medical school, students recite the Hippocratic Oath to ‘do no harm.’  Sleep deprivation of trainees has the potential to lead to physician errors and adverse patient outcomes. Being a medical doctor is not protective against obesity, heart disease, or other preventable diseases. Wellbeing is achieved through application of medical knowledge. As stewards of medicine, it is important that we practice what we preach and lead by example. That is our true superpower.


  1. Anderson C, Sullivan JP, Flynn-Evans EE, Cade BE, Czeisler CA, Lockley SW. Deterioration of neurobehavioral performance in resident physicians during repeated exposure to extended duration work shifts. Sleep, 2012;35(8):1137-1146.


James R. Agapoff IV, M.D., M.S.a Anandam Hilde, M.D., M.P.H.b

aDepartment of Psychiatry, University of Hawai‘i at Mānoa, Honolulu, Hawai‘i, USA

bDivision of Clinical Psychology, School of Medicine, Oregon Health & Science University

*Corresponding Author: James R. Agapoff, IV, M.D., M.S., Twitter: @dragonnovelist Facebook: @dragonnovelist


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