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Medical Resident Driving

Simulator Performance
Following a Night on Call
J. Catesby Ware , Mathew R. Risser , Thomas Manser
& Karl H. Karlson, Jr.
Published online: 07 Jun 2010.

To cite this article: J. Catesby Ware , Mathew R. Risser , Thomas Manser & Karl H.
Karlson, Jr. (2006) Medical Resident Driving Simulator Performance Following a Night
on Call, Behavioral Sleep Medicine, 4:1, 1-12, DOI: 10.1207/s15402010bsm0401_1

To link to this article: http://dx.doi.org/10.1207/s15402010bsm0401_1

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 BEHAVIORAL SLEEP MEDICINE, 4(1), 1–12
Copyright © 2006, Lawrence Erlbaum Associates, Inc.

Medical Resident Driving Simulator

Performance Following a Night on Call
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J. Catesby Ware and Mathew R. Risser

Departments of Internal Medicine and Psychiatry
Division of Sleep Medicine
Eastern Virginia Medical School, Norfolk

Thomas Manser
Department of Internal Medicine
Eastern Virginia Medical School, Norfolk

Karl H. Karlson, Jr.

Department of Pediatrics
Wake Forest University School of Medicine

This study compared driving simulation performance after night call and after being
off call in 22 medical residents and 1 medical student in a prospective within-subjects
counterbalanced design. The results demonstrated an unexpected interaction be-
tween call and sex wherein men performed more poorly after night call than women
as measured by lane variance and crash frequency. Secondary measures, including
caffeine, actigraphy, and subjective total sleep time, did not differ between men and
women. Collectively, results of this study and others suggest that medical residents
are at risk when driving after a night on call and support the need for resident educa-
tion to address sleep needs, consequences of sleep disruption, postcall recovery
sleep, and countermeasures that may reduce residents’ driving risks.

American medical residents are among those professional groups that work long
hours. Before the current Accreditation Council of Graduate Medical Education
(ACGME) rules limiting the workweek to 80 hr (ACGME, 2003), residents were
logging between 95 and 136 of the 168 hr in a week (Daugherty, Baldwin, & Rowley,
1998). To help prevent fatigue-related errors, New York State established work-hour

Correspondence should be addressed to J. Catesby Ware, Sleep Disorders Center, Sentara Norfolk
General Hospital, 600 Gresham Dr., Norfolk, VA 23507. E-mail: warejc@evms.edu
 2 WARE, RISSER, MANSER, KARLSON

limitations and augmented supervisory requirements (Brensilver, Smith, & Lyttle,

1998). House of Representatives Bill 3236, the Patient and Physician Safetyand Pro-
tection Act of 2001, placed limits on resident schedules (H.R. 3236, 2001).
A number of studies document deleterious effects of call on resident perfor-
mance and fatigue (Veasey, Rosen, Barzansky, Rosen, & Owens, 2002). For in-
stance, 1 night on call may impair creative thought (Nelson, Dell’Angela, Jellish,
Brown, & Skaredoff, 1995), and a weekend on call negatively affects cognitive
performance and mood (Wesnes et al., 1997). Although sleep-deprived house offi-
cers may be able to overcome sleep loss in short-term crises, optimal performance
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during repetitive, routine, and prolonged tasks is particularly at risk (Samkoff &
Jacques, 1991). Furthermore, sleep-deprived residents perform more poorly on
simulated patient monitoring tasks that require a response to specific, discrete
events (Denisco, Drummond, & Gravenstein, 1987).
Concern for patient safety motivated the change in the New York work rules;
thus, studies have typically focused on the effects of resident schedules on patient
care rather than resident safety (Samkoff & Jacques, 1991). Prolonged work
schedules, however, also pose risks for residents. Insufficient sleep can affect resi-
dents’ mental health, pregnancy, and motor vehicle operation (Hart, Buchsbaum,
Wade, Hamer, & Kwentus, 1987; Klebanoff, Shiono, & Rhoads, 1990;
Mozurkewich, Luke, Avni, & Wolf, 2000). Questionnaire data indicate that medi-
cal house staff members frequently fall asleep when driving postcall (Marcus &
Loughlin, 1996; Steele, Ma, Watson, Thomas, & Muelleman, 1999). Also, medical
residents have reported that the prevalence of near motor vehicle crashes due to
falling asleep at the wheel increased to 60% from 26% before residency
(Kowalenko, Kowalenko, Gryzbowski, & Rabinovich, 2000). Furthermore, Barger
and colleagues (2005) administered a Web-based survey to 2,737 medical resi-
dents to evaluate their hours of work, driving behavior, and motor vehicle crashes.
The authors found that every extended shift worked in a month increased the risk
of a crash during that month by 9.1% and increased the risk of a crash during the
commute to work by 16.2%.
Among those populations at risk for motor vehicle crashes, fatigue-related
crashes have been identified as a valid concern for highway safety. The year 2002
report from the Department of Transportation indicated that an average of 117 peo-
ple died daily in motor vehicle crashes and 8,411 were injured (Department of
Transportation, 2002). Therefore, it is important to identify those populations and
individuals at risk for fatigue-related crashes and examine those factors that con-
tribute to the problem. For example, shift workers have demonstrated impaired
driving simulator performance after a normal night shift as compared with a nor-
mal night of sleep (Akerstedt, Peters, Anund, & Kecklund, 2005).
Studies have validated the use of driving simulators to assess continuous perfor-
mance. Freund, Gravenstein, Ferris, and Shaheen (2002) and Lee, Cameron, and
Lee (2003) have demonstrated positive correlations between driving simulator
 DRIVING SIMULATOR PERFORMANCE 3

performance and actual on-road driving performance in older participants. Risser,

Ware, and Freeman (2000) used a driving simulator to demonstrate impaired per-
formance in patients with sleep apnea and excessive sleepiness. Compared with a
control group, patients with apnea and excessive sleepiness had more crashes,
more lane variance, and more speed variance. Furthermore, a positive correlation
between increased lane variance and EEG-defined attention lapses suggested that
lapses in attention contributed to the increased lane variance. The shift-work driv-
ing simulator study of Akerstedt et al. (2005) demonstrated that driving after a
night shift increased lane excursions, lateral deviation, eye closure duration, and
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subjective sleepiness. To help quantify the immediate effects of call on residents

and medical students after a night on call, the present study examined driving sim-
ulator performance after both night call and off-call periods.
In the present driving simulator study, it was hypothesized that night call would
impair performance; that is, lane position variance, speed variance, and crash fre-
quency would increase participants’ postcall as compared with their off-call per-
formance. Identifying and quantifying call-induced performance decrements
should improve the understanding of impaired driving after call and help in the de-
velopment and implementation of countermeasures.

METHOD

Participants
Following Institutional Review Board approval and after giving informed consent,
22 medical residents and 1 medical student who were on call every 3rd or 4th night
participated in the study. Nineteen participants (12 men and 7 women) completed
the study (for men, mean age = 29.4, SD = 4.3; for women, mean age = 28.7, SD =
2.4). All participated in the study before the implementation of the ACGME
(2003) 80-hr workweek limit.
Participants were excluded if they took medications that had sedative or stimu-
lant properties, had signs and symptoms of a sleep disorder (e.g., sleep apnea,
narcolepsy), had a significant medical disorder (e.g., diabetes), drank more than
five cups of caffeine beverages per day, smoked more than 1/2 pack of cigarettes
per day, or consumed any caffeine or nicotine 3 hr before testing. Otherwise, caf-
feine and nicotine use was not limited.

Driving Simulator
The fixed-platform PC-based driving simulator (STISIM, Systems Technology
Inc., Hawthorne, CA) consisted of force feedback steering wheel, gas and brake
pedals, a single 50 × 50-in. (127 × 127-cm) roadway projection display, surround
 4 WARE, RISSER, MANSER, KARLSON

sound, and a road vibration system. The seat, controls, video monitoring, and road-
way display system were housed in a 5 × 10-ft (approximately 1.5 × 3-m) room
covered with sound attenuation carpeting. The simulator setup and placement of
controls were similar to the specifications of an actual car. The seat was fully ad-
justable with arm rests on both sides. The experimenter, computers, and the
video–audio monitoring equipment were in an adjacent room. The simulator was
located in the hospital.

Practice scenario. The practice drive consisted of 10 min through a city sce-
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nario allowing participants to adapt to the vehicle handling and dynamics. This
was designed to reduce practice effects by including intersections, stoplights, traf-
fic, and pedestrians that required participant responses.

Test scenario. The test drive consisted of 60 min through a rural highway sce-
nario at a speed of 55 miles per hour (mph; approximately 88.5 km per hour; kph)
with long, wide curves and an oncoming vehicle every 10 min. This type of drive re-
quired participants to maintain vigilance to stayon the road but no other responses.

Call Conditions
The night on-call condition began the day before the driving simulator testing
(DST) at 1700 and ended at 0800 the following day. On-call participants continued
their normal daytime patient care hospital duties until the DST was completed be-
tween 1200 and 1500. The off-call condition was the same as the night on call with
the exception that participants spent the night at home without call responsibility.
Sleep quality was assessed with actigraphy (Mini-Mitter Actiwatch® 32, Sunriver,
OR) and self-reported total sleep time. Several single bed call rooms were avail-
able for either male or female residents.

Actigraphy
The actigraphy was used to assess the number of 30-s epochs with no activity (rest
epochs) for 15 hr from 1700 to 0800 prior to the DST. The higher the number, the
less activity and presumably the more sleep.

Design
A repeated measures mixed design included the within-subject factors time (six
10-min segments of the drive) and call condition (night call and off call). Sex was
the between-subjects factor. The primary dependent variables were lane position
variance (measured in feet), speed variance (measured in miles per hour), and the
frequency of crashes. Secondary measures included actigraphy, self-reported total
sleep time, self-reported caffeine use, and the visual analog scale (VAS). The VAS
was a 100-mm line with not at all sleepy and extremely sleepy as anchors.
 DRIVING SIMULATOR PERFORMANCE 5

Procedure
Participants made three visits to the sleep center and driving simulator facilities,
which were located in the hospital: a screening visit, an off-call visit, and a
night-call visit. At the screening visit, investigators reviewed the medical and sleep
history of the participants. Participants were asked about snoring, pauses in breath-
ing, and other signs and symptoms suggesting sleep apnea, as well as other specific
sleep disorders. Participants reported their total sleep time, reported their caffeine
use during night call and off call, and completed the Epworth Sleepiness Scale
(ESS; M. Johns & Hocking, 1997).
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After screening and prior to DST, participants were given actigraphs at least 24
hr prior to the DST. Participants then completed two counterbalanced 60-min DST
sessions at least 1 week apart between 1200 and 1500 hr, one after a night on call
and one after a night off call.
Immediately prior to the DST, participants removed pagers and watches. Par-
ticipants completed the 10-min practice scenario. Then they completed a VAS
for their current sleepiness level and began the 60-min rural-driving test sce-
nario. Participants were instructed to maintain a speed of 55 mph. After the
drive, participants completed a second VAS. See Figure 1 for an illustrated
timeline of the procedure.

RESULTS

Analysis
The simulator sampled lane position (in feet), speed (in miles per hour), and
crashes (counted when the vehicle crossed 3 feet (approximately .9 m) over the
edge line on the road) once per second. These data were compiled into six 10-min
time blocks for analysis. SPSS was used for the repeated measures analysis of vari-

FIGURE 1 A timeline of the procedure for both off-call and night on-call conditions. ESS =
Epworth Sleepiness Scale; VAS = visual analog scale.
 6 WARE, RISSER, MANSER, KARLSON

ance with a criterion probability value of .05 for statistical significance. Univariate
post hoc analyses were used to examine the interactions. The Mann–Whitney
nonparametric test was used to examine the crash frequency after a night on call
and off call in men and women.

Driving Performance Measures

There was a significant call by sex interaction for lane position variance, F(1, 17) =
7.96, p = .012. As shown in Figure 2, men had twice the lane position variance (M
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= 1.8 ft [approximately 0.55 m], SD = 0.2 ft [approximately 0.06 m) as compared

with women (M = 0.9 ft [approximately 0.27 m], SD = 0.3 ft [approximately 0.09
m]) after a night on call. However, there was no main effect of call, F(1, 17) = 1.81,
p = .196, or sex, F(1, 17) = 4.33, p = 0.053. As expected, mean lane position vari-
ance increased over time, F(5, 85) = 2.53. In order, the means (with standard errors
in parentheses) in feet for the first 10-min block through the sixth 10-min block
were 1.05 (0.13), 1.30 (0.19), 1.29 (0.15), 1.23 (0.15), 1.29 (0.16), and 1.36 (0.15).
The effect of time did not interact with call or sex.
Speed variance did not significantly change as a function of call, time, or sex.
However, there was a trend for men to have greater speed variance (M = 4.4 mph
[approximately 7.08 kph], SD = 1.0 mph [approximately 1.61 kph]) than women
(M = 1.4 mph [approximately 2.25 kph], SD = 1.2 mph [approximately 1.93 kph)
after a night on-call, F(1, 17) = 3.23, p = .09.
As illustrated in Figure 3, men had a significant increase in crashes following
the night on call as compared with women, U = 17.50. However, there were no dif-
ferences between men and women after a night off call, U = 41.50, p = .96.

FIGURE 2 Resident total lane position

variance for both off call and after a night
on call in men and women. Men had
greater lane variance as compared with
women following a night on call.
 DRIVING SIMULATOR PERFORMANCE 7

FIGURE 3 Resident crashes following

the off-call and night-on-call conditions in
men and women. Men had more crashes as
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compared with women following a night on

call. Crash frequency for men was greater
in the night-on-call condition. Women did
not differ between night-on-call and off-call
conditions.

Self-Report and Actigraphy Measures

The ESS measured during the screening visit was above normal for the residents
(M = 8.9, SD = 3.5) but not in the pathological range (i.e., EES > 10). There were
no differences between men (M = 9.3, SD = 3.7) and women (M = 8.3, SD = 3.5),
F(1, 17) = 0.371, p = .550.
Self-reported total sleep time significantly decreased during a night on call,
F(1, 15) = 130.13, p < .001, and was confirmed by a decrease in actigraphy rest ep-
ochs, F(1, 17) = 7.78, p = .004, as shown in Table 1. In addition, more caffeine was
consumed after a night on call as compared with off call, F(1, 15) = 5.98, p = .027,

TABLE 1.
Means and Standard Deviations (M ± SD) for Actigraphy and Secondary
Measures for Men and Women After a Night On Call and Off Call

Actigraphy Rest
Variable Epochs TST (Hr) Caffeine Predrive VAS Postdrive VAS

Night call
Men 994 ± 318 3.3 ± 1.2 2.5 ± 0.8 64 ± 16 79 ± 25
Women 1,007 ± 221 3.8 ± 0.9 1.5 ± 2.1 65 ± 12 83 ± 12
Off call
Men 1,237 ± 365 7.4 ± 1.3 1.6 ± 1.9 19 ± 14 45 ± 33
Women 1,330 ± 111 8.4 ± 0.9 0.4 ± 0.5 14 ± 8 45 ± 23

Note. Night call results were significantly different from the off-call condition for all measures.
There were no differences between men and women or Sex × Call interactions. Actigraphy, total sleep
time (TST), and caffeine were recorded for 15 hr from 17:00 to 08:00 prior to the driving simulator test.
VAS = visual analogue scale.
 8 WARE, RISSER, MANSER, KARLSON

as shown in Table 1. There was no effect of sex and no call by sex interaction on
self-reported total sleep time, actigraphy, or caffeine.
The VAS measures indicated significantly greater sleepiness after a night on
call as compared with off call, F(1, 16) = 52.25, p < .001. There also was a signifi-
cant increase from the predrive to the postdrive VAS, F(1, 16) = 26.79, p < .001.
See Table 1 for the means. There was no difference between men and women or in-
teraction effect for these measures.
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DISCUSSION

A night on call impaired simulated driving performance for men as measured by

lane position variance (i.e., weaving) and the number of crashes. The effect of call
was moderated by sex and was not significant in this study. A night on call did af-
fect the self-reported measures of total sleep time, caffeine use, and VAS-mea-
sured subjective sleepiness. Presumably, the crashes and increased lane variance in
men resulted from more frequent and prolonged attention lapses and microsleep
episodes secondary to increased sleepiness. However, these variables were not
measured as they were in an earlier study with patients with apnea (Risser et al.,
2000). Compared with the performance of patients with severe apnea and healthy
participants in the earlier study by Risser et al., medical residents demonstrated
less lane variance than did patients with apnea (1.4 to 2.6 ft [approximately 0.43 m
to 0.79 m] during the hour-long drive) but more variance than did healthy partici-
pants (0.7 to 0.9 ft [approximately 0.21 to 0.27 m]). The residents performed more
poorly than the healthy group recorded in the earlier study, which suggests they
may carry a chronic sleep debt that impairs driving simulation performance. Al-
though we did not measure sleep subjectively or with actigraphy in the days prior
to testing, the residents’ ESS scores in this study support the idea of increased
sleepiness in residents (published normal ESS data mean is 4.6; M. W. Johns,
1994). The ESS score of these residents was better than residents in other studies
(M = 14.6, SD = 4.4; Papp et al., 2004), suggesting that performance decrements
may be even more severe at other times or in other training programs.
Sleep loss can impair cognitive and psychomotor performance to the same de-
gree as a 0.1% blood alcohol level (Dawson & Reid, 1997). In terms of objectively
measured daytime sleepiness, 6 hr of sleep loss is equivalent to a 0.1% blood alco-
hol level (Roehrs, Burduvali, Bonahoom, Drake, & Roth, 2003). The reports of
crashes and near crashes and the weaving on the simulated drive in this study sup-
port the concern that at least male residents are at increased risk when driving after
night call. This concern is supported by the results of other studies (Kowalenko et
al., 2000; Steele et al., 1999). Fortunately, most residents have less than a 1-hr
commute home when leaving the hospital. Also, on their drive home, they experi-
ence more alerting stimuli such as the arousing effects of passengers, highway
 DRIVING SIMULATOR PERFORMANCE 9

noise, and increased vibration when drifting off the edge of the road. Presumably,
these factors decrease the likelihood of actual crashes. Nevertheless, these results
and those of other studies suggest that residents need to be aware of the increased
risks of driving postcall and of possible countermeasures.
The results of this study suggest that women are less affected by sleep loss,
perhaps because of a better ability to overcome sleep deprivation and maintain
alertness when driving. Although this was not an anticipated result, there are
data that support this finding. The automobile insurance industry recognizes a
sex difference by granting lower insurance premiums to young women. Further-
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more, data from the U.S. Department of Transportation (2002) indicate that for
most ages, women have fewer fatal crashes per miles driven. One explanation is
that young men take more risks. In this study, the sex difference occurred only in
the night call condition and not in the off call condition. If risky driving behav-
iors such as speeding or purposely varying the vehicle’s lane position occurred
in men, greater lane variance in the off call condition also would be expected.
Sleepiness does increase risk-taking behavior by reducing decision accuracy
(Roehrs, Greenwald, & Roth, 2004). However, the driving task in the present
study was a long rural drive and did not require decision making. Therefore, in-
creased risk taking due to sleepiness is unlikely to explain the difference be-
tween men and women found in the present study.
In a review of daytime sleepiness, Young (2004) cited studies suggesting that
men are more likely to report sleepy behaviors (i.e., the ESS), whereas women are
more likely to report sleepy feelings. Reasons that men and women may differ are
unclear. Data do indicate that women have greater slow wave sleep recovery ability
after sleep loss (Armitage, Smith, Thompson, & Hoffman, 2001). In addition,
actigraphy data from others show that women sleep better than men irrespective of
age (Jean-Louis, Mendlowicz, Von Gizycki, Zizi, & Nunes, 1999). Thus, women,
possibly because of more efficient deep sleep recovery and better sleep, may expe-
rience fewer deficits from night call sleep loss. Alternatively, women may have
better alerting abilities that help to ameliorate impairments from sleep loss. Con-
sistent with this possibility is the report that female residents are more worried
about a motor vehicle accident when driving home after call than are men (Owens,
Arnedt, Crouch, & Stahl, 2004). If female residents in this study were more anx-
ious about the drive than were the male residents, heightened vigilance may have
resulted in better performance. Also, a recent study reported that partial sleep re-
striction appeared to affect men more than women in terms of cortisol secretion
(i.e., there was greater suppression in men than women; Vgontzas et al., 2004).
Therefore, further research is needed to examine sleep loss and recovery differ-
ences in men and women including separating the effects of underlying chronic
sleepiness (e.g., residents) from the effects of acute sleep loss.
Behavioral differences also may exist between men and women that could help
account for performance differences. In larger data sets of nonresidents, women
 10 WARE, RISSER, MANSER, KARLSON

appear to sleep longer than men (Vorona et al., 2005). Thus, it is possible that
women residents behaviorally protect their sleep better during the off-call condi-
tion. In the present study, women reported greater total sleep time by approxi-
mately 1 hr and had more rest epochs when off call as compared with men; how-
ever, these differences were not significant. Finally, although Akerstedt et al.
(2005) demonstrated differences between a night shift and a normal night of sleep,
sex differences between the 5 men and 5 women were not analyzed. Furthermore,
differences may exist between the present study and Akerstedt’s shift-work study
because the residents in the present study were allowed to sleep when possible.
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In summary, the present study demonstrated that all residents drove more
poorly over time and, more important, male residents drove more poorly than
women after a night on call. It is unknown whether the male–female difference is
explained by differences in sleep behaviors or differences in the susceptibility to
consequences of sleep deprivation. Although other studies have indicated an in-
creased driving risk for residents (Barger et al., 2005; Kowalenko et al., 2000;
Marcus & Loughlin, 1996; Steele et al., 1999), they have not indicated a perfor-
mance difference between men and women. Therefore, further research is needed
to confirm and clarify this sex difference.
The recently enacted intervention of restricting resident work hours appears
justified if some of the hours are spent in recovery sleep. However, further inter-
ventions are necessary because changing resident call schedules is difficult, select-
ing residents based on ability to withstand sleep loss is impractical, and changing
sleep need is not yet possible. At a minimum, medical training programs should
educate residents about sleep needs and the consequences of sleep loss. Further,
residents should be provided with instructions on how to monitor total sleep debt
and maximize sleep hygiene. In addition, discussion of behavioral countermea-
sures (judicious use of caffeine, napping, and increased sleep when off call) should
help residents better withstand the risks and rigors of call. One attraction of educa-
tional interventions is that they may produce benefit with relatively little expense
to the program. However, this will need to be compared with pharmacological in-
terventions, such as modafinil (Provigil), which is approved for shift-work sleep
disorder and will likely be tried by some residents. Finally, to what degree the new
work hour rules will have an effect, to what extent residents will implement recom-
mendations, and whether the recommendations will alleviate any problems associ-
ated with chronic sleepiness in residents remains to be demonstrated.

ACKNOWLEDGMENTS

This research was supported, in part, by National Institute of Health Award

HL03652–01A1.
 DRIVING SIMULATOR PERFORMANCE 11

We are grateful to Cheri Cain for her help with conducting the experiments and
to Nicole Anthony for assisting with the manuscript preparation.

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