There were 823/3791 individuals (20.7% of all EM residents) who logged onto the website. Multiple choice questions (question 1 to 8 and demographics) were completed by 602/3791 (15.9%) and detailed questions on sleep aid and stimulant use (questions 9 to 11) were completed by 458/3791 respondents (12.1%).
Among the 602 residents responding to multiple choice questions, mean age was 30 years (SD 4 years), 71.4% were male. Race was 78% white, 11% Asian, 4% black and 4.0% other, race was not given for 3%. Hispanics comprised 4% of respondents. Residency format was PGY1–3 for 71%, PGY1–4 for 14%, and PGY2–4 for 14%. There were 32% 1st year, 32% 2nd year, 28% 3rd year, and 8% 4th year residents. For all EM residents in 2004, the ACGME reported a mean age of 31.2 years, 64% males, with 33% in the first year, 32% in the second year, 31% in the third year, and 4% in the fourth year of residency [18
The mean Epworth Sleepiness Scale (ESS) score was 10.0 (SD 4.2, Figure ). The ESS was normal (<10) in 332/602 (55%), indicative of excessive sleepiness in 227/602 (38%), and indicative of severe sleepiness in 43/602 (7%) of residents. The time taken to fall asleep was more than 10 minutes for 22%, between 5 and 10 minutes for 40%, and less than 5 minutes for 38% of respondents.
Distribution of the Epworth Sleepiness Scale score.
Factors causing fatigue and difficulties initiating sleep are shown in Table . To differentiate usual causes of fatigue from extraordinary events, residents were asked to report factors only if present at least four times a month for two consecutive months. In addition to pre-specified factors, residents volunteered that maintaining sociality (n = 8), problems sleeping (n = 5), relationship problems (n = 4), eating habits (n = 4), financial stress (n = 2), medications (n = 2), and hormonal cycles (n = 1) were causes of fatigue. Financial stress (n = 1), stress over household maintenance (n = 2), lack of exercise (n = 1), pregnancy (n = 1), and health problems (n = 1) were identified as causes of difficulty in initiating sleep.
Causes of fatigue and difficulty initiating sleep, and methods used to initiate sleep among the 602 responding to multiple choice questions.
Sleep aid use
Methods that respondents used to help them fall asleep more than four times a month for at least two months included medication in 17% (102/602), alcohol in 9% (57/602) of cases, and both medications and alcohol in 8% (48/602) of respondents; overall 34.4% (95 CI 30.6% to 38.4%) responded positively when asked directly if they used medication or alcohol to help them fall asleep. Reading (61%), television (42%), sexual activity (36%) and meditation (13%) were also used.
Of the 458 residents responding to detailed question on sleep aid use, 255 (55.7%, 95 CI 51.0% to 60.3%) reported the use of aids to fall or stay asleep, including pharmaceuticals, homeopathic remedies, and alcohol. Types of sleep aid are shown in Figure . Antihistamines were primarily diphenhydramine, although two respondents used a doxylamine-based product. Analgesics included oxycodone (n = 2) and acetaminophen with codeine (n = 1). Sleep adjuncts were melatonin supplements, zolpidem, and zaleplon. Anti-anxiety medications were primarily benzodiazepines although one respondent used buspirone and two used citalopram. Sleep aids characterized as 'other' included vitamins, herbal remedies, and anti-emetics.
Sleep aids used by the 458 respondents who provided detailed information.
We compared responses to the direct question on use of medications or alcohol to fall asleep to the detailed reports of sleep aid use (Table ). Overall, agreement between the two questions was modest (Phi = 0.684). Combining responses to obtain an estimate of the maximum number of residents using a sleep aid suggests 278 of the 602 respondents (46.2%, 95 CI 42.2% to 50.3%) used some form of sleep aid. Exclusive of alcohol, 234 of the 602 respondents (38.9%, 95 CI 35.0% to 42.9%) used a sleep aid.
Responses to detailed questions on use of sleep aids and responses to the direct questions asking whether or not medications or alcohol were used to help initiate sleep.
There were 380/458 residents describing stimulant use to help them stay awake (83.0%, 95 CI 79.1–86.2%). The majority of stimulants were caffeine based, both tablet and drink. Amphetamine use was reported by five respondents, methylphenidate hydrochloride by two respondents, modafinil by five respondents, and ephedrine by six respondents. Nicotine gum and tobacco products were used as stimulants by 21 respondents.
Factors related to sleep aid use
Table shows the results of univariable logistic regression models exploring the influence of year of training, program type, moonlighting, causes of fatigue, causes of difficulty initiating sleep, sleepiness, and demographics on the odds of using sleep aids. In these univariable models, respondents who identified positively with the various causes of fatigue and causes of difficulty initiating sleep were significantly more likely to use sleep aids, both inclusive and exclusive of alcohol.
Table 3 Univariable logistic regression showing the influence of year of training, program type, moonlighting, causes of fatigue, causes of difficulty initiating sleep, and demographics on the odds of using sleep aids either inclusive or exclusive of alcohol. (more ...)
Table shows the results of the multivariable modeling. The use of sleep aids was more likely among respondents who reported work-related emotional stress, family commitments, or changing circadian rhythms to be causes of fatigue or difficulty initiating sleep than among residents who did not. Respondents from programs with a PGY 1–4 format were more likely to use sleep aids than participants in three-year programs. For the use of sleep aids inclusive of alcohol consumption, older respondents were less likely to use sleep aids.
Multivariable logistic regression models for predicting the odds of using sleep aids, either inclusive or exclusive of alcohol.