APGO Papers www. AJOG.

org

The effect of sleep deprivation on fine motor

coordination in obstetrics and gynecology residents
Roy D. Ayalon, MD; Frederick Friedman Jr, MD

OBJECTIVE: The purpose of this study was to evaluate the effect of
acute sleep deprivation on the fine motor coordination in obstetrics
and gynecology residents.
STUDY DESIGN: Twenty-eight obstetrics and gynecology residents
completed a series of tasks using the Purdue pegboard standardized
protocol for testing fine motor coordination both before and after a
24-hour call.
RESULTS: Twenty-three participants were women and 5 were men.
There was a learning curve demonstrated for performance of the tasks.
There was a statistically significant decline in performance of residents
after overnight call. When adjusting for the learning curve, effects of
sleep deprivation were magnified for all tasks: right (dominant) hand (P
⫽ .0005), left hand (P ⫽ .0020), both hands (P ⬍ .0001), and assem-
bly (P ⬍ .0001). There were significant differences in performance
when segregated by year of training and sex; female residents appeared
to tolerate better lack of sleep.
CONCLUSION: Acute sleep deprivation has a deleterious effect on fine
motor coordination in this group of obstetrics and gynecology
residents.
Key words: fine-motor coordination, sleep deprivation

Cite this article as: Ayalon RD; Friedman F Jr. The effect of sleep deprivation on fine motor coordination in obstetrics and gynecology residents. Am J Obstet
Gynecol 2008;199:576.e1-576.e5.

F ollowing the death of Libby Zion in

1984, the time-honored tradition of
virtually unrestricted and limitless resi-
dent work hours was called into ques-
tion. New York State adopted as law in
1989 restrictions on the amount of time
residents could work; these are referred
to as the 405 (Bell Commission) Regula-
tions.1 The Accreditation Council for
Graduate Medical Education (ACGME)
issued similar requirements governing
resident work.2 While the idea was to im-
From the Department of Obstetrics,
Gynecology, and Reproductive Science,
Mount Sinai School of Medicine, New York,
NY.
Presented at the 16th Annual Resident
Research Day Conference, Mount Sinai School
of Medicine, New York, NY, June 13, 2007,
and the joint Annual Meeting of the Association
of Professors of Gynecology and Obstetrics
and the Council on Resident Education in
Obstetrics and Gynecology, Orlando, FL,
March 5-8, 2008.
Received Feb. 24, 2008; revised May 3, 2008;
accepted June 25, 2008.
Reprints: Frederick Friedman Jr, MD, Mount
Sinai School of Medicine, 1 Gustave L Levy
Place, Box 1170, New York, NY 10029.
frederick.friedman@mssm.edu.
0002-9378/$34.00
© 2008 Mosby, Inc. All rights reserved.
doi: 10.1016/j.ajog.2008.06.080
prove patient care and outcomes, the ac-
tual effect of limiting resident work
hours has been debated.3-6
Sleep deprivation is known to cause a
variety of physiologic and psychologic
changes. Lack of sleep has been reported
to result in a decline in both peak and
baseline cognitive functioning7 and op-
erative performance.8,9 It is possible that
different individuals will respond differ-
ently to a given demand; the circum-
stances in which one operates also may
affect one’s performance. Similarly, it is
possible that experience may allow cer-
tain individuals to perform better. Youth
may offer some advantages, while famil-
iarity with a task may allow a certain de-
gree of compensation for stressors such
as fatigue. In addition, it is likely that cer-
tain medical specialties have more de-
mands on resident time and perfor-
mance than do others.
Despite research on the effects of sleep
deprivation on residents in other medi-
cal specialties, there has been little in-
volving obstetrics and gynecology, a field
that clearly mandates around-the-clock
surveillance and surgical or procedural
intervention. We sought to determine
the effect of a 24-hour call on the fine
motor coordination in our obstetrics
and gynecology residents.
M ATERIALS AND M ETHODS
This study was exempted by the Mount
Sinai School of Medicine Institutional
Review Board. All 29 residents in the ob-
stetrics and gynecology residency pro-
gram were recruited and agreed to par-
ticipate in this study. Demographic
information consisting of age, sex, year
of training, and handedness was re-
corded, as was the number of hours slept
during the night prior to testing.
The study participants were asked to
complete a series of tasks using a stan-
dardized protocol testing fine motor co-
ordination both before and after a 24-
hour (overnight) call. In order to
eliminate a learning effect of the exer-
cises, they were randomized by selection
of a sealed envelope that contained the
order of task completion to which they
would be assigned, that is, whether they
would be tested precall first or postcall
first. These envelopes were shuffled and
individually chosen. Due to the small
numbers in each group, randomization
was not carried out by sex or within each
year of training. Performance was com-
piled for each of 4 specific exercises as
was information regarding year of study,
sex, and hours of sleep.
The Purdue pegboard (Model 32020;
Lafayette Instrument Company, Lafay-

576.e1 American Journal of Obstetrics & Gynecology NOVEMBER 2008

www.AJOG.org
FIGURE 1
Hours slept during an overnight
call by year of residency
3 as appropriate. These results are re-
H
2.5
o
u raw score postcall minus the raw score
r
2 precall. When tabulated, residents who
s
1.5
s
1 tive score (“postcall minus precall per-
l
e
p
0.5
t
0 postcall will have a positive score. Statis-
1st 2nd 3rd 4th
year year year year
Ayalon. The effect of sleep deprivation on fine motor
coordination in obstetrics and gynecology residents. Am J
Obstet Gynecol 2008.
ette, IN) was used to evaluate manual
dexterity in standardized fashion, as per
established protocol.10 The protocol and
pegboard have been utilized in the selec-
tion of prospective industrial workers
and normative data have been estab-
lished.10 After completion of a brief
questionnaire, the participant was read
instructions and then asked to complete
the specific task described. Each task
consisted of a practice period followed
by 3 timed attempts. The mean score of
the 3 trials was derived.
The 4 exercises consisted of placement
of as many pegs in the pegboard as possible
in 30 seconds using the dominant hand.
The second task was the same as the first,
but using the nondominant hand. The
third exercise involved peg placement in
each of the corresponding columns of
holes using both hands simultaneously.
The final task involved the assembly of
units of pegs, washers, and collars using
both hands in 1 minute. To maintain uni-
formity, instructions were read and data
tabulated by the principal investigator.
The SAS (version 9.1; SAS Institute,
Cary, NC) statistical analysis package
was utilized. Mixed model analysis of
variance was used to estimate and com-
pare mean precall and postcall scores
among different subgroups of year of
training and sex. A compound symmet-
ric covariance structure was assumed to
account for the correlation between
measurements taken on the same subject
and the Kenwardoger method was used
to estimate the degrees of freedom used
in all hypothesis testing. Results were re-
corded as a raw score in terms of number
of pegs placed or components assembled
ported in terms of the mean difference in
perform worse postcall will have a nega-
formance”), whereas residents who place
more pegs or complete more assemblies
tical significance was defined as P ⬍ .05.
R ESULTS
Due to an advanced gestation with cor-
responding diminution in overnight call
during the study period, 1 fourth-year
resident was excluded from participating
in this study. Thus, the data for 28 resi-
dents were available for analysis.
Twenty-three participants were women
and 5 were men. Sixteen residents were
tested precall first and 12 were tested
postcall first. There were 8 first-year res-
idents, 7 residents in each of the second
and third year of training, and 6 fourth-
year residents. All study participants
were right-hand dominant. The number
of hours slept precall varied dramatically
from 6 to 11 and was not statistically sig-
nificant. The number of hours slept dur-
ing an overnight call varied from none to
6, with a direct relationship to year of
training (Figure 1). On average, first-
year residents slept 0.5 hours, second-
year residents slept 0.8 hours, third-year
residents slept 2.5 hours, and fourth-
year residents slept 2.9 hours. The
fourth-year residents got significantly
more sleep than both first-year (P ⫽
.0048) and second-year residents (P ⫽
.0136); third-year residents also slept
more than first-year (P ⫽ .0129) and sec-
ond-year residents (P ⫽ .0354). There
was no difference in number of hours
slept between the 2 groups of junior res-
idents or between the 2 groups of senior
residents.
There was a learning curve demon-
strated for performance of the tasks.
There was a statistically significant dif-
ference (P ⫽ .0018) in performance of
residents after overnight call compared
NOVEMBER 2008 American Journal of Obstetrics & Gynecology
APGO Papers
to before their call (Table 1). Residents,
with the exception of third-year resi-
dents, performed worse when postcall.
Third-year residents did not show a
change in performance following a 24-
hour shift and in fact had more peg
placements postcall than they did pre-
call, using the dominant hand, non-
dominant hand and both hand exercises,
although this did not reach statistical sig-
nificance. The overall drop-off in post-
call performance was true even when ig-
noring a learning effect (P ⫽ .013) (Table
2). The largest difference was demon-
strated in residents who slept the least.
When adjusting for the learning curve,
the effects of sleep deprivation were even
more glaring. For the right (dominant)
hand task, the mean decline following
overnight call was 1.01 (P ⫽ .0005); for
the left hand task, it was 0.90 (P ⫽ .0020).
For both hands, it was 0.94 (P ⬍ .0001),
and for the assembly task, it was 4.56 (P
⬍ .0001) (Table 3). All of these indicate a
statistically significant decline in test
performance due to sleep deprivation. In
addition, there were statistically signifi-
cant differences in performance when
segregated by year of training; fourth-
year residents demonstrated the greatest
decline in performance following over-
night call, especially in the dominant
hand task (P ⫽ .0048) and when per-
forming the assembly (P ⫽ .0016).
Third-year residents showed no signifi-
cant changes when postcall. With respect
to sex, men generally performed signifi-
cantly worse postcall as compared to
women residents (Table 4), although this
was true for the dominant hand and as-
sembly tasks only.
C OMMENT
The concept of limited work hours for
residents was based on the desire to op-
timize patient care. While there is some
dispute as to the actual benefits of such
limitations, there are several studies
which have shown declining function
following sleep deprivation. Landrigan
and colleagues demonstrated fewer seri-
ous medical errors by interns in an inten-
sive care unit when following a schedule
designed to reduce sleep deprivation.11
While Jha et al,7 in their report on
576.e2
APGO Papers www.AJOG.org

healthcare quality, discuss a decline in

cognitive function reported by some TABLE 1
studies, other reports found less signifi- Comparing performance postcall vs precall by year of residency
cant or no cognitive impairment or im- Mean differencea
pact on acquisition of new skills follow- (postⴚpre) SE P value Overall P value
ing sleep deprivation.7,12,13 Studies in Right hand 1st year -0.3125 0.3520 .3762 .0123
..............................................................................................................................................................................................................................................
surgical residents did not uniformly sup- 2nd year -0.7619 0.3763 .0448
..............................................................................................................................................................................................................................................
port a decline in operative skills after lack 3rd year 0.1667 0.3763 .6585
of rest.8,9,12,13 ..............................................................................................................................................................................................................................................

Jakubowicz et al studied the effect of 4th year -1.1667 0.4064 .0048

..............................................................................................................................................................................................................................................

sleep deprivation on 8 surgery residents Left hand 1st year -0.0833 0.3575 .8160 .1141
..............................................................................................................................................................................................................................................
through the use of an endoscopic sinus 2nd year -0.3571 0.3822 .3517
..............................................................................................................................................................................................................................................
surgical simulator.13 They found no in- 3rd year 0.2619 0.3822 .4943
fluence of fatigue in their study, which ..............................................................................................................................................................................................................................................

was limited by the small sample size. In 4th year -1.0278 0.4128 .0140
..............................................................................................................................................................................................................................................

this study, residents performed faster Both hands 1st year -0.4583 0.2930 .1201 .0552
..............................................................................................................................................................................................................................................
postcall but with more errors. They dem- 2nd year -0.4762 0.3133 .1308
..............................................................................................................................................................................................................................................
onstrated continued learning of the tasks 3rd year 0.3810 0.3133 .2261
despite apparent fatigue. Reznick and ..............................................................................................................................................................................................................................................

Folse studied the performance of a total 4th year -0.6111 0.3384 .0731
..............................................................................................................................................................................................................................................

of 21 residents in 4 different surgical Assembly 1st year -1.1667 1.1426 .3090 .0200
..............................................................................................................................................................................................................................................
training programs.9 They evaluated cog- 2nd year -0.6429 1.2215 .5995
..............................................................................................................................................................................................................................................
nitive and dexterity performance before 3rd year -0.7619 1.2215 .5348
and after a 24-hour shift, and utilized the ..............................................................................................................................................................................................................................................

Purdue pegboard as well as simulated 4th year -4.2500 1.3193 .0016

wound-closure exercises for dexterity
testing. The effect of sleep deprivation
was only observed in the Purdue task us-
ing the dominant hand; no other statis-
tically significant findings in operative or
cognitive tasks were recorded. Eastridge
and colleagues evaluated 35 surgical res-
idents pre and postcall using a minimally
invasive surgery trainer to test laparo-
scopic skills.8 They reported that follow-
ing sleep deprivation, more surgical er-
rors were made in all of the 6 tasks
studied, and there was a slight, but not
significant, prolongation of time re-
quired to complete the tasks. Taffinder et
al also used a laparoscopy simulator and
evaluated 6 residents and response to
sleep deprivation; they also found de-
creased dexterity using the simulator fol-
lowing fatigue.14 Similar findings were
reported by Grantcharov et al in their
study of 11 surgical trainees.15
..............................................................................................................................................................................................................................................
Performance is segregated by task and year.
a
Results are reported as number of pegs placed or assemblies performed postcall minus the number of pegs or assemblies
completed precall. A negative number indicates better performance precall; a positive number indicates better performance
postcall.
Ayalon. The effect of sleep deprivation on fine motor coordination in obstetrics and gynecology residents. Am J Obstet
Gynecol 2008.
changes were most pronounced when studies and is clear from our studies as
using just the dominant hand or in as- well. Webb and Agnew demonstrated
sembly tasks. While not tested directly in that adaptation to fatigued states oc-
patient models, these tasks may demon- curs16; this may explain the findings in
strate critical performance issues in such our third-year residents. Our third-year
scenarios. There is clear learning of tasks residents are the only ones who per-
that continues even in a fatigued state; formed better after overnight call. This
this has been demonstrated in other may be result of their role as a “night
TABLE 2
Comparing performance postcall vs precall
(ignoring the learning curve)
Mean differencea
(postⴚpre) SE P value Overall P value
Right hand -0.4881 0.190 .011 .013
..............................................................................................................................................................................................................................................

We believe our study is the first one to Left hand -0.2679 0.190 .160
..............................................................................................................................................................................................................................................
evaluate the effect of sleep deprivation Both hands -0.2857 0.190 .134
..............................................................................................................................................................................................................................................
on fine motor coordination in obstetrics Assembly -1.5952 0.616 .011
and gynecology residents. The use of the ..............................................................................................................................................................................................................................................
Performance is segregated by task for all participants combined.
Purdue pegboard allows a validated a
Results are reported as number of pegs placed or assemblies performed postcall minus the number of pegs or assemblies
method of comparing subjects to each completed precall. A negative number indicates better performance precall; a positive number indicates better performance
other, as well as to themselves. In our postcall.
Ayalon. The effect of sleep deprivation on fine motor coordination in obstetrics and gynecology residents. Am J Obstet
study, residents showed a definite effect Gynecol 2008.
as a result of sleep deprivation. These

576.e3 American Journal of Obstetrics & Gynecology NOVEMBER 2008

www.AJOG.org APGO Papers

ences between the genders or this is a re-

TABLE 3
flection of the testing technique is not
Comparing performance postcall clear from our study. The fact that there
and precall, adjusting for learning curve
are only 5 men in our residency program
Mean differencea limits further conclusions.
(postⴚpre) SE P value Overall P value
Limitations of the study include the
Right hand Post first -1.0139 0.2861 .0005 .0173 small sample size. It would be interesting
..............................................................................................................................................................................................................................................
Pre first -0.0938 0.2477 .7057 to follow residents over time and observe
..............................................................................................................................................................................................................................................
Left hand Post first -0.9028 0.2869 .0020 .0044 changes in performance as they progress
..............................................................................................................................................................................................................................................
Pre first 0.2083 0.2485 .4032 through their training. It has yet to be
..............................................................................................................................................................................................................................................
determined whether or not the perfor-
Both hands Post first -0.9444 0.2312 ⬍ .0001 .0003
.............................................................................................................................................................................................................................................. mance using the pegboard can be trans-
Pre first 0.2083 0.2003 .3000 lated to clinical situations. While the
..............................................................................................................................................................................................................................................
Assembly Post first -4.5556 0.8831 ⬍ .0001 ⬍ .0001 protocols used in our study are derived
..............................................................................................................................................................................................................................................
Pre first 0.6250 0.7647 .4152 from those used in a variety of industries
..............................................................................................................................................................................................................................................
Performance is segregated by task and order of performance by randomization. and have been validated for those indus-
a
Results are reported as number of pegs placed or assemblies performed postcall minus the number of pegs or assemblies tries,10 there has yet to be a study com-
completed precall. A negative number indicates better performance precall; a positive number indicates better performance paring pegboard performance with live
postcall.
Ayalon. The effect of sleep deprivation on fine motor coordination in obstetrics and gynecology residents. Am J Obstet surgical procedures. Similarly, to date
Gynecol 2008. there have been no studies looking at
sleep deprivation and in vivo surgical
float” on the labor floor. In such a situa- and experience in management, they dexterity or complications. Clearly, fur-
tion, they are the primary caregivers and showed clear effects of sleep deprivation ther studies are necessary in order to de-
overseers of a busy labor floor. Improved on their fine motor skills; they showed termine optimal working conditions for
performance may represent their accli- the greatest decline in performance fol- residents, especially as they relate to pa-
mation to night work and a heightened lowing the overnight call. It would be in- tient care and outcomes. f
sense of awareness and responsiveness to teresting to evaluate the performance of
acute stressful situations. In contrast, junior and senior attending physicians in
ACKNOWLEDGMENTS
our fourth-year residents, who function these settings.
The authors would like to thank Erin Moshier for
mostly as consultants during the night, The impact of sex on the performance
assistance in the statistical analysis and prepa-
and are not directly involved in the on- is intriguing. The Purdue pegboard nor- ration of this manuscript.
going evaluation and care of patients mative tables do report better perfor-
during the overnight call, may be “de- mance by women than men in all tasks.10
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