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Original Article
Psychomotor Performance of Medical Students:
Effect of 24 Hours of Sleep Deprivation

Abhinav Dixit, Rajat Thawani, Abhishek Goyal, Neelam Vaney

ABSTRACT
Context: Sleep deprivation is known to have detrimental effects on attentional resources and cognitive functions.
Aim: The aim of this study is to assess the changes in performance, due to 24 h of sleep deprivation, in medical students
Materials and Methods: The performance was assessed using simple paper–pencil tasks, such as digit symbol substitution
test, digit vigilance test, and letter cancellation tasks. Results: The results revealed an increase in the number of errors
in letter cancellation tasks and digit vigilance test, with a significant decrease in the number of correct responses on
the letter cancellation task. The time taken to complete the tests increased with lack of sleep, with the digit symbol
substitution test being affected the most. Discussion: This study infers that sleep deprivation for 24 h affected the
judgment ability more than the response speed. Conclusion: Sleep deprivation might lead to compromised performance
of medical students in examinations.

Key words: Digit symbol substitution test, digit vigilance test, letter cancellation task, sleep deprivation

INTRODUCTION affecting the cognitive processes.[4] However, in modern-

day society, sleep is getting lesser and lesser priority,
Vigilance is a term used synonymously with alertness thereby affecting performance at work. Sleep deprivation
or sustained attention and reflects arousal and cognitive brings about an increase in reaction time and errors.[3]
performance.[1] Vigilance can be assessed either by The decrease in vigilance and performance can lead to
computer-based tests or by well-established paper- disastrous outcomes in professions such as medicine,
pencil tasks such as the letter cancellation tasks and air traffic monitoring, and armed forces where a
digit symbol substitution test.[2,3] The paper-pencil tasks high level of vigilance and performance is always
are easy to administer and inexpensive, making them required.
suitable for operational settings wherein computer-based
tasks cannot be used. Various studies have been done to evaluate the
effect of sleep deprivation and performance. In a
Vigilance and sleep are inseparable from a physiologist’s study on anesthesiology residents, Bartel et al. found
point of view. Sleep by itself is an important factor a psychomotor deficit in 52% of sleep-deprived
doctors.[5] This was accompanied by increased reaction
Access this article online time especially in simple reaction task, thereby
Quick Response Code
suggesting that monotonous tasks were more susceptible
Website:
to deterioration of performance. Santhi et al. also found
[Link]
a slowing of response with decreased accuracy due to
sleep deprivation.[6] However, Webb and Levy reported
DOI: no effect of 48 h of sleep deprivation on performance
10.4103/0253-7176.101777 of the one-letter cancellation task.[7] In contrast, Lubin
et al. found a significant impairment after complete

Department of Physiology, University College of Medical Sciences, Delhi, India

Address for correspondence: Prof. Neelam Vaney

228, First Floor, Kailash Hills, East of Kailash, New Delhi 110 065, India. E-mail: neelamvaney@[Link]

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Dixit, et al.: Sleep deprivation in medical students

sleep loss.[8] Babkoff et al. evaluated the effect of 72 h test along with the number of correct responses and
of sleep deprivation by using three versions of a search errors was noted.
task having two, four, and six target letters.[9] They 3. Letter cancellation tasks: The one-letter and three-
found a significant decrease in performance, more for letter cancellation tasks were used in the study. The
the four- and six-letter versions, with the decrease being subjects had to cancel ‘A’ in the one-letter version
more on the third day a compared to the first day. In and ‘A’, ‘Q’, and ‘T’ in the three-letter version. The
contrast to performance, accuracy was not compromised total number of correct responses with the number
in the first 24 h. Similar decrease in the number of hits of errors and the time taken to complete the task
on letter cancellation tasks with an increase in false was recorded for every subject.
positives on sleep deprivation has been reported by
Casagrande et al.[3] The subjects were tested at 8.00 a.m., 1.00 p.m.,
5.00 p.m., 10.00 p.m., 1.00 a.m., and 8.00 a.m. No
Studies have been done on health-care professionals time during the day were they allowed to sleep or have
in various specialties to evaluate the effect of sleep any stimulant such as tea or coffee. The timing of the
deprivation, but there is scant literature on the effect testing was kept in accordance to the daily activity
on performance of medical students. Students usually of the students of attending lectures, practicals, and
spend sleepless nights in the hope of securing better clinics. At all times during the test day, the subjects
grades. But is it really so, or is it that lack of sleep can were accompanied by one of the investigators. Since
compromise their performance? This study evaluated they were under continuous observation, there was no
the performance on simple paper-pencil tasks in order opportunity for them to sleep unobserved. Whenever
to address this issue. the subjects felt sleepy, they were kept awake by talking.

MATERIALS AND METHODS The data obtained were analyzed by repeated-measures

analysis of variance followed by Tukey’s test by using
The study was conducted on 30 medical undergraduate SPSS, version 17. The data for response time for one-
students in the age group of 18–25 years (mean age letter and three-letter cancellation tasks were analyzed
21.08±2.15 years) after taking their written consent. by using unpaired t test at the corresponding time
The study was approved by the institute’s ethical points. All the results were compared with the baseline,
committee. i.e., 8.00 a.m. on day 1.

Students not having any current illness, those with no RESULTS

history of drug intake during the last two weeks, and
nonalcoholics and nonsmokers were recruited. The Digit symbol substitution test [Table 1]: There was a
subjects were asked to refrain from caffeine or any other significant progressive increase in the time taken to
stimulant intake for at least 12 h prior to the study. complete the test, with the time after 24 h being the
maximum. Digit vigilance test [Table 2]: Although
The testing was done following a restful overnight sleep the time for completing the test increased as the day
on days when no examination was scheduled. They progressed, the change was however nonsignificant.
were called a day before the actual testing to familiarize There was no significant change in the number of correct
them with the tests. responses. The errors increased significantly with time,
with the maximum number of errors occurring after
The following tests were done: 24 h. Letter cancellation tasks [Tables 3 and 4]: Analysis
1. Digit symbol substitution test: It is a test of of the data revealed no significant difference between
visuomotor coordination, sustained Attention, the time taken to complete one-letter and three-letter
and response speed requiring rapid information cancellation tasks. However, in both the tests, there
processing in order to substitute symbols accurately was a progressive increase in the response time. The
and quickly. The test consisted of numbers 1–9 number of correct responses decreased significantly
arranged randomly in 4 rows of 25 squares each. when compared to the baseline. Also, the numbers of
The subjects were asked to substitute each number errors were significantly more with sleep deprivation.
with a symbol given in the key. The time taken to
complete the test was noted.
DISCUSSION
2. Digit vigilance test: This test is a marker of sustained
attention. It consisted of number 1–9 arranged The present study evaluated the effect of 24 h of sleep
randomly in rows. There were 30 digits per row deprivation on vigilance by using paper–pencil tests.
and 50 rows per sheet. The subjects were asked to The results revealed increased errors with a decrease in
cancel out digits 6 and 9. The time to complete the the number of correct responses on letter cancellation

130 Indian Journal of Psychological Medicine | Apr - Jun 2012 | Vol 34 | Issue 2
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Dixit, et al.: Sleep deprivation in medical students

Table 1: Results of digit symbol substitution test and Levy.[7] In contrast, Angus et al. and Lubin et al.
Time Response time reported a significant impairment of performance.[8,10]
8:00 a.m. 2.21±0.25 Babkoff et al found no significant difference in hit
1:00 p.m. 2.29±0.26*** percentage in first 24 h.[9] But their study had time
5:00 p.m. 2.32±0.23*** constraint wherein the test administered had duration
10:00 p.m. 2.31±0.21*** of 1 min and hence lesser number of letters were
1:00 a.m. 2.33±0.19*** scanned. On the other hand, our study had the target
8:00 a.m. 2.46±0.38***
letter occurrence of 300 and hence was more effective
Data represent mean±SD values ***P<0.001 in picking up the change in judgment ability. In a study
that evaluated performance every 2 h, Monk and Leng
Table 2: Results of digit vigilance test demonstrated a decrease in the accuracy of performance
Time Response time Correct hits Error hits from 8.00 a.m. to 11.00 p.m.[11]
8:00 a.m. 4.59±0.64 299.6±8.4 1.4±1.6
1:00 p.m. 4.62±0.71 293.96±13.39 1.83±1.8*** Our findings were contrary to that of Porcu et al.,
5:00 p.m. 4.80±0.76 296.26±13.39 2.8±2.9*** who found no change in performance of digit symbol
10:00 p.m. 4.88±0.86 297.73±14.60 2.3±2.3*** substitution task with sleep lack but reported a
1:00 a.m. 4.91±0.7 296.13±11.62 4±4***
decreased performance on the letter cancellation
8:00 a.m. 5.11±2.14 296.57±11.69 4.93±4.3***
task.[12] They postulated that the letter cancellation task
Data represent mean±SD values ***P<0.001 was more complex, thereby requiring higher attentive
load and thus is more sensitive to the effect of lack of
Table 3: Showing results of one-letter cancellation task sleep. We, on the other hand, believe that had that been
Time Response time Correct hits Error hits the case, the performance of the subjects in our study
8:00 a.m. 2.31±0.13 299.6±8.39 1.4±1.6 should have decreased on the letter cancellationtask
1:00 p.m. 2.35±0.12 238.83±7.10*** 0.9±1.1 and digit vigilance test since both are similar in nature.
5:00 p.m. 2.39±0.14 238±7.40*** 1.1±1.3 The digit symbol substitution test was more complex
10:00 p.m. 2.42±0.28 238.9±6.42*** 1.03±1.27
as it required the subject to first see and interpret the
1:00 a.m. 2.47±0.33 239.23±6.78*** 1.8±1.58***
number and then select and fill the correct symbol
8:00 a.m. 2.57±0.75 239±7.85*** 2.27±2.07***
for it, thereby increasing the attentive load and
Data represent mean±SD values ***P<0.001
task complexity. It tested the subject’s information
processing, visuomotor coordination, and response
Table 4: Showing results of three-letter cancellation task speed and hence was affected more than the letter
Time Response time Correct hits Error hits cancellation and digit vigilance tests.
8:00 a.m. 2.75±0.41 299.6±8.4 0.77±0.9
1:00 p.m. 2.79±0.43 238.83±7.09*** 1±1.1 We conclude that sleep deprivation leads to impairment
5:00 p.m. 2.85±0.52 238±7.4*** 1.4±1.3
of judgment ability before the change in response speed
10:00 p.m. 2.84±0.61 238.9±6.41*** 1.37±1.21
and information processing is manifested. The change
1:00 a.m. 2.89±0.5 239.23±6.78*** 1.73±1.81
is more in the complex task as compared to the simple
8:00 a.m. 2.91±0.49 239±7.85*** 3.2±3.73***
ones, thereby increasing the probability of errors. In
Data represent mean±SD values ***P<0.001
occupations such as medicine and air traffic control,
such a decrease in performance can be detrimental
tasks. The error rate was also increased on the digit and lead to undesired outcomes. The performance of
vigilance test. There was a significant increase in the students too can be compromised in examinations,
time taken for completing digit symbol substitution especially in situations such as multiple-choice
test. Thus, it was evident that the tasks requiring questions where they have to choose and respond to
sustained attention were affected by sleep deprivation often similar appearing responses.
and the effect was more on judgment ability than on
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performance after complete sleep loss: experiment I. Psychomotor performance of medical students: Effect of 24 hours of sleep
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Source of Support: Nil, Conflict of Interest: None.
topology of performance curves during 72 hours of sleep

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