Caffeine Consumption Among Orthopedic Residents is Higher Than the General Population

Background: The purpose of this study was to evaluate caffeine consumption among orthopedic surgery residents. We hypothesized that compared to the general population, residents will consume more caffeine. Patients/Methods: An electronic survey consisting of 13 multiple-choice questions was created to query residents on their caffeine consumption. The survey link was e-mailed to all residency program coordinators in the United States who then forwarded the survey to their residents. A subgroup analysis was performed based on respondents’ post-graduate year (PGY), to identify variations in caffeine use.

Caffeine is a naturally occurring alkaloid substance found in numerous plant species including the seeds, leaves, and fruit of coffee, tea, cocoa, guarana, and more than 60 other plants [1]. Energy drinks are now a commonly used source of caffeine and market value is predicted to reach $61 billion by 2021 [10]. Energy drinks are promoted as supplements that can boost performance and cognition, but have been reported to have side effect [10,3,7,11].
The purpose of this study was to evaluate the consumption of caffeine among orthopedic surgery residents. We hypothesized that compared to the general population, orthopedic surgery residents will consume more caffeine.

Materials And Methods:
An electronic survey was created to query orthopedic residents on their caffeine consumption. It consisted of 13 multiple choice questions and was made using Google Surveys (Google; Mountain View, CA). The link to the survey was e-mailed to all orthopedic residency program coordinators in the United States who then forwarded the survey to their residents. The survey remained active for a 2-week period between March and April of 2020 and responses were made anonymous.
Descriptive statistics were used to evaluate the data along with a chi-square test of independence. A subgroup analysis was performed based on respondents' post-graduate year (PGY), to identify variations in caffeine use. All analyses were performed using Minitab (Minitab, Inc; State College, PA), and signi cance was set at p = 0.05.

Source of Funding:
No outside sources of funding were used.

Results:
We received 209 completed surveys which represents approximately 5.4% of all orthopedic residents in the country [6]. Of those 209 residents, 189 (90.4%) participants indicated regular caffeine usage. Over half of the residents who consume caffeine (59.8%) indicated that they need caffeine to perform their daily work duties while 64.6% indicated that they are dependent on caffeine and will experience withdrawal symptoms if they do not consume it daily (Table 1). Respondents were asked about their preferred sources of caffeine. They could make multiple selections in this category which may be seen in Table 1. Coffee was the preferred source of caffeine as 170 (89.9%) residents indicated that they consume it on a regular basis (p < 0.001). Energy drinks were the second most popular source of caffeine as 91 (48.1%) residents indicated they drink them regularly. In a direct comparison, coffee and tea are consumed more than energy drinks (p < 0.001). There was an even distribution of milligrams (mg) consumed per day from < 200 mg to > 600 mg. Nearly one-fourth (24.3%) of respondents indicated that they consume more than 400 mg of caffeine per day and forty residents (21.2%) were unsure how much daily caffeine they consumed. A majority of residents (64%) felt that they consumed the most caffeine on their trauma rotations (p < 0.001) ( Table 1). Most residents (84.2%) reported they began consuming caffeine prior to residency (p < 0.001). Table 2 demonstrates a nearly even distribution of responses across PGY classes except for fellows. Due to the low number of responses from fellows their responses were excluded from the subgroup analysis.
There were no statistically signi cant differences across resident PGY groups. Universally the most caffeine is consumed on trauma followed by night oat/call shift rotations. Though not statistically signi cant, residents reported increasing concern regarding their caffeine consumption from PGY-1 to PGY-5 (Table 2). Discussion: Most Americans consume caffeine, as 85% drink at least one caffeinated beverage daily averaging 150-200 mg of caffeine [3]. Our goal for this study was to evaluate the consumption of caffeine among orthopedic surgery residents and compare it to the general population.
As we expected the amount of caffeine consumed among orthopedic surgery residents would be greater than the general population [3]. In our study cohort 90% (189 out of 209) of respondents consumed caffeine daily with 59% of them consuming more than 200 mg/day. The Food and Drug Administration recommends limiting caffeine consumption to 400 mg/day, however, nearly one-fourth of residents (24.3%) exceeded this limit. Increased consumption of caffeine among our study population is most likely due to the rigors placed on them at work combined with sleep deprivation. Previously reported by Basner et al., the average number of hours spent sleeping across all rotations by an intern averaged 6.8 hours and 2.19 hours during a call shift [5].
Although caffeine can be bene cial by improving mental focus, alertness, and memory, it may lead to agitation, tremors as well as dependency and withdrawal [9,11]. Daily energy drink consumption has also been found to have numerous deleterious cardiovascular side effects [10,11]. Most surveyed residents indicated that they feel withdrawal symptoms if they do not consume caffeine daily. Additionally, roughly 12% of the residents felt that caffeine not only negatively affected their work but, also led to disruptions in their sleep although a minority of the cohort (12%), was concerned about the amount of caffeine they consumed.
The weakness of our study is that of many survey studies as we were not able to survey the entire cohort of orthopedic surgery residents. However, this is the rst study to evaluate caffeine consumption among residents in any medical specialty.
We have demonstrated that when compared to the general population, a larger proportion of orthopedic Declarations: Ethical Approval: There were no required ethical board approvals. All participants in this survey openly consented to participation by voluntarily completing the survey.

Consent for Publication:
Not applicable.
Availability of Materials: Raw data was generated at Orlando Health. Derived data supporting the ndings of this study are available from the corresponding author Chris Garrett, MD on request.
Competing interests: We have no competing interests and there was no outside funding for this study. Funding: No funding was obtained for this study.
Authors Contributions: As the corresponding author for this study I worked to create a questionnaire and sent this by email to as many orthopedic residency programs in the country as possible, once we reached our desired number of responses Dr. Kareem Shaath and myself reviewed this information and ran the statistical analysis. Dr. Shaath and I then wrote the manuscript with oversight and editing being performed by Dr. Avilucea.