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An Industry in Need of Sleep

Sleep deprivation is a common problem that affects our work, our relationships, and our leisure hours—in short, our ability to live fully. The National Sleep Foundation estimates that nearly 50 million Americans chronically suffer from sleep problems and disorders that affect their careers, their personal relationships and safety on our roads.

 While physicians often are called on to treat sleep problems in their patients, many also suffer from sleep difficulties of their own. In fact, sleep deprivation has become such a problem among physician trainees that the Accreditation Council for Graduate Medical Education (ACGME) has mandated work-hour limitations of less than 30 continuous work hours and less than 80 work hours per week.

MD News talked to two local physicians with expertise in physician sleep deprivation to get the lowdown on how this condition affects physicians, and ways to deal with and overcome it.

Desmond Carson, M.D., is the medical director of the emergency department at Doctors Medical Center in San Pablo, and he recalls that sleep deprivation starts as early as medical school for most physicians. “Before residency even starts, the competition in medical school causes students to short themselves on sleep. Students become used to sleeping four to six hours a night,” he says.

In the residency years, physicians are often challenged to cram as much on-the-job learning into their working time as possible. Dr. Carson recalls that while working as a resident on the plastic surgery rotation, he found that fellow residents were finishing their cases at 3 am and then going home to read up on a medical case before being back at the hospital at 6 am. “I started to ask myself, can I really do plastic surgery?”

Going without sleep is, in fact, considered a rite of passage for many doctors, Dr. Carson says. “To make the grade, you need to prove that you can stay up long hours and be bright at the same time.” While Dr. Carson notes that this kind of training can prepare one for the rigors of practicing medicine, it also affects physicians’ quality of life and can actually be dangerous. He recalls that while working as a resident at Martin Luther King Hospital in downtown Los Angeles, he fell asleep in his automobile, and only awoke when someone tapped on the window. (Luckily the automobile was stopped at the time). He also remembers being so tired that as soon as he sat down to write notes after seeing a patient, he would fall asleep, and would have to be jostled awake by a co-worker.

Clete Kushida M.D., Ph.D., president-elect of the American Academy of Sleep Medicine and director of the Stanford Center for Human Sleep Research, notes that whether you’re a physician or not, sleep deprivation has some significant effects: it decreases attention and vigilance, affects learning and memory, and is also associated with mood changes. Sleep deprivation has also recently been associated with altered glucose metabolism, associated weight gain, and diabetes.

“There have been some very severe consequences of sleep deprivation such as motor vehicle and industrial accidents, Dr. Kushida says. “It’s a problem that affects us in several different domains.”

A number of studies have looked at the effects of sleep deprivation on physicians, especially residents. The problem with these studies is that they are often small, and their conclusions have been conflicting. Yet there are a few things scientists know about sleep among physicians. Often the sleep that physicians get—particularly those who do shift work or are in training—is impaired and fragmented. Physicians such as those who work in emergency rooms get less total and REM sleep than day shift workers, according to Dr. Kushida. After taking neuropsychological tests, physicians whose sleep is impaired show that their reaction time, vigilance and reasoning are somewhat impaired.  “We do know that sleep deprivation can definitely affect your ability to perform the next day,” Dr. Kushida says.

In one study published in 2007 in the journal Chest by Parthasarathy et al., researchers studied the effect of work hour limitations on physicians’ quality of life, sleepiness and sleep-work habits. In the study of 34 residents and 10 fellows working in a city hospital ICU unit, the physicians underwent a battery of tests after their work schedules were reduced according to ACGME guidelines.

The researchers found that after the work hour reduction, the physicians experienced statistically significant but minor improvements in sleep time, subjective sleepiness and quality of life. However, both before and after the work hour reduction, sleepiness and quality of life deteriorated during the course of an ICU rotation. The work hour reduction also failed to affect some important benchmarks. Even after the work hour reduction, the ICU team had mean sleep latency of less than 10 minutes and 14% manifested sleep-onset rapid eye movement periods (signifying severe sleepiness) before their extended work-hour period.

“There was a clear persistence of residual pathologic sleepiness despite the implementation of the work-hour reductions,” the researchers wrote in their paper.

The investigators concluded that more stringent measures might be needed to address the persistent sleepiness of the ICU physician staff. They noted that a further reduction in work hours to less than 16 continuous hours might be one solution. However they also noted that their study had some significant limitations, including the fact that it was a single-center study and might not be generalized to other institutions and non-ICU settings.

In another study published in the journal Clinical Medicine in 2006 by Horrocks et al., researchers noted that physicians need practical help to deal with the hazards of shift work.

Not only does such work affect quality of life, but also work performance—leading to fatigue-related medical errors. The study was initiated by UK-based researchers after the institution of the European Working Time Directive Regulations, which mandated that junior physicians in the UK had to work round-the-clock night shifts. The researchers found that two recommendations could help impact sleep debt: taking additional two-hour naps in the afternoon before a shift, and 20 to 45-minute naps during the night shift. “It’s hoped that this advice will make the challenge of night shift work not only easier to tolerate, but also safer for both hospital patients and their doctors,” they said.

Still, even among physicians, there is individual variation in the amount of sleep each person needs, and the amount of sleep deprivation a person can take without effects on function, reasoning and judgment. Younger people tend to better with sleep deprivation than those who are older. A pre-existing medical disorder, such as sleep apnea, can make the symptoms of sleep deprivation much more severe, according to Dr. Kushida.

How can physicians or physician trainees deal with sleep deprivation? Dr. Kushida recommends finding a period where you can maximize your sleep—i.e. sleep as much as you can. During this period, if you’re having trouble sleeping or are having symptoms of fatigue or sleepiness, it may be time to seek professional help. These symptoms could be the sign of an underlying sleep disorder, which will need to be evaluated by a sleep specialist at an accredited sleep center.

If a physician works night shifts, Dr. Kushida offers tips for maximizing the quality and quantity of sleep. These include:

·         Keeping a regular sleep schedule as much as possible

·         Using bright light therapy to stay alert during work time, and going to bed earlier. To get the most out of bright light therapy, you should avoid bright lights a few hours before bedtime. Then as soon as you wake from sleep (within 5 minutes), try exposure to bright light for about 30 minutes. Although outside light is best, a light box can also work, Dr. Kushida says.

He doesn’t recommend medication for physicians, since sleep medications can affect sleepiness during the day as well as cognitive function. However, he notes that short-acting medications are now available that can help initiate sleep, and don’t have the same risk for cognitive side effects the next day. Any medication should only be prescribed or taken under the guidance and monitoring of a sleep specialist, according to Dr. Kushida.

At Doctors’ Hospital, Dr. Carson notes, two of the physicians on his staff like to work the night shift—relieving the burden on the rest of the staff, who only have to work night shifts one or two times a month. “And that’s certainly a manageable schedule for most physicians,” he says. To minimize the strain of working the night shift, physicians also work only seven hours per night, and those over 55 are not mandated to work on-call at night. These rules ensure good quality patient care as well as manageable schedules for physicians, Dr Carson says.

If you do work the night shift, regular exercise is key to maintaining good quality and quantity of sleep, he notes.

“After you get through residency, sleep deprivation is simply not as much of a problem as it is during training. It’s something we deal with occasionally, but even those of us who work the emergency room aren’t troubled too much by sleep deprivation,” Dr. Carson says.

 

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