Doctors are human. Doctors worry. They get cranky. Doctors feel stress, boredom, surprise.
Doctors get tired.
As a sleep specialist, I understand all too well one area that affects every aspect of physician decision making: sleep deprivation.
Dr. Goldman says we send our medical professionals the message to "Be perfect. Never, ever, ever make a mistake. But you worry about the details, about how that's going to happen." In this already-untenable and impossible expectation, sleep is the crucial "detail" that too frequently is treated like an afterthought.
Our culture says tiredness is to be ignored; it says the need for sleep is a weakness to be overcome if success is to be achieved. Not just a physical weakness, but a weakness of character: In many corners of the medical world, admitting to being tired is akin to admitting you're less than committed to your work.
In the physician culture, we don't just deny our doctors actual sleep, we expect them to learn how to deny themselves the need to sleep. We expect them to be impervious to fatigue, to remain somehow immune to the effects of sleep deprivation.
They are neither.
What they are is woefully -- and dangerously -- disconnected from sleep. Physicians and other medical professions frequently are not getting enough sleep. They're also under-educated in recognizing the symptoms of sleep deprivation and sleep disorders... in their patients and themselves.
The consequences of sleep deprivation among doctors are real and serious:
- Surgical complications increase when attending surgeons had less than a six-hour window for sleep between their final evening procedure and their first procedure the following day, according to research.
- Extended-duration shifts among medical interns in one study were associated with significantly increased risk of errors. Interns who worked five or more extended-duration shifts a month reported 300 percent more preventable errors associated with fatigue that resulted in fatalities.
- Residents in this study were 22 percent more likely to commit medical errors when sleep deprived.
Our cultural disconnect between medicine and sleep is apparent as early as medical school. Fewer than 5 percent of medical schools devote more than four hours of time to teaching students about sleep, and just 11 percent of medical schools offer students the chance to participate in a clinical evaluation of patients with sleep disorders.
Residency is when young doctors start their on-the-job training as physicians in practice. Residency is also the time when physicians start working particularly grueling hours and sacrificing sleep to even greater degrees. It's a well-known rite of passage for doctors to work extremely -- and dangerously -- long hours during their residency. On the Epworth Sleep Scale, which measures daytime sleepiness, when tested, residents rank between patients with sleep apnea and narcoleptics! In many cases residents are likely performing life saving -- or life-threatening -- surgeries while chronically and seriously sleep-deprived.
In 2011, new regulations for medical residents went into effect, limiting work hours. First-year residents may now work only 16-hour shifts before having an eight-hour break. Previously, first-year residents were allowed to work shifts as long as 30 consecutive hours. Second- and third-year residents may still work as long as 28 hours in a single shift, but they are not allowed to take new patients during the final four hours.
These changes came after years of debate and amid much disagreement within the medical community. These changes were also prompted in part by studies like this one, which showed that first-year residents who worked 16-hour shifts made half as many errors as their counterparts who worked 24-hour shifts.
The truth is, every individual's need for sleep is different. What's also true? The overwhelming majority of people need something in the range of 6-8 hours of sleep per night in order to function at our best. Our individual need for sleep is a genetically-determined characteristic. We can no more change our individual need for sleep than we can change the color of our eyes.
After residency, the thinking often goes, the worst is over. Those grueling, extended hours of training -- and the sleep deprivation that accompanies them -- are expected to ease. But do they? Depending on what specialty a physician pursues, on-call hours and rotating shift work can vary tremendously. So do the length of workdays. The work lives of an obstetrician, a cardiologist, and an ophthalmologist will look very different from one another. So will their sleep habits and the challenges they face in getting adequate rest.
What's more, illness and injury are just so... inconvenient. If calamity and sickness could just occur during normal office hours, life for physician and patient would be so much easier -- and safer. Obviously, this is not the case. As a result, many doctors remain shift workers throughout their careers. This means they remain vulnerable to sleep deprivation and sleep disorders.
What can we do differently?
We can teach sleep. I'm talking about teaching sleep in medical school and making sleep and sleep disorders a mandatory part of the curriculum. Students need to learn how to talk to patients about sleep and how to identify sleep disorders in patients and also in themselves.
I'm also talking about teaching residents how to sleep and how to recognize when they are sleepy. Research has shown that doctors, like the rest of us, aren't great at accurately assessing their own levels of tiredness. And the more tired you become, the less adept you are at making judgments about your level of fatigue and your ability to function.
Sleep is not an on-off switch. You can't just go home after a long, difficult day, close your eyes, and fall into a perfect slumber. Sleeping well, especially amid a high-pressure, high-stress professional life, takes planning and commitment. We're foolish if we expect residents and doctors to sleep well without giving them the education and tools they need to do so.
We can be smart about sleep. Rather than denying the problem of sleep deprivation, we can use what we know about sleep to our advantage:
- Genetics -- Some people are night owls, others are larks. By adulthood, most of us know which type we are. Why not take this genetic predisposition into consideration when creating schedules?
- Tools -- Consider use of light therapy for our docs to help move their circadian rhythms when needed, use of portable testing to determine levels of fatigue, and off-hours education modules to teach docs how to schedule their outside lives to help promote wakefulness.
- When it comes to rotating shifts, direction matters. It's easier for the body to adjust to shifts that change in a clockwise direction, moving from day to evening and overnight. When doctors and other medical personnel must work rotating shifts, why not structure shifts to rotate in this more sleep-friendly way?
- Technology allows us to connect across cultures -- and time zones. Rather than consulting with another sleep-deprived doctor down the hall, why not create networks that allow for consultation with physicians in other time zones?
Bringing about structural and cultural changes in our medical system is no simple matter, nor easy. Dr. Goldman calls for a new way of thinking -- and talking -- about mistakes and fallibility among medical professionals. I say sleep must be part of that conversation.
Michael J. Breus, PhD
The Sleep Doctor™
The Sleep Doctor's Diet Plan: Lose Weight Through Better Sleep
Everything you do, you do better with a good night's sleep™
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