Sleep: the topic has been discussed so many times, it has
become soporific. Sleep is good for you. We can’t exactly tell you why it’s
good for you, but it is. Wait though: too much sleep isn’t good for you either.
Everyone’s ideal ‘sleep quota’ is different but there’s no easy way to figure
out what that quota is beyond figuring it out yourself. No one can chronically
survive on less than five hours of sleep without delving into hallucinations
and altered mind-frames. Sleep deprivation is driving the developed world’s
diseases: obesity, hypertension, diabetes. Much of the Western World is
chronically sleep deprived. Maybe we can solve the New World’s chronic diseases
through rectifying sleep deprivation? We know that we can catch up on acute
sleep deprivation, but chronic sleep deprivation? -- Forget it! Doctors are
urging Americans to sleep more, rely less on caffeine: You’ll be more
productive. You’ll be less hungry and less inclined to binge on junk food. Your
blood pressure could go down. Various components of your memory will be
improved. The list goes on.
We have, nevertheless, a conundrum: Humans are trying
more and more to sleep less and less, squeezing productivity and work-time into
an unchanging quantity of hours – the so-called “24-hour human”. And yet, we as
a species have not (yet) evolved to require less sleep. What are we to do?
Let’s go back to the workplace. Specifically, my
workplace: the hospital. We’ve all heard that physicians are sleep-deprived
individuals. However, after the famous Libby Zion case and the reluctant admission
that severely sleep-deprived individuals making crucial medical decisions was akin
to a drunk person making those decisions[i], the new ACGME 2003
work-hour restrictions were instituted. Now that they are in place, the dangers
associated with sleepy physicians is somewhat less of a problem. Interns – the primary
providers for patients – can now only work 16-hour shifts at a time, maximum. Despite
this, there are now new concerns over patient care due to the loss of
continuity – the same physician taking care of the patient from admission to
discharge – and also, about the loss of information that comes from passing-off
information about a patient to a new team, which happens multiple times with
the same patient.
And yet, there is something about the culture of medicine
that is resistant to change, and I feel it as a medical student. Attendings
laugh at the interns, saying “you have it easy”. “Back in my day” is a common
way that attendings like to initiate their jibes directed at interns. Before
work-hour restrictions, patient care was sublime: the god-like physician strode
around the hospital at all hours of the day and night, healing the sick and
bringing them back to life. They were macho, invincible. Sleep was for the
weaklings. And to them, that’s us – the new wave of interns.
This culture of constantly being ‘on’ and present seeps
down to the medical students. Medical students actually don’t have work-hour
restrictions. It hasn’t happened too many times to me that I’ve gone over an
80-hour work week, but it has happened, and it has certainly happened to some
of my friends. With the added stress of trying to learn new material and studying
for NBME Shelf exams, the long hours spent physically at the hospital can be
quite detrimental. The worst about it is that, in the majority of the time, we
are – quite honestly – useless. I recall so many times during my third year
where I was present in the hospital and, frankly, doing nothing – too preoccupied
to study, too afraid to go home. We all laugh as we look back on the shared
experience of pulling on the intern’s elbow like little children, as we ask, “Is
there anything I can help you with?” (because we can’t ask outright to go home,
since they’re likely evaluating us, and we need the highest grade possible) –
and the clueless (--which always astounded us: weren’t they medical students
just a few months ago? Don’t they remember?) intern would reply, “Not for now,
maybe in a bit”. Or they hand us some scut work (often calling for appointments
for patients or trying to obtain medical records from another hospital – things
that probably will save time for the intern, but which none of us went to
medical school to excel at), which then takes us several hours to complete –
and now it’s 11pm, we muddle home, too exhausted to be productive, before
having to wake up at 4:30am to return to the hospital. And so it goes on.
Also, as medical students, we carry pagers, just like the
physicians. This does have its advantages: we are easy to contact, and can
(mostly) stay apprised of what is going on with our teams. But it has its major
downsides too. I, with my medical student colleagues, have gone through the
experience of staying overnight in the hospital ‘on-call’, trying to sleep for
a few hours in the call room. The pager always remains by my head for fear that
I won’t hear it otherwise, should I be paged in the middle of the night. (And
even then, I have friends who use the same strategy and yet somehow manage to
sleep blissfully through any cacophony, including the shrill beep of their
pager.) Many of us have never been paged out of sleep (the residents thankfully
taking pity on us), but in spite of this, I would inevitably wake up every half-hour
to check whether my pager had gone off. This fitful sleep left me feeling more
stressed than rested. And the stress of sleep would spill over outside of the
hospital. Our circadian rhythms became completely thrown off. Many of us,
stressed about school and studies, would find it difficult to fall asleep no
matter how tired we were, or we would wake up before our alarm clocks. Many of
us, myself included, abused various sleep aids – Benadryl, Nyquil, Ambien,
melatonin. We’d confide in each other about it, but I still wonder if any of us
told our mentors. As future physicians, we were already beginning to behave in
the manner that was counter to what we would be advising our own patients.
Should we have clear work-hour restrictions for medical
students? I’m not sure. Actually, it is still unclear how much of an improvement
in sleep deprivation and quality of life has been seen with work-hour
restrictions[ii].
Further, the interns are often forced to work over the work-hour restrictions in
many specialties of medicine. This may be for various reasons: type A
personalities who can’t let go of their work or their patients; they are slow
and need extra time to finish their work (especially at the beginning of intern
year); they are influenced by attendings who push them to work harder and
belittle them for trying to follow the guidelines (especially true in male-dominated
slash macho specialties such as surgery); or, interns may feel a sense of loss
of autonomy and ownership when they are constantly forced to hand over their
patients to someone else, and stay on to try to retain a sense of satisfaction
for caring for ‘their’ patient. Always, they are encouraged to brush aside
those additional hours, not to document them – so that the institution does not
get into trouble for violations. But, perhaps the hidden work-hour violations
are a symptom of the fact that the current solution to the original problem is
not ideal.
Here’s an idea: what about taking the
still-sleep-deprived interns and going back to retaining patient continuity
with slightly longer hours, but using the ideas that cultures globally have
been using for centuries: taking a nap?
Americans like to laugh at Europeans and their need to
take a nap in the middle of the day. After eating a nice, hearty lunch, the
shop vendors close the stores, head home – and sleep, for 2-3 hours. It’s the
daily siesta, commonly practiced in Mediterranean cities such as in Spain and
Italy. It’s not just in Europe that the siesta is commonplace. The Taiwanese do
it too, with workers taking half-hour naps mid-day with the belief that it will
improve productivity, maintain dexterity, wellbeing and alertness.[iii] However, with the
economy in crisis, a lot of workplaces in the Mediterranean that had formerly
enjoyed long lunch-breaks have now moved to a more routine workday. There are
places that are trying innovative ways to do both – for instance, using the
Ostrich Pillow to allow short naps in the workplace.[iv] Tech and start-up companies
in the US are reported to use these strategies as well – all to keep workers
comfortable, happy, and productive – even past the regular work-day hours.
So, we know that sleep is beneficial, but what about
naps? While the days of taking regular naps as babies and toddlers are gone,
are there good reasons – whether they be social, health, economic benefits – to
take naps?
Well, there’s been several studies and articles trying to
answer the question: are daytime naps good for you? Firstly, there are
different reasons that adults would nap during the day. It may be out of habit,
due to sleep-deprivation from long work shifts, or as a result of a sleep
disorder – and the reason could modify the benefits of the nap. Several studies[v] found that a nap of just 10
minutes’ duration would promote wakefulness, improve the individual’s learning
ability and performance for up to three hours – and that it is mainly the Stage
2 of sleep that contributes to the observed improvements. However, naps lasting
30 minutes and longer were actually associated with a loss of productivity and ‘sleep
inertia’ – aka, the grogginess felt when trying to get back to work immediately
upon waking – but on the other hand, the benefits on performance and efficiency
after the nap will last longer. There is also thought that you would optimize
your nap if you coincide it with your circadian rhythm by taking the nap in the
early afternoon. While one paper suggests there is epidemiologic evidence illustrating
some concern that frequent, longer naps can lead to adverse long-term health
effects, there is also evidence that it is precisely those individuals who take
regular naps who will benefit more from the naps compared to those who nap
sporadically.
Going back to the idea I proposed earlier: what if
medical interns could take a nap? Well, I’m certainly not the first person to
have this idea. A study[vi] published in 2012 titled “The
effects of a mid-day nap on the neurocognitive
performance of first-year medical residents: a controlled interventional pilot
study” took 29 residents and instructed 19 of them to nap in an EnergyPod (a reclining
chair) for up to 20 minutes (a duration chosen to reduce the effect of sleep
inertia), while keeping the other 11 awake through conversation. The average
nap-time was found to be about 8 minutes, and – no surprise – they found that
the cognitive function and alertness of the internal medicine residents was
improved. A slightly different study[vii] from
2006 allowed naps in medical interns who were working overnight, so that they
could sleep up to 210 minutes’ of sleep while on call. This is different from
the day-time naps that I’ve been discussing. In this study, while the
participants did report a reduction in fatigue, they were concerned about continuing
the core function of their jobs - taking care of their patients. They would
frequently choose to answer calls about their patients, or complete tasks for
their patients, in lieu of napping.
What about drugs? Caffeine has been studied
as well in nighttime drivers[viii] – and,
in fact, may be more effective than napping in terms of restoring performance.
There are concerns, however, that while caffeine may restore simple cognitive
functions, it may fail in preserving the more complex cognitive performances.[ix] And what
about real pharmacotherapy? Currently, modafinil is the only awake-promoting
drug approved to treat sleepiness associated with shift-work disorder. It also
does not have the abuse potential that drugs such as amphetamines do. In spite
of its efficacy in improving users’ performance, users reportedly do not return
to near-normal levels of function.
So, what is the solution to the current
problem? I believe we need to make a decision about what we prefer: physicians
who are sleep-deprived and unfocused or inattentive but are continually present
– or ones who were absent for those 20 minutes to nap and to recuperate, and thereafter
function measurably better? Is the physician’s responsibility to patients to be
omnipresent, or to provide the best care possible? We may be a few studies away
from figuring out how best to provide physicians with time to rest without
disrupting patient care. A large source of resistance stems from the older
generation of physicians who are resistant to these new ways, and feel it is
leading to a demise in the resilience of physicians, and consequently, in the
care of patients. At least for now, there doesn’t seem to be any move to change
the current system. But change can happen – and it did. There may be several
bumps in the road as we try to smooth out and optimize the system – after all,
it was the way it was for decades. All it requires is realizing that doctors
are human, and need rest to function optimally – and to take the best care of
their patients. I think we can agree we’d all be pleased with that outcome.
*Click on PMID below for link to original PubMed article.
[iii] Moore,
Lisa. The Afternoon Nap Attack. U.S. News & World Report. 3/26/2007, Vol.
142 Issue 11, p57-57. Accessed from
[v] Dhand
R, Sohal H. Good sleep, bad sleep! The role of
daytime naps in healthy adults.
Curr Opin Pulm Med. 2006 Nov;12(6):379-82. PMID 17053484
Lovato N, Lack L. The effects of napping on
cognitive functioning. Prog Brain Res. 2010;185:155-66. PMID 21075238
Brooks A, Lack L. A
brief afternoon nap following
nocturnal sleep restriction: which nap duration is
most recuperative? Sleep. 2006
Jun;29(6):831-40. PMID 16796222
Hayashi M, Motoyoshi N, Hori
T. Recuperative power of a short daytime nap with or
without stage 2 sleep. Sleep. 2005
Jul;28(7):829-36. PMID 16124661
[vi]
Amin MM, Graber M, Ahmad K, Manta D, Hossain S, Belisova Z, Cheney W, Gold MS, Gold AR. The effects of a mid-day nap on
the neurocognitive performance of first-year medical residents: a controlled
interventional pilot study. Acad Med. 2012
Oct;87(10):1428-33. PMID 22914520
[vii]
Arora V, Dunphy C, Chang VY, Ahmad F, Humphrey HJ, Meltzer D. The effects of on-duty
napping on intern sleep time and fatigue. Ann Intern Med. 2006 Jun 6;144(11):792-8. PMID 16754921
[viii]
Philip P, Taillard J, Moore N, Delord S, Valtat C, Sagaspe P, Bioulac B. The effects of coffee and
napping on nighttime highway driving: a randomized trial. Ann Intern Med. 2006 Jun 6;144(11):785-91. PMID 16754920
[ix]
Guilleminault C, Ramar K. Naps and drugs to combat
fatigue and sleepiness. Ann Intern Med. 2006 Jun 6;144(11):856-7. PMID 16754928
No comments:
Post a Comment