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Importance of sleep in Medical School & Beyond

Posted by LaViidaLocaa , 04 August 2014 · 1,374 views

medicine sleep berkeley psychology
Think about it: would you let your children be sleep deprived? What about the bus driver of the bus you take to work, or the pilot flying you overseas? Of course not, they usually aren’t sleep deprived, but what about the people in the medical field? Surely, you wouldn’t want people dealing with humans’ lives to lack the ability to concentrate, do you?
Yet, medical students during residency have to work extra hard (and long) in order to get experience and meet the expectations, regardless of the price they pay for it. Doctors, too, are subjected to shifting work schedules and night duty, more often than not. Considering the enormous impact medical practitioners can have on people’s lives, the subject of sleep becomes even more important.

Modern medical training was founded by William Halsted, the first surgeon-in-chief at Johns Hopkins University of Medicine, in the 1890s. He required his residents to be on call no less than 362 days a year, a ‘suck-it-up’ attitude that resembled Medicine for the next 100 years. However, doctors and medical students are not a special class of people and are still subjected to the normal limitations of physiology, even though they often have to act like superhumans.

A Libby Zion Story

A tragic example of the severe sleep deprivation medical residents go through, happened in 1984. On the evening of March, 4th 1984, Libby Zion, an 18-year old college freshman with depression, was admitted to New York Hospital because of fever, agitation, disorientation and strange jerks.
Two residents evaluated Libby but couldn’t find a clear diagnose and called it a mere overreaction to a flu-like ailment. After being approved by calling the senior clinician, she was given meperidine, a sedative and painkiller to control her shaking. During the night, one of the residents went to sleep, while the other treated other patients. When Libby started making sudden jerks again, the remaining resident ordered the nurses to place medical restraints on her so she could not hurt herself. She also prescribed an injection of haloperidol, another sedative, without reevaluating Libby.
In the early morning, Libby’s temperature was dangerously high (107 °F/42 °C) and emergency measures were tried to lower the temperature. Despite the several attempts, Libby had a cardiac arrest and died. The doctors called the case a “bad outcome of a mysterious infection”.

Libby’s father, Sidney Zion, a lawyer and writer for The New York Times, couldn’t believe the diagnosis and was sure her death had something to do with inadequate staffing at the teaching hospital. Zion discovered that Libby’s chief doctors were busy residents with little supervision and that no senior clinician evaluated his daughter. He wanted to ensure that nobody else would have to go through such tragedy, which made him start his campaign to change the regulations.

One of the probable causes of Libby’s death was the interaction between meperidine and phenelzine, an antidepressant she was already taking, but which wasn’t clearly checked by the residents. Another point of discussion was the use of shots and restraints for an agitated patient. Instead of treating her increasing agitation, she was just ‘tied to her bed’. Zion also complained about the fact that the available resident was on a 36-hour shift while handling cases of life-and-death and covering several patients, the senior clinician was not around and the other resident wasn’t notified.

Zion’s complaints stood strong until the state of New York adopted new rules –the Bell Commission-, mandating residents to work a maximum of 80 hours per week and no longer than 24 consecutive hours. Also, the attending physicians needed to be physically present in the hospital at all times.
In 2003, the Accreditation Council for Graduate Medical Education (ACGME) introduced similar regulations for residents across the United States. In 2011, work hours were reduced even more, letting first-year residents go home to sleep after shifts of 16 hours.

Medical School & Sleep Deprivation

A study published in Sleep in 2004, showed that medical students in their first and second postgraduate year go through a high amount of sleep deprivation.1 Over 20% reported sleeping less than 5 hours per night, while 66% reported sleeping 6 hours or less per night. The former were more likely to report use of alcohol, serious accidents or injuries, weight changes, conflict with professional staff, use of medication to stay awake, making significant medical errors etc.

Residents in the fields of, for example, internal medicine and surgery often go through shifts of thirty straight hours, making the impact of lack of sleep even bigger. Regulations mandate a maximum of 80 hours of work per week, but logging false duty hours and working over 100 hours is not uncommon. A study published in the Sept. 6, 2006, issue of the Journal of the American Medical Association found that 80 percent of interns nationwide still sometimes work excessive hours.

In 2011, new rules were established to ensure first-year residents do not work longer than 16 straight hours, yet second and third-year residents still have to go through shifts lasting up to 28 straight hours. In contrast, a 2009 survey by BMC Medicine amongst American households showed that patients preferred a well-rested doctor over one that has been working for more than 24 hours, making the new rules still somewhat questionnable amongst the public.
Importance of sleep

Medical school, with its dozens of exams and rotations, as well as life as a licensed MD, calls for highly capable and quickly responding students. Nonetheless, sleep deprivation goes hand in hand with a severe decline in cognitive performance and reactivity.
A study done in 2000 showed that people who went without sleep for 17-19 hours showed a similar performance on cognitive tests as people with a blood alcohol content of 0.05% (roughly 2 alcoholic beverages).2
During wakefulness of more than 16 hours, sleep-deprived brains show significant changes in activity, which is reflected as a decline in alertness shown in EEGs. Also, the prefrontal cortex, responsible for many higher-level cognitive functions, is especially vulnerable to a lack of sleep, making logical reasoning and complex thoughts harder to execute.
Logically, these declines in performance do not go without consequences. It has been shown that sleep-deprived interns are more likely at incurring percutaneous injury as well as being in a motor vehicle accident.3,4 Furthermore, performance on surgical exercises may be negatively affected, leading to lower grades and less developed skills.5
As if it that’s not enough, even doctors themselves show consequences of sleep deprivation. After all, they’re just humans too. Surgeons who slept less than 6 hours during the night inflicted more surgical complications the following day than those who slept longer than 6 hours.6
Medical students find themselves on the intersection of sleep and memory. They have to recall vast amounts of situations, knowledge and skills, while at the same time, they are required to do 24-to-36 hour calls with minimal or no sleep, even though the latter is actually essential for residents to be at their cognitive best.
In 2004, the New England Journal of Medicine published two studies comparing the traditional 80-hour weeks with a reduced schedule of <63-hour week without >24-hour shifts. Residents from the intervention group reported over 6 hours more sleep per week, 22% less serious medical errors and half the amount of attentional failures during on-call nights.7,8
Mental health is another area that is severely affected by chronic sleep deprivation. In 2006, the Association of American Medical Colleges published a study about the correlation of sleep-deprived interns and their mood regulation. From the start until the end of the year, interns showed a significant increase in prevalence of depression, burnout and empathy due to chronic sleep deprivation. Students also reported lower quality of life together with their worsened mood.7

How can medical students, doctors and everybody in general improve their sleep?

The saying «Social life, sleep, good grades. Choose two of them» doesn’t always have to be true. By organizing your time and life and planning ahead, you might be able to get the best of all of them.
Here are some tips to improve your sleep and, consequently, your grades, evaluations, performance, mood, productivity, and so much more:

· Sleep about 7-8 hours on a regular basis. Sleeping less than 6 hours has been associated with a higher risk of obesity, cardiovascular disease, mood disorders, cancer, dementia and even mortality. On the other hand, sleeping for more than 9 hours has been associated with diabetes, obesity, dementia and mortality. Furthermore, try not to ‘sleep in’ in the weekends, as this might disrupt your circadian rhythm. It is recommended to go to bed and wake up each day at the same time, in order to optimize your circadian rhythm and eventually even wake up without the need of an alarm clock.
· Avoid bright and blue light before bedtime. As the evening goes on, our pineal gland starts to increase its production of melatonin, the darkness hormone that makes us sleepier when it gets dark at night. The production is, however, suppressed by light, making it harder to fall asleep when using bright light before bed. In order to maximize melatonin production, it is best to dim the lights at night and avoid the television, computer, smartphone or any other personal electronic devices, which send out blue light. On the other hand, in the morning, try to expose yourself to natural light from outside, in order to wake up.
· Avoid caffeine and alcohol in the late afternoon and evening. As we all know, caffeine (e.g. coffee, green tea, energy drinks, Coca Cola) gives most people a boost in the morning to kick-start the day. However, consumption of these beverages later in the day will keep you up late at night, thus interfering with sleep. Alcohol, despite being used as a ‘nightcap’, makes your sleep lighter and decreases the amount of time you spend in REM and deep sleep, which are essential for proper functioning. Alcohol can also increase stomach-acid secretion and relax throat muscle tone, leading to increased obstructions and arousals during sleep.
· Limit stress. In today’s life, everybody tends to run from one place to the other, from one class to their books, from one patient to another, without pausing for a minute or enjoying the beauty of life and what surrounds us. Stress not only increases your risk for several cardiovascular conditions, but is also associated with mood disorders. The latter are in turn highly comorbid with sleep disturbance.
· Associate your bed with sleep. If you lie in bed, but cannot fall asleep after about 20-30 minutes, get up and go to another room to read or write until you are sleepy. This trick, called stimulus-control therapy, lets you associate your bed only with sleep and not with being awake, in order to make you fall asleep faster.
· If you nap, do it wisely. If you’re going through a period of inevitable sleep-deprived nights and wish to catch up by napping, make sure to nap on the same time each day. This way, your body anticipates the rest, similar to your nightly tiredness. Also, make sure not to rest for more than 30 minutes, as that might work counterproductive, by deregulating your circadian rhythm and giving you a post-nap funk.
· Do not count sheep. A lot of people have trouble falling asleep due to stress and having many things on their mind. In order to limit spending time on unnecessary thoughts, try writing them down so you can handle them the next day. Another trick is often said to be ‘counting sheep’, but research has proven this to be too easy to be effective. Instead, try this: count back from 300 with steps of three (or any other boring math exercise). It keeps out the stressful thoughts and makes you fall asleep due to boredom.

Even though many of the tips and explanations appear to be logical, especially for medical students and doctors, they don’t often apply them in real life, even though they are the ones who should set a good example. It’s true what they say: you really should practice what you preach!


References:

1) Baldwin DC Jr, Daugherty SR.
Sleep deprivation and fatigue in residency training: results of a national survey of first- and second-year residents. Sleep. 2004 Mar 15;27(2):217-23.
2) Williamson AM, Feyer AM. Moderate sleep deprivation produces impairments in cognitive and motor performance equivalent to legally prescribed levels of alcohol intoxication. Occup Environ Med. 2000;57:649-655.
3) Ayas NT, Barger LK, Cade BE, et al. Extended work duration and the risk of self-reported percutaneous injuries in interns. JAMA. 2006;296:1055-1062.
4) Barger LK, Cade BE, Ayas NT, et al; for the Harvard Work Hours, Health, and Safety Group. extended work shifts and the risk of motor vehicle crashes among interns. N Engl J Med. 2005;352:125-134.
5) Kahol K, Leyba MJ, Deka M, et al. Effect of fatigue on psychomotor and cognitive skills. Am J Surg. 2008;195:195-204.
6) Rothschild JM, Keohane CA, Rogers S, Gardner R, Lipsitz SR, Salzberg CA, Yu T, Yoon CS, Williams DH, Wien MF, Czeisler CA, Bates DW, Landrigan CP. Risks of complications by attending physicians after performing nighttime procedures. JAMA. 2009 Oct 14;302(14):1565-72. doi: 10.1001/jama.2009.1423.
7) Lockley SW, Cronin JW, Evans EE, Cade BE, Lee CJ, Landrigan CP, Rothschild JM, Katz JT, Lilly CM, Stone PH, Aeschbach D, Czeisler CA. Harvard Work Hours HaS Group. Effect of reducing interns’ weekly work hours on sleep and attentional failures. New England Journal of Medicine. 2004;351(18):1829–1837.
8) Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, Lilly CM, Stone PH, Lockley SW, Bates DW, Czeisler CA. Effect of reducing interns’ work hours on serious medical errors in intensive care units. New England Journal of Medicine. 2004;351(18):1838–1848.
9) Rosen IM1, Gimotty PA, Shea JA, Bellini LM. Evolution of sleep quantity, sleep deprivation, mood disturbances, empathy, and burnout amonginterns. Acad Med. 2006 Jan;81(1):82-5.





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redFishBlueFish
Aug 07 2014 11:26 AM

This story has everything to do with carelessness than being over-stressed or lack of sleep. I like how the "doctor" just randomly gives the patient another dose of some other shit. This is why malpractice lawsuits exist because of utter carelessness like this story. The fact the other person fell asleep only distracts the fact the shitty job the person did. 

 

The story is tragic, but so are the recommendations by these people. Of course they are going to recommend 7 to 8 hours. The lack of research and real facts behind sleeping almost pisses me off. I could sleep 8 hours with a pillow over my face, but that doesn't mean I dove into REM.

 

"On the other hand, in the morning, try to expose yourself to natural light from outside, in order to wake up." I giggled on that one. And what of other colors besides blue? How about red?

 

"Alcohol can also increase stomach-acid secretion and relax throat muscle tone, leading to increased obstructions and arousals during sleep." Don't drink before bed because you might get a boner... lmfao. I now understand why all my German friends absolutely refuse to go to any US doctor.

 

Are these PhDs or people that work at your local bar?

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LaViidaLocaa
Aug 08 2014 04:21 AM

This story has everything to do with carelessness than being over-stressed or lack of sleep. I like how the "doctor" just randomly gives the patient another dose of some other shit. This is why malpractice lawsuits exist because of utter carelessness like this story. The fact the other person fell asleep only distracts the fact the shitty job the person did. 

 

The story is tragic, but so are the recommendations by these people. Of course they are going to recommend 7 to 8 hours. The lack of research and real facts behind sleeping almost pisses me off. I could sleep 8 hours with a pillow over my face, but that doesn't mean I dove into REM.

 

"On the other hand, in the morning, try to expose yourself to natural light from outside, in order to wake up." I giggled on that one. And what of other colors besides blue? How about red?

 

"Alcohol can also increase stomach-acid secretion and relax throat muscle tone, leading to increased obstructions and arousals during sleep." Don't drink before bed because you might get a boner... lmfao. I now understand why all my German friends absolutely refuse to go to any US doctor.

 

Are these PhDs or people that work at your local bar?

 

I haven't heard about the Libby Zion story until about a week ago (in Europe, there's not much attention given to the US education system in Medical School). I'm just relying on the facts given by literally every newspaper that wrote about the case. Nonetheless, I agree that US health care (and possibly the doctors themselves) isn't the best one, especially compared to most West-European countries. Health care in Belgium, for example, is pretty good.

 

Of course, REM is the most important part of sleep, but it's nearly impossible to trigger REM without electrical devices and in most people who sleep 7-8 hours, REM occurs during the second half of sleep. Thus, it's important to sleep long enough to reap the benefits of REM.

 

Regarding the different lights: blue has the biggest impact on your circadian rhythm and suppresses melatonin about twice as long as green light. Red light has the smallest impact on shifting your circadian rhythm. (Source: harvard.edu)

 

I was surprised to have read that piece about alcohol as well, but the arousal part isn't about sexual arousals, but waking up during the night (I'm not sure if you were being sarcastic on that one, hard to say online).

 

Lastly, the sources outside the tips are pretty much all scientific studies and reviews that have been conducted properly. The tips themselves are mentioned in the lectures at UC Berkeley, my professor being a sleep researcher herself and based on earlier findings.

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redFishBlueFish
Aug 08 2014 06:32 AM

Sometimes I sound argumentative online and I don't mean to, so if I come off as such, I am sorry for that.

 

I was being sarcastic on the arousal part, good catch. ;) I was a little annoyed with the "conformed" results of these studies. But I guess you have to start somewhere.

 

I think that if someone's throat relaxes enough to close their airway due to drinking, they may have an underlining issue. I know I can "feel" my airway being restricted without drinking, but it isn't because of alcohol and why I sleep with a cpap machine.

 

Many people in the polyphasic community use various devices to assist in diving into REM. I use my own imagination to dive into sleep, whether I dive into REM is something I won't know until I buy tracking devices to tell me such. All I have to do is put my head back, imagine this scene, and I will be out until my alarm goes off to wake me up.  

 

I feel 8 hours of monophasic sleep is a luxury. When I sleep 8 hours, I feel horrible. My body aches and I have a cloudy head feeling. When I sleep 4~4.5 hours monophasic or everyman, I am alert, sharp, and the cloudy head feeling is not there. I can stay up just as long, if not longer, than any 8 hour monophasic.

 

I am not questioning the studies in a way it was done improperly. Coming from someone that has had sleep problems his entire life and had to find his own solutions, these results seem face value. 

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LaViidaLocaa
Aug 08 2014 07:00 AM

Sometimes I sound argumentative online and I don't mean to, so if I come off as such, I am sorry for that.

 

I was being sarcastic on the arousal part, good catch. ;) I was a little annoyed with the "conformed" results of these studies. But I guess you have to start somewhere.

 

I think that if someone's throat relaxes enough to close their airway due to drinking, they may have an underlining issue. I know I can "feel" my airway being restricted without drinking, but it isn't because of alcohol and why I sleep with a cpap machine.

 

Many people in the polyphasic community use various devices to assist in diving into REM. I use my own imagination to dive into sleep, whether I dive into REM is something I won't know until I buy tracking devices to tell me such. All I have to do is put my head back, imagine this scene, and I will be out until my alarm goes off to wake me up.  

 

I feel 8 hours of monophasic sleep is a luxury. When I sleep 8 hours, I feel horrible. My body aches and I have a cloudy head feeling. When I sleep 4~4.5 hours monophasic or everyman, I am alert, sharp, and the cloudy head feeling is not there. I can stay up just as long, if not longer, than any 8 hour monophasic.

 

I am not questioning the studies in a way it was done improperly. Coming from someone that has had sleep problems his entire life and had to find his own solutions, these results seem face value. 

 

I understand that you are have the best position to know and feel what's best for yourself. Only a small amount of people are biphasic (except for most toddlers or some elderly), one of the reasons why most studies/recommendations suggest 7-8 hours of sleep. Of course, in your (and other polyphasics) case, it is better to do as you do, no one will argue with that. :)

 

I'm actually quite curious to see how those REM-devices will develop and become more available in the future, and if they show benefits to people that don't have any sleep disorders. 

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redFishBlueFish
Aug 08 2014 07:18 AM

That's the thing though, I believe most people are bi or more, -phasic. Most studies and recommendations are always going to be 8 hours because there are no real studies behind beyond monophasic.  It's modern society that has forced us into a monophasic mode. I bet if everyone did a siesta sleep cycle the world would be a better place and less reliant on stimulants. Not going on a random tangent or anything, lol.

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LaViidaLocaa
Aug 08 2014 07:39 PM

That's the thing though, I believe most people are bi or more, -phasic. Most studies and recommendations are always going to be 8 hours because there are no real studies behind beyond monophasic.  It's modern society that has forced us into a monophasic mode. I bet if everyone did a siesta sleep cycle the world would be a better place and less reliant on stimulants. Not going on a random tangent or anything, lol.

 

I think that is more because of modern society that people become bi/polyphasic. Electronics, nightlife, etc. keeps people up late at night, while work, school, etc. requires people to get up early. Hence, they need to get some sleep during the day.

 

Personally, I'm monophasic, for sure. I only sleep at night and it's impossible for me to sleep during the day or take a nap, even while traveling. But I do agree that more people would benefit from siestas, be it because their polyphasic, or just to catch up on sleep.

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redFishBlueFish
Aug 10 2014 12:05 AM

I agree with you completely with modern society forcing people to become polyphasic.


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