Najib Ayas remembers his days studying respiratory and critical care at Brigham and Women’s Hospital in Boston, Massachusetts, a decade ago. Like all other residents—doctors receiving specialty training—he worked gruelling shifts, anywhere from 24 to 36 hours straight.
“In Boston, I regularly stayed up for 30 hours at a time,” recalls Ayas, who’s now an assistant professor of medicine at UBC. “I do remember some afternoons feeling like I couldn’t function very well.”
Ayas, who’s also a consultant with UBC’s Sleep Disorders Program, has done extensive research into sleep, most recently coauthoring a study titled The Impact of Sleep Deprivation in Resident Physicians on Physician and Patient Safety: Is it Time for a Wake-up Call? The report, which the British Columbia Medical Journal published in December, concludes that lack of sleep might negatively affect the quality of care doctors deliver and that sleep-deprived physicians are at greater risk of car crashes, hospital-related injury and infection, and compromised mental health than their better-rested peers.
It’s not exactly what people who are already nervous about going to the doctor want to hear.
A 2005 New England Journal of Medicine study that followed 2,737 medical interns for one year found that those working shifts longer than 24 hours were more likely to have a car accident than those working shorter shifts.
In a 2006 Web-based survey of interns for the San Francisco, California–based Public Library of Science, interns made significantly more fatigue-related medical errors, which resulted in adverse patient outcomes, during months when they worked five or more overnight shifts.
And a 1998 Lancet study looked at surgical performance before and after a sleepless night. Surgical residents who had been awake the previous night made 20 percent more errors and took 14 percent longer to complete a simulated laparoscopic task than their colleagues who had slept well the previous night.
That fatigue can cause human error has been proven time and again. Look at such major disasters as the Chernobyl nuclear power plant meltdown and the Exxon Valdez oil spill, which were attributed to a lapse of judgment among sleep-deprived workers. But although maximum working hours have been legislated in some places for pilots and truck drivers, the same can’t be said for most medical residents.
“No one really wants the guy flying the plane to be sleep-deprived, but”¦residents are obligated to work these long hours—30 hours in a row—and still take care of patients,” Ayas says.
So given all the evidence pointing to the inherent dangers of sleepy doctors, why not just have them work shorter hours? It’s not as simple as that, Ayas explains.
Shorter shifts could mean doctors end up being less familiar with patient details. As the BCMJ study notes, doctors at the Mayo Clinic have reported that discontinuity of care presents a greater threat to patient safety than physician fatigue.
“If you have residents switching over after 12 hours, it’s more dangerous for the patients,” Ayas says.
Sleep deprivation is by no means limited to medical residents or shift workers.
According to the College of Family Physicians of Canada, 30 to 40 percent of adults experience some degree of insomnia every year. Canadian pharmacists filled 5.6 million prescriptions for sleep medication in 2007, totalling $128 million in sales.
For those who don’t have to work nights but still don’t sleep properly, the consequences can be serious. Besides leaving people feeling cranky, a lack of sleep leads to difficulty concentrating and making decisions.
A study published in the journal Nature in 1997 found that the decline in hand-eye coordination after 28 hours of wakefulness was about the same as what would result from a blood-alcohol level of 0.10 percent.
Women who sleep five or fewer hours a night are more likely to have a heart attack than those who sleep eight hours, according to a 2003 study in the Archives of Internal Medicine.
If you find yourself routinely unable to fall asleep, there are many things you can do to help yourself reach a state of slumber.
Maureen Ceresney, a consulting psychiatrist at UBC’s Sleep Disorders Program, says that people should fall asleep within about 15 minutes of hitting the pillow.
“You should wake up feeling refreshed and alert,” Ceresney says in a phone interview. “The most common problem these days is that people don’t give themselves enough opportunity for sleep.”¦People don’t take enough time to relax and unwind at night, so they go to bed still bothered by the worries from the day.”
B.C. Partners for Mental Health and Addictions Information suggests getting up if you can’t sleep and doing something relaxing, like having a bath or listening to soft music. Among other tips the group shares on its Web site (www.heretohelp.bc.ca/) are: avoid smoking, or drinking alcohol or caffeine within two hours of bedtime, exercise at least two hours before bedtime, and keep the same routine, even on weekends. Some people take prescription medication to help them sleep, while others use melatonin, a naturally occurring hormone available in supplement form that helps regulate circadian rhythms, or sleep-wake cycles.
Another treatment is light therapy, in which your eyes are exposed to intense but safe amounts of light. In some cases, where people have developed negative thought patterns related to sleep, cognitive behavioural therapy can help.
Relaxation training is also useful. British author Jan Sadler shares techniques in her recent book, A Good Night’s Sleep: A Drug-Free Solution (Healing Arts Press, 2008). Among her strategies are deep breathing, visualization, and a full-body relaxation scan.
Still others take power naps, rests no longer than 20 to 30 minutes. Winston Churchill relied on them. “You must sleep some time between lunch and dinner, and no halfway measures,” the late, great leader reportedly said. “Take off your clothes and get into bed.”
The strategy worked for Churchill. Maybe those catnaps would also help pooped doctors in training.