• Rosalind Kaplan, MD

To Sleep...Perchance to Dream

By Rosalind Kaplan, MD

Last night at a small gathering of women physicians, two of us stood talking about how it felt to have more time to ourselves as we got older and eased out of some of our obligations.

"I'm finally not tired all the time," my companion told me.

"Same!" I replied. "For the first time in my adult life, I have gotten 7 hours of sleep a night for almost a month straight! I finally think I know what it feels like not to be sleep-deprived."

What it feels like not to be sleep deprived:

* I wake up in the mornings clear-headed, ready to start my day.

* I drink 2 cups of coffee in the morning, and maybe some decaf later in the day. I drink the coffee because I like it, not because I need it to wake up or stay awake or concentrate.

* I don't have to force myself to exercise, because I have enough energy to do it.

* I no longer spend my whole day wishing I could have a nap.

I do think it's a little sad that, in my early 60's, I feel that I have spent my entire adult life sleep-deprived, but apparently all the women physicians I know feel the same way. I suspect that many or all of the male physicians I know do, too--we just haven't discussed it. And I am certain that many non-physicians also feel sleep-deprived- people who have infants, people who do shift work, people who have insomnia, people who work more than one job...but I can only speak from my own experience in this post, so it will focus on sleep deprivation in doctors.

In medical training, it was drilled into our heads that the more time we spent awake, taking care of patients, the more we would know and the better we would be at our profession. Outdated, poorly performed research studies showing that people could continue to make correct decisions after sleep deprivation were bandied about, gaslighting us into believing that it was okay for us to work 36 hours at a stretch without sleep. Since 'on-call' was mandatory every third or fourth night through years of medical school and residency, we chose to believe that we were not hurting ourselves or anyone else with our lack of sleep.

As an attending doctor, with my training completed, my sleep patterns were better, but they never really normalized. First, it was parenting babies and little kids, with the attendant nightly interruptions to sleep, accompanied by night and weekend on-call by phone. Once the kids were old enough to sleep through the night, we were still being awakened by our beepers on many nights. My husband, also a doctor, was also on call, often on different nights than I was. At least 3 or 4 nights a week, we were awakened by my beeper or his. He went back to sleep easily; I didn't, especially if the call was one of my patients and the symptoms they had were worrisome.

There were other nights, when nobody was on call, that I didn't sleep well because I was wound up over something at work, worried or sad or angry. Some nights, I got home late and it took me a long time to 'wind down', which meant less sleep. And some nights, I had too much to do (or at least believed I did) to go to sleep. There was always something interfering, right on up to about a month ago, when both the work stress and the personal stress caused by covid made sleep elusive. I felt exhausted, but I'd been conditioned to believe that sleep was an indulgence, not a necessity, and I often made do with a few hours a night.

More recent research, some specific to physicians and some relating to humans in general, clearly shows that lack of sleep causes impairment in multiple realms. Decision-making, particularly the kind of complex decisions made by physicians, suffers, as does memory.

Performance of fine-motor activities (think about medical procedures!) is less accurate. Burnout is more likely. Chronic sleep deprivation is strongly associated with depression, as well. Read enough about sleep and you'll find numerous other effects of sleep deprivation from obesity to menstrual irregularities. A study of neurotransmitters in chronic sleep deprivation showed that there are changes in the amount and ratios.

It is crystal clear that we are hurting ourselves with sleep deprivation and increasing the risk of medical errors, as well.

Resident work hour restrictions, instituted initially in 2003 and revised more recently, have probably alleviated some of the problems of sleep deprivation due to in-house trainee on-call. However, restricting the number of hours worked at a stretch means that trainees must rotate through 'night float', during which they are night shift workers. In addition, studies done on the effects of work hour restrictions show only a modest improvement in amount of sleep (less than 1 hour more/night on average) and modest improvement on some performance measures but not all. This disappointing data, rather than leading to further curtailing of work hours, led to pressure to loosen the work hour restrictions.

As was obvious for me, sleep deprivation did not end with the end of residency training. It continued through several decades. I suspect it strongly contributed to burnout several years ago. And the fact that I feel so much better, now that I am sleeping regularly, makes me realize that I lost more than sleep!

We need to pay attention to sleep, not just in medical training, but throughout our careers. It must be one of the pillars of self-care for physicians.

For me, it took a real desire to change my sleep patterns, along with some sleep hygiene techniques, such as going to bed and rising at the same time every day, avoiding screen time before bed, and avoiding long naps, even when I feel tired. I consulted a psychologist for

a little-known treatment called CBT-I (Cognitive Behavioral Therapy for Insomnia) to help me further correct my sleep habits and my tendency to insomnia. He helped me stay on track and to identify erroneous thoughts and ideas I had that made it difficult to fall asleep or to get back to sleep if i wake up during the night. A brief course of CBT-I (weekly sessions for just a few weeks) was very helpful. I still have an occasional restless night, but it's a whole lot better. For anyone who is taking sleep medication or using recreational drugs or alcohol to sleep, CBT-I may be an option, since drug-induced sleep is not as restorative as natural sleep, and many of the medications used can have unwanted side effects.

After a life of sleep deprivation, it feels amazing to have a 'normal' sleep schedule! I wish I'd addressed this long ago, but better late than never.

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