Physician Sleep Deprivation: To Sleep or Not to Sleep?

1
Physician Sleep Deprivation To Sleep or Not to
Sleep?
Don Hayes, Jr., MD University of Kentucky College
of Medicine
2
No Financial Disclosures
3
(No Transcript)
4
Learning Objectives

• Review the medical literature regarding the
  impact of sleep deprivation in residency training
• Examine factors that place physicians at risk for
  sleepiness fatigue
• Discuss the impact of sleep loss on physicians
  personal professional lives
• Review the signs of sleepiness fatigue in
  yourself other physicians
• Discuss common misconceptions among physicians
  about sleep sleep loss
• Examine alertness management tools strategies
  for yourself your training program

5
The Scope of the Problem

• Sleep deprivation is a tradition in medicine
  medical education
• Most physicians including residents recognize
  sleep is reduced fragmented
• Sleep deprivation is known to affect mood,
  cognition, motor performance in healthy
  controls
• Most physicians underestimate their own
  sleepiness fatigue

6
Assessment of Sleepiness

• Behavioral
• Facial expression, posture, yawning, myosis
• Subjective
• Epworth Sleepiness Scale (ESS)
• Stanford Sleepiness Scale (SSS)
• Objective
• Multiple Sleep Latency Test (MSLT)
• Maintenance of Wakefulness Test (MWT)
• Polysomnography (PSG)
• Actigraphy

Mitler Miller. Behav Med 199621(4)171-83
7
The Epworth Sleepiness Scale   How likely are you
to doze off or fall asleep in the following
situations, in contrast to just feeling tired?
This refers to your usual way of life in recent
times. Even if you have not done some of these
things recently, try to work out how they would
have affected you. Use the following scale to
chose the most appropriate number for each
situation 0 would never doze 1 slight
chance of dozing 2 moderate chance of
dozing 3 high chance of dozing   Situation
Chance of Dozing   Sitting and
reading _____ Watching TV _____ Sitting
, inactive, in a public place _____ As a
passenger in a car for an hour _____ Lying
down in the afternoon _____ Sitting and
talking to someone _____ Sitting quietly
after a lunch without alcohol _____ In a car,
while stopped for a few minutes in
traffic _____  
8
Typical ESS Scores

• Subject ESS mean (SD)
• Normal controls 5.9 (2.2)
• Primary snorers 6.5 (3.0)
• OSA 11.7 (4.6)
• Narcolepsy 17.5 (3.5)
• Idiopathic hypersomnia 17.9 (3.1)
• Insomnia 2.2 (2.0)

Johns. Sleep 199114(6)540-5
9
Epworth Sleepiness Scale
Sleepiness in residents is equivalent to that
found in patients with serious sleep disorders.
Mustafa Strohl, unpublished data. Papp, 2002
10
Why are physicians sleepy?

• Most physicians know relatively little about
  sleep needs sleep physiology
• No test for sleepiness
• Hospitals, medical practices, etc. do not
  recognize address the problem of sleepiness
• The culture of medicine
• Sleep is optional (youre a wimp if you need
  it)
• Less sleep more dedicated doc

11
Perspective on Sleepiness?
27 felt it was normal to fall asleep during
lectures
12
The Etiology of Excessive Daytime Sleepiness in
Physicians
Insufficient Sleep(on call sleep loss/inadequate
recovery sleep)
Fragmented Sleep(pager, phone calls)
EXCESSIVE DAYTIME SLEEPINESS
PrimarySleep Disorders(sleep apnea, etc)
Circadian Rhythm Disruption(night float,
rotating shifts)
13
Distribution of Sleep Requirement
14
Effects of Sleep Fragmentation on Sleep Quality
NORMAL SLEEP
Paged
MORNING ROUNDS
ON CALL SLEEP
15
Circadian Clock Also Impacts Physicians

• It is easier to stay up later than to try to
  fall asleep earlier.
• It is easier to adapt to shifts in forward
  (clockwise) direction (day ? evening ? night).
• Night owls may find it easier to adapt to
  night shifts.

16
Opponent-Process Model of Sleep Regulation
Sleep Homeostatic drive (Sleep Load)
Wake
Sleep
Alertness level
Circadian alerting signal
9 AM
3 PM

3 AM
9 PM
9 AM
Time
17
Adaptation to Sleepiness During Residency
Myths/Facts
Myth Ive learned not to need as much sleep
during my residency.
Fact Sleep needs are genetically determined
cannot be changed.
Fact Human beings do not adapt to getting
less sleep than they need.
Fact Although performance of tasks may improve
somewhat with effort, optimal performance
consistency of performance do not!
18
Evolution of Sleep Deprivation Mood during
Internship
Rosen et al. Acad Med 200681(1)82-5
19
Correlates of Reduced Sleep Duration Residents

• Residents averaging 5 hrs sleep/night were more
  likely to
• report
• Serious accidents or injuries OR 1.84 (1.23
  2.74)
• Conflict with other professional staff OR 1.41
  (1.08 1.84)
• Use of medications to stay awake OR 1.91 (1.39
  2.62)
• Working in an impaired condition OR 2.19
  (1.79 2.68)
• Making significant medical errors OR 1.74 (1.47
  2.06)
• Being named in malpractice suit OR 2.02 (1.17
  3.47)

Baldwin Daugherty. Sleep 200427(2)217-23
20
Impact of Sleep Deprivation upon Housestaff
Performance

• Surgery 20 more errors 14 more time required
  to perform simulated laparascopy post-call (two
  studies) (Taffinder et al 1998 Grantcharov et
  al 2001)
• Internal Medicine Efficiency accuracy of ECG
  interpretation impaired in sleep-deprived interns
  (Lingenfelser et al 1994)
• Pediatrics Time required to place an
  intra-arterial line increased significantly in
  sleep-deprived (Storer et al 1989)
• Emergency Medicine Significant reductions in
  comprehensiveness of history physical exam
  documentation in second year residents (Bertram
  1988) Longer intubation time required after
  call (Smith-Coggins 1994)
• Family Medicine Scores achieved on the ABFM
  practice in-training exam negatively correlated
  with pre-test sleep amounts (Jacques et al 1990)

21
Impact on Performance, cont

• Surveys more than 60 of anesthesiologists
  report making fatigue-related errors
  (Gravenstein 1990)
• Case Reviews
• 3 of anesthesia incidents (Morris 2000)
• 5 preventable incidents
• 10 drug errors (Williamson 1993)
• Post-op surgical complication rates 45, higher
  if resident was post-call (Haynes et al 1995)

Fatigue-related
22
Professionalism

• Your own patients have become the enemybecause
  they are the one thing that stands between you
  a few hours of sleep.
• Surgical resident, Time Magazine, March 2001

23
Resident Learning

• Residents working longer hours report decreased
  satisfaction with learning environment
  decreased motivation to learn.
  Baldwin et al 1997
• Study of surgical residents showed less operative
  participation associated with more frequent call.
  Sawyer et al 1999

24
Resident Safety

• 50 ? risk of blood-borne pathogen exposure
  incidents (needlesticks, lacerations, etc) in
  residents between 10 pm 6 am Parks
  2000
• 58 of emergency medicine residents reported
  near-crashes driving
• 80 post night-shift
• ? with number of night shifts/month
• Steele
  1999

25
Drowsy Driving Interns

• Nationwide Web-based survey 2002-03
• 2,737 PGY1 residents (interns)
• Results from 17,003 reports
• Participants prompted monthly to report
• Work hours
• Motor vehicle crashes
• Near-miss accidents

Barger. N Engl J Med 2005352(2)125-34
26
Drowsy Driving National Survey Results

• Interns had 2.3 (OR) risk of crashes
• If they reported working a gt 24-hr shift
• Each extended shift per month ? the risk by 9.1
• Interns reported working 5 extended shifts had
• ? risk of falling asleep while driving (OR 2.39)
• ? risk of falling asleep while stopped in traffic
  (OR 3.69)
• ? risk of after extended vs nonextended shift
• For crash (OR 2.3)
• For near miss (OR 5.9)

Barger. N Engl J Med 2005352(2)125-34
27
Medical Resident Driving Simulator Performance
after Night Call
Ware et al. Behav Sleep Med 20064(1)1-12
22 medical residents 1 medical student
28
Medical Resident Driving Simulator Performance
after Night Call, cont
Ware et al. Behav Sleep Med 20064(1)1-12
29
Differential Vulnerability To Cognitive Effects
Of Sleep Loss Type 1 (Resistant) Versus Type 3
(Vulnerable) People
Van Dongen et al. Sleep 200427(3)423-33
30
(No Transcript)
31
(No Transcript)
32
Accident Risk Related to Subjective Sleepiness
(Commercial Drivers)
Howard et al. Am J Respir Crit Care Med
2004170(9)1014-21
33
Impact on Personal Health
Baldwin Daugherty, 1998-9 Survey of 3604
PGY1,2 Residents
34
Effects of Schedule Performance Post ACGME
Changes

• Prospective, randomized study
• Medical interns
• Harvard Intensive Care Unit
• Traditional work schedule
• Extended (24 hrs or more) work shifts, every
  other shift ("every third night" call schedule)
• Intervention Schedule
• No extended shifts
• Reduced work hours (lt 65 hr/wk)

Landrigan et al. N Engl J Med 2004351(18)1838-48
35
Harvard Study Results

• 2,203 patient-days involving 634 admissions
• For traditional vs intervention schedule, rates
  were higher for serious
• Medical errors 35.9
• Medication errors 20.8
• Serious diagnostic errors 5.6 times

Landrigan et al. N Engl J Med 2004351(18)1838-48
36
Recognizing Sleepiness in Yourself Others
37
Sleep Deprivation Facts

• Decline in performance starts after about 15-16
  hrs continued wakefulness
• The period of lowest alertness after being up all
  night is between 6-11 am (eg, morning rounds)

38
More Sleep Deprivation Facts

• Studies show that sleepy people underestimate
  their level of sleepiness overestimate their
  alertness
• The sleepier you are, the less accurate your
  perception of degree of impairment
• You can fall asleep briefly (microsleeps)
  without knowing it!

39
Stanford Resident Study

• 11 anesthesia residents completed the study
• Daytime sleepiness was assessed using the
  Multiple Sleep Latency Test (MSLT)
• Residents did not perceive themselves to be
  asleep almost half of the time when they had
  actually fallen asleep
• Residents were wrong 76 of the time when they
  reported having stayed awake

Howard et al. Acad Med 200277(10)1019-25
40
Recognize The Warning Signs ofSleepiness

• Falling asleep in conferences or on rounds
• Feeling restless irritable with staff,
  colleagues, family, friends
• Having to check your work repeatedly
• Having difficulty focusing on the care of your
  patients
• Feeling like you really just dont care

If you dont recognize that youre sleepy,
youre not likely to do anything about it!
41
Alertness Management Strategies
42
Sleep Management Myths/Facts
Myth Id rather just power through
when Im tired besides, even when I
can nap, it just makes me feel
worse. Fact Some sleep is always better
than no sleep. Fact At what time and for
how long you sleep are key to
getting the most out of napping.
43
Napping
Pros Naps temporarily improve alertness Types
Preventative (pre-call) Operational (on
the job) Length Short naps 30 mins to
avoid grogginess (sleep inertia) that
occurs when youre awakened from deep
sleep Long naps 2 hrs (range 30-180 mins)
44
Napping
Timing -- If possible, take advantage of
circadian windows of opportunity (2-5 am 2-5
pm) -- If not, nap whenever you can! Cons Sleep
inertia allow adequate recovery time
(15-30 mins) Bottom line Naps take the edge off
but do not replace adequate sleep
45
Healthy Sleep Habits
Get adequate (7 to 9 hrs) sleep before
anticipated sleep loss Avoid starting out with a
sleep deficit!
46
Recovery from Sleep Loss Myths/Facts
Myth All I need is my usual 5 to 6 hrs the
night after call Im fine. Fact
Recovery from on-call sleep loss
generally takes 2 nights of extended
sleep to restore baseline alertness. Fact
Recovery sleep generally has a higher
percentage of deep sleep, which is
needed to counteract the effects of sleep
loss.
47
Healthy Sleep Habits

• Consistent sleeping routine
• Relaxation techniques if you cannot fall asleep
• Sleeping environment
• Cooler temperature
• Dark (eye shades, room darkening shades)
• Quiet (unplug phone, turn off pager, use ear
  plugs, etc.)
• Avoid going to bed hungry, but no heavy meals
  within 3 hrs of sleep
• Get regular exercise
• Protect your sleep time enlist your family
  friends!

48
Caffeine as a Countermeasure

• Strategic consumption is key
• Effects within 15-30 mins half-life 3-7 hrs
• Use for temporary relief of sleepiness
• Cons
• Disrupts subsequent sleep (more arousals)
• Tolerance may develop
• Diuretic effects

49
Caffeine Sleep Loss

• 300 mg at 2300 improved sleepiness for 7.5 hrs
  (Walsh, Psychopharm 1990)
• Repeated 150-300 mg doses maintains alertness
  compared with placebo for 44-48 hrs (Bonnet,
  Sleep 1995)
• 300 mg caffeine approximates 3-4 hr prophylactic
  nap (Bonnet, Sleep 1995)
• 200 mg caffeine 4 hr nap improved performance
  (Bonnet, Ergonomics 1995)

50
How Much Caffeine is in.?http//www.cspinet.org/
new/cafchart.htm

• Starbucks Brewed Coffee (Grande) 320 mg
• Brewed coffee (12 oz) 204 mg
• Starbucks Vanilla Latte Grande 150 mg
• Starbucks Espresso, solo (1 oz) 100 mg
• Full Throttle 144 mg
• Jolt 72 mg
• Snapple tea 42 mg
• Soda (12 oz)
• Mountain Dew 54 mg
• Mello Yellow 53 mg
• Dr. Pepper 42 mg
• Pepsi 38 mg
• Coca-Cola Classic 35 mg
• Ale-8-One 37 mg

51
(No Transcript)
52
Light

• Bright light can shift circadian rhythms
• Studies of night shift workers suggest improved
  performance

53
Drugs

• Melatonin little data in physicians (residents)
• Hypnotics may be helpful in specific situations
  (eg, persistent insomnia)
• AVOID using stimulants (methylphenidate,
  dextroamphetamine, modafinil)
• AVOID using alcohol to help you fall asleep
  induces sleep onset but disrupts sleep later in
  the night

54
Recognize Signs of Drowsy Driving

• Trouble focusing on the road
• Difficulty keeping your eyes open
• Nodding
• Yawning repeatedly
• Drifting from your lane, missing signs or exits
• Not remembering driving the last few miles
• Closing your eyes at stoplights

55
Risk Factors for Drowsy Driving

• Taking any sedating medications
• Drinking even small amounts of alcohol
• Having a sleep disorder (sleep apnea)
• Driving long distances without breaks
• Driving alone or on a boring road

Number of Crashes
Pack et al, Accid Anal Prev 199527(6)769-75
56
Drive Smart, Drive Safe

• AVOID driving if drowsy
• If you are really sleepy, get a ride home, take a
  taxi, or use public transportation
• Take a 20 min nap /or drink a cup of coffee
  before going home post-call
• Stop driving if you notice the warning signs of
  sleepiness
• Pull off the road at a safe place, take a short
  nap

57
Drowsy Driving What Does Not Work

• Turning up the radio
• Opening the car window
• Chewing gum
• Blowing cold air (water) on your face
• Slapping (pinching) yourself hard
• Promising yourself a reward for staying awake

It takes only a 4 secondlapse in attention to
have adrowsy driving crash.
58
Adapting To Night Shifts Myths/Facts

• Myth I get used to night shifts right away
  no problem.
• Fact It takes at least a week for circadian
  rhythms and sleep patterns to adjust.
• Fact Adjustment often includes physical
  mental symptoms (think jet lag).
• Fact Direction of shift rotation affects
  adaptation (forward/clockwise easier to
  adapt).

59
How To Survive Night Float

• Protect your sleep
• Nap before work
• Consider splitting sleep into two 4 hr periods
• Have as much exposure to bright light as possible
  when you need to be alert
• Avoid light exposure in the morning after night
  shift (be cool wear dark glasses driving home
  from work)

60
The best laid plans

• Study Impact of night float coverage
  (2-6 am)
• Compared interns provided with 4 hrs of protected
  time for sleep by a covering resident
  ("night-float") interns without such coverage
• Results
• Protected interns slept less than controls
• Used time to catch up on work, not sleep
• No improvement in performance

Richardson et al. Sleep 199619(9)718-26
61
Alertness Strategies

• No magic bullet
• Know your own vulnerability to sleep loss
• Learn what works for you from a range of
  strategies
• Shared responsibility for fatigue management
  residency program
• Culture of support

62
Conclusions

• Fatigue is an impairment like alcohol or drugs
• If you are chronically fatigued ? Consider a
  sleep disorder
• Excessive sleepiness fatigue cannot be
  completely eliminated from medicine (residency)
• But it can be managed
• Recognition of sleepiness fatigue in
  yourself/others is important but can be difficult
• Simple strategies exist that can help optimize
  sleep on call combat sleepiness
• Talk with someone if your sleepiness interferes
  with your performance or health