An emergency room physician completes her overnight shift in a busy, inner city emergency department. She stays an extra hour and a half to complete paperwork then goes home. Although exhausted, she’s “too wired” to sleep.
Eventually she dozes off but the phone calls from family and friends begin. She’s only able to get six hours of interrupted sleep before leaving home for the next shift. The ER physician is fatigued, irritable and frustrated.
“This sleep pattern takes a terrible toll in the short and long term,” says Judith Owens, MD, MPH, director of the Center for Pediatric Sleep Disorders at Boston Children’s Hospital. “Shift work is associated with “deficient” sleep, meaning that both the amount and timing of sleep are altered. Our natural circadian rhythms result in humans being hardwired to sleep at night and be awake during the day, and the combination of this “misalignment” with insufficient sleep can be very problematic.”
According to the National Sleep Foundation, millions of Americans — approximately one-fifth of the U.S. workforce, is employed in shift work. Of this group, primarily health care, police and firefighters, food service and transportation, about one-third of shift workers reported their work schedule inhibited their sleep.
“When a clinician is sleep deprived, reaction time is slowed, and those impairments can result in real world consequences such as car accidents or hospital or patient-related injury,” Owens adds.
Sleep deprivation and misaligned circadian rhythms promotes cognitive decline, mood dysregulation, and impairments in executive function decision-making and problem-solving skills — all critical functions for practicing physicians.
“People that are severely sleep deprived sacrifice efficiency for accuracy. They get the right answer it just takes them longer to get there,” Owens says. “If you are problem-solving, decision-making and judgement are impaired, you are going to be less successful and effective health care provider.”
Defining the health risks
In addition to the potential for injury-related events, there is a list of health risks associated with chronic sleep loss. Depression, loss of psychomotor function and weight gain/obesity, which may lead to cardiovascular disease, Type 2 diabetes and metabolic dysfunction, are linked to insufficient sleep.
“One of the strategies people employ to stay up is to eat higher calorie, higher carbohydrate, higher fat content foods. All of which will further contribute to obesity and cardiovascular risk.”
Clinicians guide to healthy sleep habits
Owens says the first action physicians need to embrace is to let go of trying to be super human. “At one time, sacrificing sleep to care for patients was part of the medical community’s culture,” Owens says. “This is gradually changing. The trainees I see now are more mindful of work/life balance and they recognize that sleep needs to be right up there with good nutrition and adequate physical exercise.”
Protect your sleep
Be strategic about napping. To avoid sleep inertia, Owens recommends napping for 20 to 30 minutes. “If you sleep long enough to go into deep or slow wave sleep, you are much more likely to have sleep inertia if awaken by a page or phone call. This is an impaired state of grogginess and confusion.”
Recommendation: At bedtime, turn off the phones and pagers, and have room darkening shades in your bedroom.
Strategic use of caffeine can be helpful with caveats. A quick caffeine fix will temporarily restore alertness but will impact sleep, Owens says. “Caffeine hangs around in your system for quite a while and can disrupt your next night’s sleep.”
Recommendation: Drink caffeinated beverages in moderation and not after 6 p.m.
Some people use alcohol to help themselves fall asleep, especially if they are working different shifts and thus trying to sleep at a time they normally would not. “Drinking alcohol is not a good way to fall asleep; it may help you get to sleep but as your blood alcohol level drops during the night, your sleep becomes more fragmented,” Owens adds.
Recommendation: Use alcohol in moderation and avoid using alcohol as a sleep aid.
Some people resort to sedating or hypnotic medications to help with sleep. “In the very short term on an as needed basis, these medications can be helpful but in the longer term can lead to dependence and troublesome side effects” Owens says.
Recommendation: Engage in a calming or relaxing bedtime routine that doesn’t include drugs or alcohol to get to sleep.
Manage your light
Blue light from smartphones and tables suppress melatonin. If you have to check email before bed, turn down the blue light and when possible, expose yourself to sunlight in the morning. This will help to reinforce your natural circadian rhythms.
Nutrition and exercise
Good nutrition, physical activity and exercise are the gateway to good health. “It is important to practice what we preach: eat a well-balanced diet and exercise daily,” Owens says.
Recommendation: Avoid eating a large meal before bed because digestion may impair sleep. And avoid vigorous exercise before bed. It raises your core body temperature, making it more difficult to fall asleep.
While shift work and insufficient sleep are an inevitable part of medical training and practice for many health professionals, being mindful of the toll these can take and making changes in sleep and practices can really help to minimize the effects on your health and well-being.
About our expert:
Judith Owens, MD, MPH, is Director of the Center for Pediatric Sleep Disorders at Boston Children’s Hospital and Professor of Neurology at Harvard Medical School.