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

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 1996;21(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 SubjectESS 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 1991;14(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” (you’re 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 3PM 3 AM 9 PM 9 AM Time

17. Adaptation to Sleepiness During Residency Myths/Facts Myth:“I’ve 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 2006;81(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 2004;27(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 enemy…because 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 amParks 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 2005;352(2):125-34

26. Drowsy Driving: National Survey Results • Interns had 2.3 (OR) risk of crashes • If they reported working a > 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 2005;352(2):125-34

27. Medical Resident Driving Simulator Performance after Night Call Ware et al. Behav Sleep Med 2006;4(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 2006;4(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 2004;27(3):423-33

32. Accident Risk Related to Subjective Sleepiness (Commercial Drivers) Howard et al. Am J Respir Crit Care Med 2004;170(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 (< 65 hr/wk) Landrigan et al. N Engl J Med 2004;351(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 2004;351(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 2002;77(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 don’t care If you don’t recognize that you’re sleepy, you’re not likely to do anything about it!

41. Alertness Management Strategies

42. Sleep Management Myths/Facts Myth:“I’d rather just “power through” when I’m 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 you’re 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 & I’m 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 23:00 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