Why I am Tired of Tired Doctors

http://journals.lww.com/academicmedicine/Abstract/1991/11000/A_review_of_studies_concerning_effects_of_sleep.13.aspx

To sleep, perchance to dream-
ay, there's the rub.

William Shakespeare

I love irony. So when I read the recent editorial suggesting that surgeons be required to tell patients when they were too tired to operate, I just sighed. These writers are the trainees of the very guys who forced me to stay up 36 hours in a row, and then laughed and ridiculed me when I couldn't function.

More importantly, I feel many, if not most physicians are practicing with disrupted sleep patterns or full-on sleep deprivation, which has widespread negative impact on their practice and personal lives.

Almost every specialty requires extensive night coverage during training. Residencies require that young doctors work long and disruptive hours, in part to supply coverage, but also in part to prepare young physicians for the demands of patient care. Sleep is routinely missed, and even when sleep is possible, it is interrupted and far from normal. A fundamental skill learned in doctor training is to overcome fatigue with willpower and caffeine in order to appear to function effectively.

What the article cited today point out is that no matter what the outward appearance or self-delusion of the physician, missing sleep hurts performance, which has a negative impact on patient care. Patients suffer because their doctors are tired.

Unfortunately, even when doctors finish training, the situation does not change. Call may be less frequent, but hours remain long, patients call incessantly and sleep routinely interrupted. The reality is that the poor sleep habits learned in residency persist. Physicians function in a sleep-deprived world. Many have full blown sleep disorders, recognized or not. Chronic fatigue becomes the new normal. We may never know the true impact upon patient care because we may never be able to locate a group of well rested physicians. I did not know how tired I was until I retired.

The impact has implications beyond medical care. Depression, substance abuse, divorce, and early death, are common among physicians, may well be related to the chronic stress of abnormal sleep. Yet another thing you should know before your child applies to medical school.

Who is Your Doctor Sleeping With? Maybe Nobody.

"I'll sleep when you are dead,"

With apologies to Warren Zevon

http://abcnews.go.com/Health/Sleep/sleep-deprived-surgeons-disclose-lack-sleep/story?id=12500360

http://www.medicalnewstoday.com/articles/15551.php

A surgeon once told me that he spent a month of his residency on the service of the famous surgeon Dr. Debakey. He said he never got more than 2 hours of sleep a day during the entire month. His most intense memory was seeing a medical student fall asleep and dropping into the surgical field after being awake 36 hours in a row. Dr. Debakey would operate on 16 patients in a day, until he was in his 80's.

I knew I would never be a surgeon the first night of my surgical rotation in medical school. We would spend our normal 16 hour day, then stay up all night admitting patients. We then had the privilege of holding retractors during the surgeries on the patients we admitted the following day. Hopefully one could then go home for 8 hours, and do it all again the next day. I have never been able to stay up much past midnight, and was not only miserable, but almost dysfunctional the entire rotation. Spending the five years of a surgical residency doing this was pretty much out of the question.

Yet another dirty little secret of medicine is the ubiquity, intensity and impact of sleep deprivation upon both physicians and patients. Large numbers of doctors are practicing in states of both acute and chronic lack of sleep. More importantly, they are not admitting it to either themselves or their patients. Illness does not respect normal circadian rhythms and patient care requires doctors stretching the limits of their endurance. This need has long been appreciated by medical training programs, and learning how to function when tired, hungry and stressed is a key portion of medical training.

However, somewhere along the way, due to dominance behavior, one-upmanship, machismo, and a bit of sadism, the ability to function without sleep became a symbol of superiority, and a fundamental determinate of medical success . Residents would brag about how many hours they could work, and then party on their day off. Success in residency and fellowship competition was often based on the ability to function in this chronic sleep-deprived state, not upon intelligence or skill. The single most important secret component for success in medicine, the ability to function without sleep, is virtually never discussed.

Many doctors will contend that overcoming fatigue is a matter of will-power. I feel there is also a substantial genetic component. The problem is that sleep deprivation clearly impairs performance to some degree in everyone, even those who seem to function normally, and may be even more ubiquitous than the articles above indicate. More to come.