SHUTEYE STANDARDS NEEDED
By Jason Contant
Doctor, doctor – get yourself some sleep.
More shuteye for physicians is in order, notes a public release on a recent editorial in the Canadian Medical Association Journal (CMAJ). Drs. Noni MacDonald, Paul Hébert, Ken Flegel and Matthew Stanbrook suggest that “licensing, accreditation, insurance and government institutions need to establish minimum best practice standards for maximum work and minimum uninterrupted sleep hours.”
Beyond best practice, however, is the need for a shift in physicians’ professional culture. Working long periods on call should not be a source of pride, the CMAJ statement adds.
Sleep deprivation – defined as less than six hours of uninterrupted sleep – resulting from “overnight call” has been shown to cause a similar degree of impairment in judgement and motor performance as a blood-alcohol level above 0.05 per cent, the editorial notes. “Those of us who remain overconfident that we can continue to perform our duties properly without adequate sleep should imagine the reaction if we were made to seek informed consent from each of our patients to accept treatment under these conditions.”
The doctors cite numerous studies, findings of which include the following:
• a comparison of anesthesiologists and other specialists on 16-hour night-calls found that duties were compatible with a short-term recovery in both groups, but limited sleep duration still implies a long-term health concern;
• a study of 39 subjects (30 from the transport industry and nine from the army) reinforces evidence that sleep deprivation is an important factor likely to compromise performance of speed and accuracy of the kind needed for safety on the road and in other industrial settings;
• an increased rate of complications was found among post-nighttime surgical procedures performed by physicians with sleep opportunities of less than six hours; and,
• duty-hour standards for residents should incorporate a more flexible, dynamic policy that features ongoing testing and evaluation.
“We learn almost nothing about sleep disorders in medical school even though sleep disorders affect the majority of conditions we are seeing patients for in the office or hospital,” says Dr. Ron Cridland, who works at the Kelowna Sleep Clinic in Kelowna, British Columbia. “Most doctors do not realize how much sleep plays a role in the health of their patients or themselves,” Dr. Cridland suggests.
Limits on maximum hours may be regarded as a matter of course for residents and medical students, but not so for practising physicians.
“Indeed, doctors in practice, being older, may be more susceptible than trainees to the effects of sleep deprivation,” the editorial notes. “Moreover, unlike trainees, whose practice is supervised, doctors in practice often have no one overlooking them to catch their mistakes.”
Studies report numerous effects of fatigue, notes information from the Canadian Centre for Occupational Health and Safety (CCOHS) in Hamilton, Ontario. Those effects include reduced ability to do complex planning, reduced reaction time (both in speed and thought), failure to respond to changes in surroundings or information provided, and increased errors in judgement.
As medical care grows more complex, the CMAJ statement notes, the problem may only be getting worse. “Increasing complexity of care at the bedside or in the operating theatre places unprecedented cognitive and physical demands on doctors who oversee and deliver care in these environments.”
Dr. Cridland says guidelines based on research would help greatly to raise physician and administrator awareness. But it must also be acknowledged that “some people tolerate the sleep disturbances very well and others do not tolerate on call or stress at all,” he says. “Enforcing best practices may be helpful for some and overly restrictive for others.”
Doctors are not the only workers whose performance can be adversely affected by sleep deprivation or disruption. Think transportation, shift work and, of course, nursing.
Margo Wilton, co-chair of the South Islands region for the British Columbia Nurses’ Union in Victoria, says good sleep hygiene – including taking breaks in a sleep room, providing different types of lighting and having nutritious food available – can help alleviate fatigue.
As well, once it is time to get some shuteye, the CCOHS notes that a light snack before bed will help to promote a restful sleep. Consider cereal with milk, fresh fruit and yogurt or a piece of toast with a small banana as possible options.
Unfortunately, Wilton suggests, good sleep hygiene recommendations often work better on paper than in practice. Characterizing the opportunity for nurses to take sleep breaks as “almost non-existent,” she reports that two major hospitals in Victoria are not even equipped with sleep rooms.
The CMAJ editorial notes that some hospitals, departments and practices have adopted innovative approaches to work scheduling for physicians, such as strict policies for going home following call, refraining from booking procedures or clinics the day after call, reorganizing call schedules to have more physician coverage, and moving to shift work.