Less than 40 winks

Trainee doctors often don’t get enough rest. New FYi editor Dr Anne Parfitt-Rogers looks at the impact of sleep deprivation

WHETHER we’re trying to stay awake in lectures the morning after a night out, studying into the early hours for an exam, or driving home from a long shift, most of us will be familiar with the effects of sleep deprivation.

The 2009 European Working Time Directive (EWTD) was brought in to limit the average working week for doctors to 48 hours, but reports suggest rotas in some hospitals are still non-compliant, with a number of doctors regularly exceeding the legal weekly limit. And although long shifts and tiredness have largely become an accepted part of being a junior doctor, the physical and mental demands of the work should not be underestimated.

Extreme tiredness poses a risk both to patient care and to the doctor’s own wellbeing. This was highlighted in the case of 23-year-old Lauren Connelly, an FY1 doctor who crashed her car and died while driving home from a nightshift in 2011. The tragedy sparked calls for improved access to overnight rest facilities for trainees amid reports that a number of Trusts had been removing on-call rooms on the grounds that staff on full shift rotas should not be sleeping while on duty. Other trainees have reported having to pay to access on-call rooms.

According to a 2006 survey of more than 1,000 specialist registrars by the Royal College of Physicians, road accidents among trainee doctors are not uncommon. Of those questioned, 16 per cent had been involved in motor vehicle collisions during their commute, with approximately half of those occurring on the drive to work and half on the drive home.

Some studies have also highlighted links between lack of sleep and medical errors. One report in the New England Journal of Medicine in 2004 analysed intensive care workers and found that serious medical errors were significantly more common among staff working long shifts as well as longer working weeks.

Despite the risks of extreme tiredness, the EWTD has not been universally popular. Many trainees feel they no longer receive sufficient clinical exposure and senior staff have remarked on the lack of patient continuity associated with the new rotas. Some also prefer a seven-night shift rota across all areas to adjust properly to nocturnal working hours. While a return to the old system is not on the cards, it is hoped the new system can be adjusted to address these concerns.

With all this in mind, it’s useful to consider exactly why we need a good night’s sleep. Simply put, it allows us to store a certain amount of metabolic energy for later periods when increased activity is needed. Certain forms of repair increase during sleep, including parts of the nervous system. In a sleep cycle, the first four stages are non-rapid eye movement (REM) sleep, followed by REM, the deeper form of sleep. People who sleep for fewer hours per night may miss out on this latter, crucial form of sleep. REM sleep is also instrumental in the formation of memories so when we are sleep-deprived, we may find it harder to remember facts on the ward round the following morning.

Many studies analysing the effects of sleep debt have compared it to the effects of consuming alcohol. In a 2005 study in the Journal of the American Medical Association, researchers found it can lead to delayed reaction times and poorer memory and concentration. Another study found that after we have been awake for just 17 hours, our alertness falls to below the point it would be at if our blood alcohol level were at the designated driving limit.

Longer term, immunity may be compromised and cortisol levels can be increased, while those on irregular shift patterns may also develop insomnia. Mood has also been found to be significantly affected by sleep deprivation - in one study by an even greater amount than cognitive or motor performance.

Although there is no official Guinness world record for the longest period without sleep, many have attempted this feat. In 1964, Toimi Soini stayed awake for 11½ days, although this was later removed from the records as it was thought to encourage unhealthy behaviour. Randy Gardner managed 11 days in 1965, experiencing hallucinations after four, but managing to beat the researcher at pinball at the end of the study. More recently, Tony Wright kept himself awake for 266 hours – two hours longer than Gardner’s record.

There are a number of ways doctors can reduce the effects of disrupted sleep. A field study on NASA astronauts found short naps to be effective in improving alertness and performance. Some doctors also find regular snacks and breaks during nightshifts boost concentration and one FY1 recommends using an eye mask to sleep during the day. Creating a quiet environment and avoiding alcohol and caffeine before sleeping may also help. If you find you are nodding off during work then ask for assistance and whenever it’s available, take a break.

The Royal College of Physicians has produced a guide for junior doctors working nights

If you are curious about your sleep patterns, you can also take a quiz 

Dr Anne Parfitt-Rogers is editor of FYi and a medical writer at HealthFriends, a patient website