Vanessa Piazza, M. D., is a board-certified emergency room physician practicing in New Orleans, Louisiana. Since 1997, Dr. Piazza has been practicing emergency medicine at the Charity Hospital, which subsequently became University Medical Center post-Hurricane Katrina. In addition to practicing emergency medicine, Dr. Piazza also has completed a fellowship in emergency medicine ultrasound. Dr. Piazza is very active in the Louisiana Chapter of the American Academy of Emergency Medicine where she currently serves as its Vice-President.
During the 4 years of medical school followed by the typical 3-7 years of residency, life can be low-level a continuous state of flight or fright, meaning a mode of persistent stress. Although a career in medicine is highly rewarding on many levels, the journey to becoming a well-trained, successful physician is an arduous process. In regard to its effect on sleep, it is an injurious process.
Medical students typically attend lectures and interactive learning during the daytime, and they study in the evening. The pressure to memorize and digest the immense amount of material demands many hours of study each night. Intense exams prompt students to spend additional hours studying. Medical students frequently pull “all-matters”, meaning a student continues studying throughout the night and into the early morning hours, without sleep. For some students who also have extracurricular responsibilities (children, spouse, a part-time job), sleeping hours are likely to decrease without compensation.
The average medical student sleep 6-7 hours per night most nights. This is less than the recommended 7-9 hours per night. When clinical rotation starts, sleeping hours are further decreased, and frequently disrupted. This deteriorating sleep practice is compounded when residency training starts, because during residency the wake/sleep hours are constantly changing, and when sleep can happen, is interrupted during “on-call” nights.
Residents are sleep-deprived. In a survey of 3604 first and second-year residents, 20% reported getting five hours or less of sleep per night, and 66% average six hours or less. Due to varying schedules as residency training continues, with “on-call” responsibilities superimposed, resident “bedtime” and “awakening time” are altered almost daily. To make the situation worse, sleeping hours are often radically broken up for unpredicted intervals. During residency time for work is so valued that sleep may be considered interference, a wasteful time that must be indulged when there is not enough discipline to work longer. Residents may consider the need for sleep as a weakness and push themselves to work more and sleepless.
What is sleep and why is it important?
Sleep is a natural, necessary, essential part of life. Sleep gives the mind and body time to recharge and refresh. Adequate, healthy sleep maintains the body’s ability to fight disease, concentrate, process memories, and learn new skills. Most adults require 7-9 hours of nightly sleep for proper cognitive and behavioral function. Sleep is crucial for the skill of thinking clearly and the ability to sustain attention and alertness. Memories are consolidated during sleep, and sleep serves a critical role in emotion regulation. Good sleep is correlated with healthy eating habits, optimal athletic performance, increased ability to fight infection and decreased risk for forgetfulness and depression.
Sleep allows cells to repair and regrow. Neuroplasticity, the ability of neural networks in the brain to charge through growth and reorganization, occurs during sleep. Memory function is improved with sleep. Short-term memory is integrated into long-term memory, and less important into that may otherwise clutter the neuron system is raised. Through repair and regrowth allowed by sleep, problem-solving skills, creativity, concentration, and attention span are maximized.
During sleep, brain activity is increased in areas that regulate emotion, subcortically, in the amygdala, striatum and hippocampus, and cortically, in the insula and medial prefrontal cortex. With enough sleep, these parts of the brain can react in a normal way. Without enough sleep, they may react inappropriately.
When sleeping, the body produces cytokine, a protein that fights infection and inflammation. Sleep deprivation inhibits the immune system and makes the body more susceptible to germs. Research has shown that multiple years of rotating night shifts puts a person at higher risk to die from heart disease and some types of cancer.
Medical school and residency, directly and indirectly, upset the balance of sleep needed for optimal cognitive, emotional, and physical functioning. They upset this balance directly because the start time of the day varies with different clinical rotations, and the sleeping hours at night are influenced by on-call work and studying. Indirectly, sleep is affected by anxiety and a controlling idea that sleep is a form of defeat, since active duties cannot be completed during sleep.
Fortunately, over the years, practices are improving and the value of sleep is becoming more realistic. Rules to limit on-call hours give residents a better chance of sleep. Importantly, student and resident wellness classes are incorporated into the curriculum offering a healthier mindset towards rest and sleep.
Rest is a quiet, relaxing time when the body can re-group. It is different from sleep in that the mind is still attuned to external stimuli; however, no movement or work is happening. Rest contributes to improving sleep and general lactation during waking hours. I believe rest and other active forms of rejuvenation such as exercise, meditation, laughter, and active nest outside of the clinical work, are all important for emotional and mental health. Adequate sleep is mandatory for proper learning; insufficient sleep is counter-intuitive to a goal of high performance.
To be a good clinician and to work effectively with others, patients and a sense of humor are needed. In my opinion, these skills Wayne with lack of rest and sleep. Based on the evidence, attention span and memory suffer from lack of sleep.
How to get better sleep and rest during medical school and residency the following are some pointers I advocate students and residents adopt during their training based on my personal experience as well as evidence-based literature:
1. Nap the right way, or don’t do it at all. Nap for 20-30 minutes, between 1-3 PM. Aim to nap at least every other day.
2. Exercise is a huge help. It aids in avoiding depression through the secretion of endorphins and improves the quality of sleep when sleep does occur.
3. Make bathing or a shower part of the sleep process. A hot bath before getting into bed can prime the body to fall asleep faster. It also trains the mind to associate going to sleep after bathing, which can give at least one constant routine to erratic sleep patterns.
4. Sleep in a darkened room, alone, with the sound machine.
5. Try to spend 20 minutes per day and rest (meditation, prayer) 20 minutes per day and exercise, and 20 minutes per day in some form of self-care (bath, massage, entertainment). This “power hour” recipe renews the mind and body, therefore, enabling better sleep in a better attitude toward sleep.
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