The sleep thing

Let me preface this by saying: You do what you’ve gotta do. While I’m not in any conceivable way a morning person, I’m not one to back down from a challenge, either.

Certainly, medical school is challenging, doctors are in demand, and there’s just not enough time in the day to do everything we want. There exists significant motivation to get that 30 hour shift out of your surgeon, or spend 42 hours a day training your resident.

On the other hand, sleep is good. Sleep helps people to function. Without sleep, we’re not very sharp.

With all that in mind - one might expect that medical professionals would be particularly sensitive to the need for sleep, and we wouldn’t try to brute force through it. That surgeon won’t be working at her best 29 hours into her shift. That resident will just be exhausted by the 75th hour he works that week. It just seems… counterproductive.

So why is that the way it is? Is it demand, need for more time than we have? Is it for the challenge, the filtering aspect of it? Does it work out for the best this way?

Many, many factors play into this ranging from “old school” culture to trying to condense experience. Some of it comes from a belief that learning to do the things that we do in a fatigued state will somehow translate into an enhanced capability to perform in said fatigued state. Research has unequivocally demonstrated that a person who has been awake for 24+ hrs functions in an “impaired” state roughly equivalent to having a blood alcohol content ~.1 - or legally intoxicated in all 50 states. However, these studies really do not take into account the ‘boost’ in cognition attributable to being in an intense & stimulating situation & how those “flight or flight” hormones potentially ameliorate, if only temporarily, the effects of fatigue. Combat/military training has also clearly demonstrated that actions, procedures & decisions inculcated under fatigue conditions eventually become essentially reflex in nature thereby allowing soldiers to function under combat-conditions in modes deemed substantively complex. But, they also have the offsetting factor of numbers vs Docs, who are much more likely to be flying solo in the middle of the night.

Also, large factors in the nature of errors is a function of experience. There are essentially two broad categories of errors: errors of commission & errors of omission - very distinct in character. Inexperiences providers are much more likely to commmit erros of omission because they forgot or neglected to recognize the need for an intervention. However, experienced providers are more likely to commit errors of commission due to many actions becoming programmed or reflex over many cycles of repetition. For example, not too long ago, I almost did a major boo-boo of the latter type because I was doing a low-risk, minimally invasive case, but allowed myself to be on auto-pilot. I did not plan to intubate or place the pt on a vent - I was going to place an LMA (type of artifical airway that requires the pt to spontaneously breath). However, due to programmed routine, I almost gave this person a paralytic, as I would have for any routine induction where I would be intubating & mechanically ventilating - with a paralytic on board, this pt would not have been able to breath at all & I would have had to urgently convert her to a more intense anesthetic due to an almost error of commission.

Another very large factor in the quantity of time spent in residency is purely volume. Essentially, you are trying to turn out well-trained, experienced practitioners with 10+ years of experience in 3 to 5 years of training. To achieve this density of practical experience, you simply must encounter a large volume of pt encounters. Negative events in healthcare, by in large, are relatively rare - despite all of the press - & therefore, to encounter & thereby learn to intervene appropriately for said rare/rarer events again requires a large volume of encounters. It is simply stats & math…

Of course, there is the culture aspects in the expectations of rigorous, intense training that serves as a a filter to entry, esp in the more competitive specialties. As I do not feel that these really are legit or rationale underpinnings, not too mention controversial & would involve a voluminoous discussion - I will not poke that skunk.

How much has been lost by the 80 hour limitation in residencies in terms of experience? Do you think the gains in mental alertness and reduced error rate compensate for the hundreds of fewer cases seen over the course of a residency?

Relating the topic to current personal experience:

Due to a bit of unfortunate timing at work, I had to miss two days of Gen. Chem. II (during a summer session, no less) or risk losing the job. With the job thing now tackled, I am playing catch-up in class (a situation I really dislike). As a result, I’ve been allowing myself about 4 hours sleep each night for the last week or so. My brain feels like it has become completely impermeable to new information, and my math/test anxiety (conquered years ago) is back with a vengeance. Now I can begin to understand the statistics regarding suicide, substance-abuse, etc. for doctors in training. I’m not even finished with pre-med! =P

I’ve done more than a few 24hr shifts as an EMT, but the familiar routine punctuated by brief catecholamine dumps never let me get to the point of utter fatigue that I feel at the moment. It has me wondering… maybe I am too old for this??


  • T_Forsythe Said:
It has me wondering... maybe I am too old for this??


I don't know how old you are but I am probably older. I couldn't do an all-nighter of studying on a bet... in med school there were times when I really felt pressed to try and stay up to consume more information and I could never, ever do it.

But I can stay up all night delivering babies, checking ICU patients, driving from one ER to another. The demand that you DO something that comes with being on call cannot be compared to sitting up all night with a chemistry book. I am racking my brain to think if I've encountered anyone who absolutely, positively couldn't do it - not that I can recall. You can do it.


Thanks for the feedback - some great points and perspective. Tim, I don’t think you’re too old; what you’re doing IS fatiguing.

As an interesting followup, I’ve become a morning person. Well, not quite, but I’m up at 6-something(this is where everyone laughs and says “Hah, that’s late!”) for an 8am class across town, then put in an 8 hour shift at work - and remarkably, for me, I’m awake and alert and functioning.

That must mean I really want this!

Thanks for the perspective.

Staying awake to study, and staying awake to keep someone from dying are totally different animals. I’ve worked some as an EMT, and while I’ve experienced a great deal of fatigue, feeling sleepy while there was something important to do was never even a consideration.

I doubt this is the last time I will question my ability to accomplish this goal, but I have no doubts about my desire to stay after it. It is good to hear encouragement from people who have been down this road. I look forward to being one of those folks farther up the road someday soon.