You Snooze, You Lose: Why Sleep Shouldn’t Be a Sign of Weakness

4-6 Minute Read

Author: Julpohng “JP” Vilai, MD, FAAP

Editors: Marin Gillis, PhD, LPh & Judy Hanrahan, JD, MA

Purpose

To provide clinician educators with an understanding of the effects of impaired sleep and strategies for promoting healthy sleep practices in medical education.

Learning Objectives

1. Explain the deleterious effects of sleep deprivation in health care;

2. Describe initiatives enacted to mitigate sleep impairment in medical education; and

3. Discuss ways clinician educators can help learners improve sleep patterns.

We all need sleep. We know this because of what happens when we don’t get enough sleep: we have more difficulty performing tasks, learning is harder, and we are even more likely to get sick.(1-3) How much sleep we need depends on our age. For example, according to the American Academy of Sleep Medicine, infants should sleep up to 16 hours per day (cue collective eye-rolling among exhausted caregivers who are well aware that this is rarely in long stretches), while 7 to 9 hours are recommended for adults 18 and older.(4)

Just as alcohol can lead to impairment, high stress and poor psychological states—things medical students and residents might know something about—can heavily influence sleep.(5) It is perhaps not too surprising that sleep disruption has been described as a pandemic for medical students compared to the general population.(6) And, research also shows that fatigue is linked to medical errors.(7,8)

But if sleep disruption is so bad, why do some medical professionals still view sleep deprivation as a rite of passage or a sign of resilience? This view largely falls prey to a common sentiment in medicine: “I had to do it, so should you.” I had a surgery attending once tell me, “The only bad thing about being on call every other night is you miss half the cases.”

Just because we had to do it, doesn’t make it any more right or acceptable, and we’re starting to see a culture shift in medicine.

ACGME no longer refers to “duty hours”, replaced instead by terms like “clinical and educational work hours”.(9)

This new terminology reinforces the point that residency is intended to be an educational experience, but also that being “off the clock” does not obviate responsibilities to patients. Additionally, several medical schools are making sleep education a formal part of their curricula, (10) and some are even creating physical spaces for rest: University of Central Florida College of Medicine employed “sleep pods” where sleep-deprived students can nap.(11)

While a lot of the focus has been on how clinicians and learners can get better sleep, much less attention is given to how clinician educators can encourage learners to prioritize sleep. Curated from my own experiences as a learner and practicing clinician, as well as validated techniques in higher education (college students are tired too), here are a few tips on ways we can help our learners.

1. Understand the rules: As medical educators, we are often timekeepers, responsible for things like how much time learners spend in an exam room and when they can go home. For residents, as an example, clinical and educational work hours must not exceed 80 hours per week, averaged over a 4-week period, and residents must have 8 hours off between clinical work and education periods and at least 14 hours free of clinical work and education after a 24-hour in-house call.(9) Knowing what can reasonably be expected of learners can help us respect not only their time but their status as a learner.

2. Teach judiciously: Yes, they are there to learn, but not every moment is a teaching moment. There is a time and place where education is best delivered and received. At the end of a 24-hours shift or in the middle of the night may not be the best time. We can acknowledge this and still be effective, e.g., “I know this isn’t a great time, but when you have a chance, read up on X” or “Here’s a good resource for X you can look at when it’s not 3 AM.” I sometimes text or email a learner with some high-yield pearls, articles, or links about patients or processes we encountered a day or two ago, especially if we were too busy or if the timing was less than ideal.

3. Look for struggling learners: Learners are usually not expecting you to take an active interest in them as individuals. However, medical students and residents are often stressed (surprise!), and they may not feel like anyone understands or can help with what they are going through (been there?). Sometimes a simple check-in, “Hey, you look a little tired,” “You seem a bit distracted,” or even “Are you doing ok?” can make a huge difference. Many mentor-mentee relationships have started that way for me, and it gives you a chance to address things like sleep, home and life stressors, etc. that may be affecting performance and ultimately patient care.

   

   

4. Model good behavior: A great way to learn is by observing. Learners are good at pattern recognition, and you’ve likely heard a variation on the theme “I try to make note of good things attendings do and things they could do differently.” If we focus solely on the job at the detriment of all other things, learners have a tendency of internalizing and perpetuating that, partly because they want to be liked and get a good grade. If we give permission—that it’s okay to go to the call room for a nap or go home early sometimes, and if we reinforce that taking time for oneself is not only acceptable but necessary, maybe those things will be paid forward.

5. Advocate: Learners are often the lowest rung of the ladder when it comes to power dynamics. Support your learner by advocating for them. This can be informal, such as letting a supervisor or program director know about a decision you made: “There was nothing going on, so I sent the learner home.” Or it can be more formal, like approaching administration with ideas on incorporating sleep education into the curriculum, giving workshops, or leaning into your influence. For example, programs cannot address issues they don’t know about. Use the power of the pen (or keyboard these days) to fill out those evaluations and assessments. Some comments I have made include: “Learners seemed to not have enough time for X.” or “The expectations seem to be too high regarding X.” Clinician educators can sometimes be the learners’ best hope of positive change.

Learners frequently need someone in their corner, especially when it comes to sleep, because some in medicine are hesitant to challenge the status quo. As clinician educators, we can help address this gap. Sleep is not for the weak; it can maintain a healthy workforce and improve patient outcomes.■

References

(1) Basner M, Rao H, Goel N, Dinges DF. Sleep deprivation and neurobehavioral dynamics. Curr Opin Neurobiol. 2013;23(5):854-863.

(2) Curcio G, Ferrara M, De Gennaro L. Sleep loss, learning capacity and academic performance. Sleep Med Rev. 2006;10(5):323-337.

(3) Irwin MR, Olmstead R, Carroll JE. Sleep disturbance, sleep duration, and inflammation: a systematic review and meta-analysis of cohort studies and experimental sleep deprivation. Biol Psychiatry. 2016;80(1):40-52.

(4) Hirshkowitz M, Whiton K, Albert SM, et al. National Sleep Foundation’s sleep time duration recommendations: methodology and results summary. Sleep Health. 2015;1(1):40-43.

(5) Yassin A, Al-Mistarehi A-H, Yonis OB, et al. Prevalence of sleep disorders among medical students and their association with poor academic performance: a cross-sectional study. Ann Med Surg. 2020;58:124-129.

(6) Seoane HA, Moschetto L, Orliacq F, et al. Sleep disruption in medicine students and its relationship with impaired academic performance: a systematic review and meta-analysis. Sleep Med Rev. 2020;53:101333.

(7) Barger LK, Ayas NT, Cade BE, et al. Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. PLoS Med. 2006;3(12).

(8) Taffinder NJ, McManus IC, Gul Y, et al. Effect of sleep deprivation on surgeons’ dexterity on laparoscopy simulator. Lancet. 1998;352:1191.

(9) Accreditation Council for Graduate Medical Education (ACGME). Common Program Requirements (Residency). 2024. Available at https://www.acgme.org/globalassets/pfassets/programrequirements/2025-prs/cprresidency_2025.pdf. Accessed October 7, 2024.

(10) Mindell JA, Bartle A, Wahab NA, et al. Sleep education in medical school curriculum: a glimpse across countries. Sleep Med. 2011;12:928-931.

(11) Hernandez C, Daly K, Mehta A, Verduin M. A pilot study examining biofeedback and structured napping to promote medical student wellbeing. MedEdPublish. 2019;8(27):110.