I have many children. It’s three children, to be exact, but many feels accurate. I’m no linguist, but in my humble opinion, two children is a couple. Three is many.
Unfortunately, my four-month-old is having a crisis of identity (the first of many, if he takes after me at all) in which he thinks he is still a newborn and has to be nursed every two hours. The American Academy of Pediatrics issued updated breastfeeding guidance in 2022 which recommend breastfeeding be continued for up to 2 years due to health benefits for mother and child. I am a woman of science and as such I fully embrace the data behind said health benefits.
Yet, I can’t help but ask myself whether they will be of any use to either one of us if I have the life literally sucked out of me, which at this rate I expect to be by about 6 months. Also, has the AAP thought to weigh those health benefits against the health implications of not sleeping? Because breastfeeding every two hours equates to waking up every two hours, while my husband’s contribution is to occasionally tap my shoulder to let me know I’ve fallen asleep sitting up for the fourth time that night.
‘Sleep when your baby sleeps’
‘Sleep when your baby sleeps’ would be an option if I could also clean when my baby cleans and work when my baby works and exercise when my baby exercises. Since my baby does none of those things, but rather insists on being carried around from the moment he wakes up so as to have a better view of his realm in between milk shots and diaper changes, my napping prospects are looking bleak.
Because I have many children, I haven’t slept in many years, which is compounded by the fact that I am an M.MD (Mom MD), a title I have awarded myself illegally because in academia there are very strict rules governing which titles one can carry. I was an MD before I became a mom, which means I stopped sleeping sometime during the second half of medical school and then never resumed. Since I also happen to be a pediatrician, there is inevitably a child that needs my attention at two o’clock in the morning.
Fatigue management
In residency, we had to complete a very official sounding fatigue management training. Most of my co-residents were annoyed at yet another mandated training, one of many in the first weeks of intern year. I, on the other hand, was enthusiastic. By then, I had a one-year-old at home and was no stranger to sleep deprivation and fatigue. I figured this renowned academic institution, this mecca of groundbreaking research would provide us with cutting edge concepts from the neurobiology of sleep or EBM-guided insights into how to manage the demands of 24-hour shifts and weekslong nocturnal rotations.
The training impressively spelled out what happens when you are overtired (the same things that happen when you are inebriated, ie: car accidents, poor decision making, texting your ex, etc.) The solution? Coffee.
Yes, coffee.
Listen, I love coffee. If I could figure out how to insert the heart emoji into this Word doc I would. But telling an exhausted resident to drink coffee is a bit like telling Jack to just hold tighter on to that floating piece of ship wreckage while the Titanic was sinking. In hindsight, I would have been better served by sleeping through the hourlong training.
Sleep is very much in the Zeitgeist. Ever since Matthew Walker’s cogent book ‘Why We Sleep’ came out, busy people everywhere are deciding to put down their proverbial ploughs and prioritize sleeping 8 hours a night. Stronger immune system, improved executive function, faster reflexes, better mood, longer life. It’s very compelling. You know who isn’t sleeping 8 hours a night? Moms. And physicians. And least of all M.MDs (I’m officially awarding all of you mother physicians out there the title. You’re welcome.)*
This may be me being oversensitive, but it feels a little bit mean to spell out all the ways in which our health, mental function, and life in general decline when we don’t sleep enough when there is, in fact, no way of sleeping enough.
Maybe I’ll write a book about motherhood and being a physician. I’m thinking of calling it Why We Can’t Sleep.
Cognitive decline
As I said, I’m clearly on the side of science, but I don’t need a randomized controlled trial to tell me my cognitive function has declined with lack of sleep. I am well aware. My four-year-old has been beating me at memory for years. Not the easy travel version with just twenty cards, either. And while, like all parents, I’d love to believe it’s because my four-year-old is a genius, I did see her lick her shoe just now, so genius may be overcalling it a bit.
Now, before you go telling me that maybe my memory was never any good, I am an MD and a Dr. med., which means I not only successfully learned the names of all 206 bones in the human body (and yes, I just googled that number) along with the origin and insertion of every muscle, of which there are over 600, apparently, I also wrote an original thesis about a topic that contributed substantively to the field of medicine. Just don’t ask me what exactly that was.
Sleeping 3 hours a night
It’s one thing when there simply isn’t a way to sleep enough. It’s another when it’s a choice that has been made for you by a system designed to ignore your wellbeing. Which brings me right back to the hospital.
There is a mixed bag of studies chronicling the controversial topic of medical resident duty hour restrictions, which refers to restricting the maximum allowable hours a resident can work. Currently, in the US, that means a maximum of 80 hours a week averaged over a 4-week-period, a maximum shift duration of 24 hours (plus 4 hours for transitioning care, so let’s call a spade a spade: it’s 28 hours) and being on call no more than once every 3 nights.
Now, I know what you’re thinking. Back in my day we knew the value of work. Seriously, though, an official 80 hour per week cap on duty hours was meant to be an improvement over the 100+ weekly hours residents were known to work in the past because some radical thinkers had concerns that perhaps working 36 hour shifts and sleeping 3 hours per night may be just a smidge risky for patients and maybe even not so great for residents either.
Still tired?
Luckily, it turns out those people were wrong. The mandated duty hour restrictions didn’t show a clear effect on patient safety or clinical outcomes. And anyway, how can residents possibly learn enough if they’re working a measly 80 hours a week?
If I may humbly offer a few thoughts.
Perhaps working an average of 13 plus hours six days a week for three or more years and taking call up to every 3 nights and working 28 hours at a time means you are, in fact, still tired. I know, crazy, right? How much rest does a resident need for crying out loud? See above, re the value of work. Regardless, maybe, just maybe, residents are still overworked and fatigued and thus unable to provide the best possible patient care.
Reprimanded rather than relieved
Add to that the fact that reported duty hours don’t necessarily equate with actual duty hours in a system that incentivizes underreporting. Violating duty hours often leads to residents being reprimanded rather than relieved of an overly burdensome call schedule.
I will never forget being called in to the chief residents’ office and questioned as to why I had violated my duty hours on a notoriously busy inpatient rotation. Surely this is a joke, I thought to myself. Weren’t these the same people who were writing the residents’ call schedules? Obviously, they knew how many hours I was working.
For the good of the program
It’s an interesting bind residents are placed in. A residency program violating duty hour regulations can lose its accreditation, which would result in residents being unable to complete their training and become board certified. This often leads to an implicit agreement that residents not report the actual hours they work ‘for the good of the program’.
Whenever a system is designed in a way that penalizes those who report its shortcomings, it makes me wonder who is benefiting on the other end. Residents are not paid an hourly rate, they aren’t paid overtime, their ‘extra’ hours are not compensated in any way, so it costs hospitals nothing to extract as many work hours as possible. The cost is borne out by the residents and, presumably, by the patients receiving care from overworked medical staff.
Of course, once you are out of residency, duty hour regulations no longer exist, so there really is no mandated limit as to how long a physician can be expected to work.
Minimal sleep: a glorified existence
Unfortunately, many physicians have bought into this myth of the necessity of long hours and the inherent value in being able to handle them. For years, I was no exception. Being able to survive on minimal sleep is a glorified existence. We’re basically the Navy Seals of the hospital world.
But there is simply no glory in being unable to remember where you’ve parked your car for the fifth time this week or forgetting what day your eldest child was born on while filling out a form (as, umm, happened to my friend once). These are the symptoms of beginning dementia, not the honor badges of an unbreakable physician.
It strikes me that in a profession whose underlying foundation is literally understanding the needs and warning signs of people’s bodies, we romanticize ignoring our own. It’s a bit like the trope of the chain-smoking cardiologist. If anyone should know better, it’s us.
Sleep when your patients sleep
As an M.MD (I really think it’s catching on now), I’m advocating for a paradigm shift. Sleep when your patients sleep. Shoot, doesn’t work there either, does it? Alright, then let’s start with an honest conversation about why physicians are expected to sacrifice their own bodily needs while counseling their patients to do the opposite.
*Also not sleeping are single parents, shift workers in various industries and the many people who have to work multiple jobs to scrape by, just to name a few.