SHORING UP THE THIRD PILLAR OF HEALTH: Getting the Sleep We Need

“I don’t sleep well and I’m exhausted” were her main complaints that day in the office. I then asked her, “What does an average 24-hour day look like for you?” She proceeded to describe her work as a janitor from 6 PM until 12:30 AM, sleeping from 1 AM until 6 AM, getting up to take her children to school, and then going to a second part-time job from 7 AM until 12 PM. After returning home from her second job, she does home errands and cooks, then picks up her children from school. She feeds them dinner before heading to her main job.  After getting a peek into a typical day of my patient’s life, and looking at her sleep study, it was clear that she had more than one sleep problem. Yes, she snored and had a crowded airway and indeed was found to have mild obstructive sleep apnea. Yes, she was under constant stress and sometimes had trouble falling asleep. But her biggest sleep disorder was the one that was eclipsing them all—insufficient sleep.

We now know that nutrition, exercise, and sleep are the three key components, or pillars, to living a healthy life and reducing the risk of poor performance and disease. 15 years ago the consequences of chronic insufficient sleep were not well-established, whereas today physicians and the general public are much more attuned to the potential consequences of sleep deprivation.  In the latest issue of SLEEP (Watson, NF et al., Recommended amount of sleep for a healthy adult: a joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society. SLEEP 2015; 38(6):843–844), experts in Sleep Medicine published their consensus statement on the desired sleep duration for adults ages 18-60. After reviewing 5314 scientific articles on the association between sleep duration and health, they came to the following conclusions:

  • “Sleeping less than 7 hours per night on a regular basis is associated with adverse health outcomes, including weight gain and obesity, diabetes, hypertension, heart disease and stroke, depression, and increased risk of death. Sleeping less than 7 hours per night is also associated with impaired immune function, increased pain, impaired performance, increased errors, and greater risk of accidents.
  • Sleeping more than 9 hours per night on a regular basis may be appropriate for young adults, individuals recovering from sleep debt, and individuals with illnesses. For others, it is uncertain whether sleeping more than 9 hours per night is associated with health risk.
  • People concerned they are sleeping too little or too much should consult their healthcare provider.”

Although wanting eight hours of sleep at night is a laudable goal, eight hours is not what everyone needs, and even 7 hours, as recommended above, may be hard to attain due to employment, home responsibilities, and other factors beyond our control. One of the treatment challenges of improving sleep duration is that by putting pressure on ourselves to sleep enough, we may inadvertently trigger anxiety about sleep and therefore push sleep further away.  In an achievement-oriented world, we easily fall into the trap of treating sleep as another “achievement,” rather than as something we let happen. We humans have the unique ability to push sleep away.  In the case of my patient described above, we’ve taken a pragmatic approach to her sleep problem–our biggest accomplishment so far has been working together to carve out a precious hour in her day….to take a nap.

Melissa Lim, MD

Sleep Specialist

Redwood City, CA

http://www.mobilesleepdoc.com

Physician Heal Thyself: Practicing What We Preach

Rushing–as usual–into the hospital on my way to work, I darted past the elevators where one of the hospital operators was kindly holding the doors open. I waived him on with a friendly “Good morning” and headed instead to the stairwell.  When I passed him, I heard him mutter, “Doctors, they always take the stairs.” Little did he know that climbing a few flights of stairs might amount to my only exercise for the rest of the day (that, and walking my dog for his “morning constitutional.”).

I began thinking about the self-care routines of my colleagues and myself. How healthy were we as a group? What healthy behaviors do we follow, and which ones do we not? Are we setting a good example for our patients?

Like the rest of the population, we too are getting heavier, but at a somewhat slower pace–a little over half of primary care doctors are considered overweight or obese, as opposed to 2/3 of the rest of the population (N. Shute, NPR report, June 5, 2013). On a more positive note, we are pretty good at not smoking. Smoking rates dropped dramatically among physicians from the 1970’s to the 1990’s, down to 3.3% by 1991 (Nelson et al., JAMA. 1994;271(16):1273-1275), compared to 25% in the general population around the same time.

The bigger concern appears to be our mental health and the health of our relationships. Doctors have extraordinarily high divorce rates, by some estimates, 10-20% higher than in the general population. We also show high rates of depression, prescription drug abuse, alcoholism, and suicide (female physician suicide rates are 4X that of other women). Medical researchers are doing their best to clarify these trends and explore possible causes. In their stark and startling article “The Painful Truth: Physicians Are Not Invincible (Southern Medical Journal, 2000, 93(10): 966-973),” Miller and McGowen describe the “culture of medicine,” beginning with and extending beyond our sleep-deprived medical training, where we ultimately learn to shut ourselves off from our feelings in order to cope with the daily tragedies and despair suffered by our patients.

As a critical care specialist for the past 25 years, I have continued living the life of a resident, spending way too many nights in the hospital. I see firsthand and have even participated in the macabre humor borne from the pain we witness, fueled by exhaustion. I recall during residency when I once told the emergency room attending physician trying to admit the umpteenth patient to me in the middle of the night that I simply refused to admit anyone else to the hospital…unless it was GOD–to which she replied, “The patient is as old as GOD.”

Beginning to fray from my evolving burn-out, I was advised this year by my very wise spouse to read Trauma Stewardship (Berrett-Koehler Publishers, Inc., San Francisco, CA; 2009) by Laura van Dernoot Lipsky. In it she describes the 16 warning signs of the “trauma exposure response,” or ‘vicarious traumatization’ that can develop in those repeatedly caring for others who have experienced trauma. I devoured chapter four of her book with highlighter and annotations as a former medical student would. Maybe you won’t see all 16 of the signs in yourself, but maybe there will be enough of them to finally hear that wake-up call–to take better care of yourself while taking care of others.  I know I did. As a result, I changed my schedule to include “walk the earth” days on a regular basis, even (especially?) playing hooky on a weekday. I leave my computer at home and place my cell phone on silence. And I walk out my door. And take the stairs.

 

Melissa Lim, MD

Pulmonary, Critical Care, Sleep specialist

Redwood City, CA

www.redwoodpulmonary.net

www.mobilesleepdoc.com