Physicians and Sleep Deprivation

The impact of stress on sleep: Pathogenic sleep reactivity as a vulnerability to insomnia and circadian disorders

Sleep reactivity is the trait-like degree to which stress exposure disrupts sleep, resulting in difficulty falling and staying asleep. Individuals with highly reactive sleep systems experience drastic deterioration of sleep when stressed, whereas those with low sleep reactivity proceed largely unperturbed during stress. Research shows that genetics, familial history of insomnia, female gender and environmental stress influence how the sleep system responds to stress. Further work has identified neurobiological underpinnings for sleep reactivity involving disrupted cortical networks and dysregulation in the autonomic nervous system and hypothalamic-pituitary-adrenal axis. Sleep reactivity is most pathologically and clinically pertinent when in excess, such that high sleep reactivity predicts risk for future insomnia disorder, with early evidence suggesting high sleep reactivity corresponds to severe insomnia phenotypes (sleep onset insomnia and short sleep insomnia). High sleep reactivity is also linked to risk of shift-work disorder, depression and anxiety. Importantly, stress-related worry and rumination may exploit sensitive sleep systems, thereby augmenting the pathogenicity of sleep reactivity. With the development of cost-effective assessment of sleep reactivity, we can now identify individuals at risk of future insomnia, shift-work disorder and mental illness, thus identifying a target population for preventive intervention. Given that insomniacs with high sleep reactivity tend to present with severe insomnia phenotypes, patient sleep reactivity may inform triaging to different levels of treatment. Future research on sleep reactivity is needed to clarify its neurobiology, characterize its long-term prospective associations with insomnia and shift-work disorder phenotypes, and establish its prognostic value for mental illness and other non-sleep disorders.

Sleep Disturbance and Short Sleep as Risk Factors for Depression and Perceived Medical Errors in First-Year Residents

Study Objectives

While short and poor quality sleep among training physicians has long been recognized as problematic, the longitudinal relationships among sleep, work hours, mood, and work performance are not well understood. Here, we prospectively characterize the risk of depression and medical errors based on preinternship sleep disturbance, internship-related sleep duration, and duty hours.

Methods

Survey data from 1215 nondepressed interns were collected at preinternship baseline, then 3 and 6 months into internship. We examined how preinternship sleep quality and internship sleep and work hours affected risk of depression at 3 months, per the Patient Health Questionnaire 9. We then examined the impact of sleep loss and work hours on depression persistence from 3 to 6 months. Finally, we compared self-reported errors among interns based on nightly sleep duration (≤6 hr vs. >6 hr), weekly work hours (<70 hr vs. ≥70 hr), and depression (non- vs. acutely vs. chronically depressed).

Results

Poorly sleeping trainees obtained less sleep and were at elevated risk of depression in the first months of internship. Short sleep (≤6 hr nightly) during internship mediated the relationship between sleep disturbance and depression risk, and sleep loss led to a chronic course for depression. Depression rates were highest among interns with both sleep disturbance and short sleep. Elevated medical error rates were reported by physicians sleeping ≤6 hr per night, working ≥ 70 weekly hours, and who were acutely or chronically depressed.

Conclusions

Sleep disturbance and internship-enforced short sleep increase risk of depression development and chronicity and medical errors. Interventions targeting sleep problems prior to and during residency hold promise for curbing depression rates and improving patient care.

The Impact of the Australian and New Zealand College of Anaesthetists’ Specialist Examinations on Trainee Learning and Wellbeing: A Qualitative Study

Assessment is an essential component of any medical specialist training program and should motivate trainees to acquire and retain the knowledge and skills essential for specialist practice, and to develop effective approaches to learning, essential for continuous professional development. Ideally, this should be achieved without creating an unreasonable burden of assessment. In this qualitative study we sought to investigate the underlying processes involved in trainees’ preparation for Australian and New Zealand College of Anaesthetists’ examinations, focusing on how the examinations helped trainees to learn the Australian and New Zealand College of Anaesthetists’ curriculum, and to identify any potential areas for improvement. We also explored the effect the examinations had on trainees’ lives, to identify if the examinations were a potential threat to their wellbeing. Using a phenomenological approach and purposive sampling, we conducted semi-structured interviews with post-fellowship trainees (n=20) selected from three different regions, with sampling continuing to achieve data saturation. We undertook a thematic analysis of the transcribed interview data utilising a general inductive approach. Our preliminary data suggest that, while the examinations are an important extrinsic motivator to learn and important for professional development, interviewees described many test-driven learning strategies, including rote learning and memorising past examination questions. A strong theme was the considerable impact on participants’ relationships and social activities for prolonged periods. Our findings support further research in this area and, in particular, into alternative testing strategies that might increase the proportion of time spent in useful study while decreasing less useful study time.