Junior doctors' shifts and sleep deprivation

Empathy and burnout: A multicentre comparative study between residents and specialists

RATIONALE, AIMS, AND OBJECTIVES

The prevalence of burnout among medical doctors and its negative effect on empathy can influence therapeutic success. The aim of this study was to compare the levels of empathy and burnout between residents and specialists as well as to study the correlation between empathy and burnout.

METHODS

This is an exploratory study of a convenience sample of 104 doctors who work in health institutions in Greater Lisbon area in Portugal, covering central hospitals, district hospitals, and health centres. Each doctor filled in a questionnaire, which included the Maslach Burnout Inventory (MBI) and the Jefferson Scale of Empathy (JSE).

RESULTS

Participants were divided in two subgroups: 51% residents (n = 53) and 49% specialists (n = 51). A difference (p = .048) in JSE scores between residents (mean 116.4, SD 12.8) and specialists (mean 120.78, SD 12.84) has been identified. Furthermore, in all three MBI subscales (emotional exhaustion, depersonalization, and lack of personal accomplishment), the group of residents showed significantly higher mean scores. In general, empathy scores showed an inverse relationship between depersonalization (r = -0.390, p < .0001) and lack of personal accomplishment (r = -0.447, p < .0001). Finally, we found that an increase in MBI level is associated with a decrease in empathy levels.

CONCLUSION

Our findings suggest that there is a significant difference in burnout subscales scores between residents and specialists and that these have a negative correlation with empathy level. These exploratory results draw attention to the importance of preventing burnout in hospital and health care centres professionals, in particular in residents, through the implementation of individual and organizational structured measures.

Fatigue in Residency Education: Understanding the Influence of Work Hours Regulations in Europe

PURPOSE

Although one proposed solution to the problem of fatigued medical trainees is the implementation of work hours regulations, concerns about the effectiveness of these regulations are growing. Canada remains one of the few Western jurisdictions without legislated regulation. Recent research suggests that fatigue is a complex social construct, rather than simply a lack of sleep; thus, the authors explored how regulations and fatigue are understood in countries with established work hours frameworks to better inform other jurisdictions looking to address trainee fatigue.

METHOD

Using constructivist grounded theory methodology, the authors conducted individual, semistructured interviews in 2015-2016 with 13 postgraduate medical trainees from four European countries with established work hours regulations. Data collection and analysis proceeded iteratively, and the authors used a constant comparative approach to analysis.

RESULTS

Trainees reported that they were commonly fatigued and that they violated the work hours restrictions for various reasons, including educational pursuits. Although they understood the regulations were legislated specifically to ensure safe patient care and optimize trainee well-being, they also described implicit meanings (e.g., monitoring for trainee efficiency) and unintended consequences (e.g., losing a sense of vocation).

CONCLUSIONS

Work hours regulations carry multiple, conflicting meanings for trainees that are captured by three predominant rhetorics: the rhetoric of patient safety, of well-being, and of efficiency. Tensions within each of those rhetorics reveal that managing fatigue within clinical training environments is complex. These findings suggest that straightforward solutions are unlikely to solve the problem of fatigue, assure patient safety, and improve trainee well-being.

The millennial doctor - A blue collar worker?

The face of medical training has transformed over the last two decades. This has impacted education and training, work ethic and pride within the profession. There are serious concerns that rigid working hours, shift systems, erosion of team-working (with all of the implications this carries for the essential 'apprenticeship' of postgraduate medical training) and repeated political interference will transform the millennial doctor into a 'blue collar' worker. Morale is at an all-time low and more needs to be done to support and value junior doctors, raise awareness of work-life balance issues and improve working lives. Initiatives such as the Royal College of Physicians' Underfunded, underdoctored and overstretched report and the chief registrar project are crucial triggers to raise morale and restore pride in this most rewarding of professions.

Effect of the full implementation of the European Working Time Directive on operative training in adult cardiac surgery

OBJECTIVES

Surgical specialties rely on practice and apprenticeship to acquire technical skills. In 2009, the final reduction in working hours to 48 per week, in accordance with the European Working Time Directive (EWTD), has also led to an expansion in the number of trainees. We examined the effect of these changes on operative training in a single high-volume [>1500 procedures/year] adult cardiac surgical center.

METHODS

Setting: A single high-volume [>1500 procedures/year] adult cardiac surgical center. Design: Consecutive data were prospectively collected into a database and retrospectively analyzed. Procedures and Main Outcome Measures: Between January 2006 and August 2010, 6688 consecutive adult cardiac surgical procedures were analyzed. The proportion of cases offered for surgical training were compared for 2 non-overlapping consecutive time periods: 4504 procedures were performed before the final implementation of the EWTD (Phase 1: January 2006-December 2008) and 2184 procedures after the final implementation of the EWTD (Phase 2: January 2009-August 2010). Other predictors of training considered in the analysis were grade of trainee, logistic European system for cardiac operative risk evaluation (EuroSCORE), type of surgical procedure, weekend or late procedure, and consultant. Logistic regression analysis was used to determine the predictors of training cases (procedure performed by trainee) and to evaluate the effect of the EWTD on operative surgical training after correcting for confounding factors.

RESULTS

Proportion of training cases rose from 34.6% (1558/4504) during Phase 1 to 43.6% (953/2184) in Phase 2 (p < 0.0001), despite higher mean logistic EuroSCORE [4.29 (6.8) during Phase 1 vs 4.95 (7.2) during Phase 2, p < 0.0001] and higher proportion of cases performed out of hours [153 (3.4) during Phase 1 vs 116 (5.3) during Phase 2, p < 0.0001]. During Phase 1, senior trainees (last 2 years of training) performed 803 (17.8%) procedures, whereas other trainees (first 4 years of training) performed 755(16.8%) cases. During Phase 2, senior trainees performed 763 (34.9%) procedures, whereas other trainees performed 190 (8.7%) cases (p < 0.0001). Independent positive predictors of training cases emerging from the multivariable logistic regression model included consultant in charge, final EWTD, and senior trainees. Independent negative predictors of training cases included logistic EuroSCORE, out-of-hours' procedures, and surgery other than coronary artery bypass grafts.

CONCLUSION

Implementation of the final phase of EWTD has not decreased training in a high-volume center. The positive adjustment of trainers' attitudes and efforts to match trainees' needs allow maintenance of adequate training, despite reduction in working hours and increasing patients' risk profile.

Mentorship for newly appointed consultants: what makes it work?

BACKGROUND

Mentorship has been identified as a beneficial practice for doctors and may be particularly valuable for newly appointed consultants. It is associated with a number of potential clinical and non-clinical gains, such as enhanced job satisfaction and well-being. Despite strong support, many formalised schemes fail to launch or gain momentum. Research to date has largely focused on the gains associated with mentorship but has lacked study of the factors that facilitate uptake and maintenance of mentoring relationships by physicians.

OBJECTIVES

To explore perceptions of mentorship, the extent to which UK doctors appear to value mentorship and factors that may contribute to its successful use.

DESIGN

Qualitative, descriptive, multi-centre study.

SAMPLE

30 doctors including registrars, those newly appointed to consultant grade, senior doctors and medical leaders from nine hospitals in the north of England.

METHOD

Semistructured individual interviews were undertaken between August and December 2013.

RESULTS

Findings revealed a demand for mentorship for new consultants, with widely recognised benefits associated with its use. Several factors were identified as critical to successful mentorship relationships, including consistent understanding and expectations of mentorship between mentee and mentor, positive prior experiences, a suitable match between mentee and mentor, making time for people to act as mentors and the ensuring that mentors can meet a diverse and changing set of needs.

CONCLUSIONS

Mentorship for newly appointed consultants is valued, but current models of mentorship may suffer from rigid structures, mismatched expectations of participants and the absence of a culture of mentorship from training into practice. A social network approach, in which doctors have the opportunity to engage with a range of mentors through informal and naturally occurring relationships, may be one way to encourage successful and sustained mentoring relationships among doctors. An organisational culture in which mentorship is permitted and is the norm may enable such approaches to be widely adopted.

Safety during night shifts: a cross-sectional survey of junior doctors' preparation and practice

OBJECTIVES

We aimed to determine whether junior doctors and trusts in the region make use of published evidence relating to best practice during night shift work that can safeguard alertness, reduce fatigue and limit mistakes. We surveyed junior doctors' preparation for and practice during night shifts, and the working and living conditions offered by hospitals for junior doctors carrying out night duties.

DESIGN

Cross-sectional survey.

SETTING

An anonymous online questionnaire was sent to junior doctors training within Health Education North West from 13 December 2012 to 14 February 2013.

PARTICIPANTS

32% (16/42) of trusts within Health Education North West sent the survey to 2139 junior doctor email addresses; 24.5% (524/2139) entered data into the survey.

RESULTS

91.6% of surveyed junior doctors worked night shifts. Prior to starting night shifts, 65% do not have a 'prophylactic' afternoon nap. At work, half (49%) can access a room with a reclining chair while 24% have a room with a bed. 37% 'never' achieve a 'natural break' on night shift; 53% 'never' achieve the recommended 20-45 min nap. 91% of respondents were unaware of the duration of sleep inertia that can affect alertness upon waking. When converting between day/night shifts, 2% use light lamps and 6% use non-benzodiazepine sedatives. Principal themes from free text analysis were feeling lethargic or unwell during night shifts, concern for patient and personal safety and inability to rest or take breaks.

CONCLUSIONS

The trainees surveyed find night shifts difficult, yet do not/are unable to implement evidence-based recommendations to limit fatigue. Results suggest those surveyed experience a lack of rest facilities within their place of work and a demanding workload. The results may indicate the need to increase awareness of the potential benefits associated with different interventions that can help mitigate the fatigue associated with rotating shift work.

Engaging junior doctors: evidence from "open spaces" in England

PURPOSE

This paper aims to report on a project undertaken in order to identify, develop and reflect on the leadership and managerial skills of clinicians. The main aim of the project was to design, plan, organise and deliver a learning session for Foundation Year 2 Doctors within the premises of one of the largest NHS Foundation Trusts in the UK. The key theme of the learning session was the introduction of the notion of competent medical leadership in the NHS. A leadership role has been traditionally seen as the task of managers and as such clinicians have seemed reluctant to engage.

DESIGN/METHODOLOGY/APPROACH

A two hour workshop was designed and delivered with the use of Open Space Technology. Foundation Year 2 doctors were invited to consider the importance of leadership in their everyday roles. An awareness of the Medical Leadership Competency Framework had been a key aspect of the learning session.

FINDINGS

The project's outcome can be identified as being the encouragement of Foundation Year 2 doctors in considering their roles as leaders in their everyday tasks.

ORIGINALITY/VALUE

Design, planning, organisation and delivery of a two hour Open Space learning session with the Foundation Year 2 doctors portrays the session's learning potentials and the potential for such sessions to provide a platform for difficult discussions in the NHS. This is particularly beneficial where a cultural shift is needed in order to see a way forward, notably when facing significant change.

Perceptions of fatigue - and perceived consequences - among Flemish obstetricians-gynaecologists: a survey

OBJECTIVES

The effects of fatigue on the performance of medical trainees have been extensively studied. Much less is known about the effects of fatigue among doctors who have completed their training. The aim of this study was to inquire about the perception of fatigue and its consequences among certified obstetricians-gynaecologists (OGs).

METHODS

A questionnaire was mailed to all certified OGs working in Flanders (Northern Belgium). Descriptive statistics as well as uni- and multivariate analyses for potential determinants of fatigue are presented.

RESULTS

Of the 450 questionnaires mailed, 260 (58%) were returned. Half (52%) of the doctors worked more than 60 h/week. During an average working day, four out of ten respondents indicated they experienced a certain degree of fatigue, and one in ten felt really tired. Fatigue was associated with long working hours and led in a sizeable proportion of respondents to dissatisfaction (29%) and to medical/surgical errors (19%). None of the perceived errors resulted in loss of life. Academic OGs worked more hours/week but fewer during the night than their colleagues in private practice. The former reported having made significantly more medical errors (26%) than the latter (11%).

CONCLUSIONS

Tired OGs have less job satisfaction, and perceive they make more errors. None of the perceived errors resulted in loss of life. Certified OGs working more than 60 h/week are more frequently tired.

[Undesirable events during the perioperative period and communication deficiencies]

In recent decades, anaesthesia and surgery have undergone major scientific and technical developments. However, these improvements have not solved a recurring problem, communication deficiencies within teams in charge of surgical patients. Current figures show that 21% to 65% of accidents and errors in patient management during the perioperative period are related to communication problems. These problems occur when gaps arise in the continuity and coordination of care within teams. Some of the contributing factors to these gaps are emergency status of patients, staff shifts and handovers following patient transfers. To minimize the impact of these phenomena, it is important to improve standardization of information flow within operating theatres and to improve teamwork between anaesthetists and surgeons. This can be done through crew resource management training programs or simulation. This should ultimately contribute to minimise medical error and improve the overall quality of care provided to patients in operating theatres and during all the perioperative period.

The impact of shift patterns on junior doctors' perceptions of fatigue, training, work/life balance and the role of social support

BACKGROUND

The organisation of junior doctors' work hours has been radically altered following the partial implementation of the European Working Time Directive. Poorly designed shift schedules cause excessive disruption to shift workers' circadian rhythms.

METHOD

Interviews and focus groups were used to explore perceptions among junior doctors and hospital managers regarding the impact of the European Working Time Directive on patient care and doctors' well-being.

RESULTS

Four main themes were identified. Under "Doctors shift rotas", doctors deliberated the merits and demerits of working seven nights in row. They also discussed the impact on fatigue of long sequences of day shifts. "Education and training" focused on concerns about reduced on-the-job learning opportunities under the new working time arrangements and also about the difficulties of finding time and energy to study. "Work/life balance" reflected the conflict between the positive aspects of working on-call or at night and the impact on life outside work. "Social support structures" focused on the role of morale and team spirit. Good support structures in the work place counteracted and compensated for the effects of negative role stressors, and arduous and unsocial work schedules.

CONCLUSIONS

The impact of junior doctors' work schedules is influenced by the nature of specific shift sequences, educational considerations, issues of work/life balance and by social support systems. Poorly designed shift rotas can have negative impacts on junior doctors' professional performance and educational training, with implications for clinical practice, patient care and the welfare of junior doctors.

The relationship between workload and medical staffing levels in a paediatric cardiac intensive care unit

OBJECTIVE

To evaluate the matching between workload in a paediatric cardiac intensive care unit (ICU) and the corresponding medical staffing levels over a 24-h period.

DESIGN

A review of workload measured by: (a) admissions, (b) severity of illness in admissions using case-mix descriptors and mortality as a proxy, (c) cardiac arrests (CA) and (d) extracorporeal membrane oxygenation (ECMO) cannulations. An evaluation of matching between workload and medical staff schedules.

SETTING

A tertiary paediatric cardiac ICU.

PATIENTS

2,799 admissions over a 49-month period.

RESULTS

New admissions peaked in the evening, and the ratio of doctors' hours to admissions was lowest between 1359 and 2000 h. Although only 515 (17.3%) cases were admitted between 2000 and 0759 h, these were more likely to be emergencies, to have higher Paediatric Index of Mortality 2 (PIM2) scores and to die (p < 0.001). There was an increased adjusted risk of death in admissions between 2000 and 0159 h (p = 0.021). There was no difference in the occurrence of either CA (p = 0.41) or ECMO (p = 0.95) between day and night. The ratio of doctors' hours to CAs and ECMOs was lowest from 2000 to 0800 h. The conventional medical staffing roster generated the greatest concentration of staff in the morning, reducing to the lowest level between 0200 and 0759 h.

CONCLUSIONS

Workload was most intense for the in-house team at night, in terms of sicker admissions, ECMOs and cardiac arrests. Conventional roster patterns may not offer ideal matching between staffing and workload. Data analysis of variable and urgent workload may be used to inform medical rosters.

A gender-based analysis of work patterns, fatigue, and work/life balance among physicians in postgraduate training

PURPOSE

To document fatigue in New Zealand junior doctors in hospital-based clinical training positions and identify work patterns associated with work/life balance difficulties. This workforce has had a duty limitation of 72 hours/week since 1985. The authors chose a gender-based analytical approach because of the increasing proportion of female medical graduates.

METHOD

The authors mailed a confidential questionnaire to all 2,154 eligible junior doctors in 2003. The 1,412 respondents were working > or = 40 hours/week (complete questionnaires from 1,366: response rate: 63%; 49% women). For each participant, the authors calculated a multidimensional fatigue risk score based on sleep and work patterns.

RESULTS

Women were more likely to report never/rarely getting enough sleep (P < .05), never/rarely waking refreshed (P < .001), and excessive sleepiness (P < .05) and were less likely to live with children up to 12 years old (P < .001). Fatigue risk scores differed by specialty but not by gender.Fatigue risk scores in the highest tertile were an independent risk factor for reporting problems in social life (odds ratio: 3.83; 95% CI: 2.79-5.28), home life (3.37; 2.43-4.67), personal relationships (2.12; 1.57-2.86), and other commitments (3.06; 2.23-4.19).Qualitative analyses indicated a common desire among men and women for better work/life balance and for part-time work, particularly in relation to parenthood.

CONCLUSIONS

Limitation of duty hours alone is insufficient to manage fatigue risk and difficulties in maintaining work/life balance. These findings have implications for schedule design, professional training, and workforce planning.

Numbers needed to hospitalize-risks and benefits of admission in the new decade

While hospitals are central to western style health care systems it is unclear which patients benefit from hospitalization and who might be put at risk. The high cost means that reasons for hospitalization will need to be reviewed in the current economic climate. Accepted grounds for hospitalization include life threatening illness, diagnostic uncertainty with the threat of deteriorating health, the need for specialist expertise or experience or the need for nursing care, including the care of the dying. Some of the traditional surveillance functions of the hospital can now be taken over by technology or alternative settings. These changes will lead to a blurring of margins between Outpatient, Inpatient and Critical Care. Beyond the care of the critically ill patient it is unlikely that all patients currently admitted to hospital benefit from this process and would be admitted in future. A generally accepted system for risk assessment of medial inpatients is urgently needed to allow researchers to examine the effectiveness of health care systems involving hospitalization and the circumstances under which hospitalization is cost effective and improves mortality, morbidity and patient reported outcomes.

Implementation of the European Working Time Directive in an NHS trust: impact on patient care and junior doctor welfare

To comply with the European Working Time Directive (EWTD), from 1 August 2009, junior doctors are required to work no more than 48 hours per week. In accordance with this, East Sussex Hospitals Trust introduced changes to working practice in August 2007. To assess the impact upon patient care and junior doctor welfare a retrospective observational survey comparing data from the year prior to and the year following August 2007 was conducted. No impact on the standard of patient care, as measured by length of stay, death during admission or readmission was found. However, there was a notable increase in episodes of sick leave among junior doctors. Implementation of the EWTD may maintain standards of patient care but may be detrimental to the welfare of doctors in training.

Implementing a 48 h EWTD-compliant rota for junior doctors in the UK does not compromise patients' safety: assessor-blind pilot comparison

BACKGROUND

There are currently no field data about the effect of implementing European Working Time Directive (EWTD)-compliant rotas in a medical setting. Surveys of doctors' subjective opinions on shift work have not provided reliable objective data with which to evaluate its efficacy.

AIM

We therefore studied the effects on patient's safety and doctors' work-sleep patterns of implementing an EWTD-compliant 48 h work week in a single-blind intervention study carried out over a 12-week period at the University Hospitals Coventry & Warwickshire NHS Trust. We hypothesized that medical error rates would be reduced following the new rota.

METHODS

Nineteen junior doctors, nine studied while working an intervention schedule of <48 h per week and 10 studied while working traditional weeks of <56 h scheduled hours in medical wards. Work hours and sleep duration were recorded daily. Rate of medical errors (per 1000 patient-days), identified using an established active surveillance methodology, were compared for the Intervention and Traditional wards. Two senior physicians blinded to rota independently rated all suspected errors.

RESULTS

Average scheduled work hours were significantly lower on the intervention schedule [43.2 (SD 7.7) (range 26.0-60.0) vs. 52.4 (11.2) (30.0-77.0) h/week; P < 0.001], and there was a non-significant trend for increased total sleep time per day [7.26 (0.36) vs. 6.75 (0.40) h; P = 0.095]. During a total of 4782 patient-days involving 481 admissions, 32.7% fewer total medical errors occurred during the intervention than during the traditional rota (27.6 vs. 41.0 per 1000 patient-days, P = 0.006), including 82.6% fewer intercepted potential adverse events (1.2 vs. 6.9 per 1000 patient-days, P = 0.002) and 31.4% fewer non-intercepted potential adverse events (16.6 vs. 24.2 per 1000 patient-days, P = 0.067). Doctors reported worse educational opportunities on the intervention rota.

CONCLUSIONS

Whilst concerns remain regarding reduced educational opportunities, our study supports the hypothesis that a 48 h work week coupled with targeted efforts to improve sleep hygiene improves patient safety.

Regulating medical bodies? The consequences of the 'modernisation' of the NHS and the disembodiment of clinical knowledge

The aim of this paper is to explore the consequences of modernisation and regulatory processes for the everyday lives of doctors working the UK National Health Service. We do this by reporting on interview data generated as part of a qualitative investigation into the working lives of 47 doctors. The analysis of the empirical findings is informed by two literatures: that which has sought to theorise the contemporary thrust of regulation and audit and that which has developed a sociology of embodiment. Doctors' views are presented in relation to four areas of work which hav--in the loosest sense of the word--been subject to regulation. Drawing on work from the sociology of embodiment we argue that changes in the institutional and cultural context of medical work could be altering both the 'field' and the 'habitus'--to use Bourdieu's terms--of medicine, with a consequence that medical knowledge is becoming less embodied.

Work patterns and fatigue-related risk among junior doctors

BACKGROUND

To reduce fatigue-related risk among junior doctors, recent initiatives in Europe and the USA have introduced limits on work hours. However, research in other industries has highlighted that other aspects of work patterns are important in generating fatigue, in addition to total work hours. The Australian Medical Association (AMA) has proposed a more comprehensive fatigue risk management approach.

OBJECTIVES

To evaluate the work patterns of New Zealand junior doctors based on the AMA approach, examining relationships between different aspects of work and fatigue-related outcomes.

METHODS

An anonymous questionnaire mailed to all house officers and registrars dealt with demographics, work patterns, sleepiness, fatigue-related clinical errors, and support for coping with work demands. Each participant was assigned a total fatigue risk score combining 10 aspects of work patterns and sleep in the preceding week.

RESULTS

The response rate was 63% (1366 questionnaires from doctors working > or =40 hours a week). On fatigue measures, 30% of participants scored as excessively sleepy (Epworth Sleepiness Score >10), 24% reported falling asleep driving home since becoming a doctor, 66% had felt close to falling asleep at the wheel in the past 12 months, and 42% recalled a fatigue-related clinical error in the past 6 months. Night work and schedule instability were independently associated with more fatigue measures than was total hours worked, after controlling for demographic factors, The total risk score was a significant independent risk factor for all fatigue measures, in a dose-dependent manner (all p<0.01). Regular access to adequate supervision at work reduced the risk of fatigue on all measures.

CONCLUSIONS

To reduce fatigue-related risk among junior doctors, account must be taken of factors in addition to total hours of work and duration of rest breaks. The AMA fatigue risk assessment model offers a useful example of a more comprehensive approach.

Are doctors working the EWTD night shift pattern less tired?

The introduction of the European Working Time Directive (EWTD) has resulted in shift pattern rotas that include a week of night shifts. The EWTD was introduced to reduce the number of hours worked per week and consequently ensure that tired doctors were not treating patients. A week of night shifts allows rotas to meet the EWTD requirements while providing night-time cover with regular interspersed rest periods, which seems an advantage over the now largely redundant on-call system.

When policy meets physiology: the challenge of reducing resident work hours

Considerable controversy exists regarding optimal work hours for physicians and surgeons in training. In a series of studies, we assessed the effect of extended work hours on resident sleep and health as well as patient safety. In a validated nationwide survey, we found that residents who had worked 24 hours or longer were 2.3 times more likely to have a motor vehicle crash following that shift than when they worked < 24 hours, and that the monthly risk of a crash increased by 16.2% after each extended duration shift. We also found in a randomized trial that interns working a traditional on-call schedule slept 5.8 hours less per week, had twice as many attentional failures on duty overnight, and made 36% more serious medical errors and nearly six times more serious diagnostic errors than when working on a schedule that limited continuous duty to 16 hours. While numerous opinions have been published opposing reductions in extended work hours due to concerns regarding continuity of patient care, reduced educational opportunities, and traditionally-defined professionalism, there are remarkably few objective data in support of continuing to schedule medical trainees to work shifts > 24 hours. An evidence-based approach is needed to minimize the well-documented risk that current work hour practices confer on resident health and patient safety while optimizing education and continuity of care.

The importance of sleep

‘Welcome little stranger’ wrote my grandmother when I was born. But I was not welcome for long. I was a ‘difficult baby’, as I was reminded half a century on. The problem was that I would not sleep. Keeping your mother awake is not the best start to a relationship. We all know the importance of sleep. Or do we?