DOCTORS' LOUNGE
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TO RETIRE, PERHAPS TO SLEEP AUTHOR Mary Barry, MD
L
ike many doctors of my generation,
I have not been getting enough sleep
since – oh, 1977. That’s when I con-
cluded, working in the CCU at General
Hospital, that I needed to learn what
doctors knew, and not just what nurses
knew. I began a long two years of work-
ing double shifts, 3pm- 7am, four days a week
so I could take college classes in the mornings. I had to complete
multiple science credits, attempting straight A’s of course, to get into
medical school. So, I only worked (learning lots about hearts), slept
and studied. The next two years I had a good gig of just studying,
only working some in the summer, but I needed many hours of
memorization to make it to the clinical years. Since August 1983, I
have been staying up all night on call or being awakened on call. I
point out that I have chosen this life and have been extraordinarily
lucky to have hospitalist partners for the past 10 years who allowed
me weekends and vacations off hospital call, including emergency
coverage when needed. They have been wonderful, and my beloved
partners are champions in every way.
Epic hit us all on April 18, 2012. That was the death knell for
sleep, since we have become primary typists who make trillions of
decisions while worrying and talking and examining and caring
fulltime for the patients we hold as our own. It takes our days and
our nights to do this right. We stay up late, to have a little bit of life,
reading and family, and get up early. Epic got upgraded today as I
write this, and all my partners were, despite inner rejoicing, imme-
diately frustrated about getting it done with no Sunday time to use.
That adds up to far too much gone forever/interrupted sleep.
Why is this bad for us? Oh, to count the ways: our ability to
sustain attention is one of the first casualties, although about one-
third of us seem to carry genetic ability to withstand that far better.
However, one-third of us are affected far worse. There is a wide
variance in the cognitive domains in which neuroscientists can
measure our declining performance, so it is quite hard to compare
individuals. But in general, it takes a huge effort to sustain attention
once we have been awake for hours and hours on end.
Chronically, loss of sleep leads to loss of connectivity among the
brain regions that coordinate laying down of memory. Functional
MRI can measure losses over time in the activity of these networks
(the true “Deep State”). Chronic and repeated insults to the quality
and length of sleep impair the connections between the thalamus
and several other parts of the brain. However, the effects vary de-
pending on which network is connecting to the thalamus. Studies
of pilots and others in the military who carry out missions requiring
prolonged sleep deprivation have shown that transcranial magnetic
stimulation of the visual cortex can actually restore some of these
connections and negate the associated memory loss.
Sleep deprivation also hurts our ability to delay gratification.
We have studied participants in the Iowa Gambling Task, a test
invented at the University of Iowa by researchers Antoine Bechara,
Antonio Damasio, Hanna Damasio and Steven Anderson (some-
how, Italian-sounding names and gambling seem to go together).
Participants have to choose from various decks of cards, some
decks having more money-winning cards in them. With practice,
most people get good at picking the leading decks. The test has
its critics, but when used by sleep researchers, the sleep-deprived
person makes worse choices as time goes on, taking more risks and
going for the immediate gratification instead of the delayed. This
also applies to choices in what to eat, what to drink, and so on. Our
executive function of chiding ourselves and controlling for “bad”
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