Importance of sleep - Shift work, fatigue and burnout (15 Mar 2023)

SPEAKER_00 0:00

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SPEAKER_02 0:33

Hello, my name is Carrie Baker, and I'm an acute physician in NHS Fife and Director of Education at the Royal College of Physicians of Edinburgh. Did you know that according to the King's Fund, 44% of doctors in the UK are female? That's over one quarter of a million of us. That includes 55% of medical students and 54% of postgraduate trainees. If this trend continues, women will make up the majority of medical workforce within the next decade. However, only 32% of consultants and 24% of medical directors are women. And women are underrepresented in leadership and academic roles. Together, the Royal Colleges of Physicians and Surgeons of Edinburgh, on behalf of the Academy of Medical Royal Colleges, are hosting an exciting two-day Women in Leadership event on the 27th and 28th of April. The first day will be a hybrid conference at the Royal College of Physicians of Edinburgh in our city centre-based conference centre and also available online via live web streaming for those who cannot attend in person. The second day will be an interactive in-person event at the Royal College of Surgeons of Edinburgh, with workshops and parallel sessions, and the opportunity to interact with a range of inspirational speakers and hosts. This event is about helping build the workplace that we and our future colleagues and public deserve. It's about celebrating and inspiring women in leadership to serve as role models. We have an incredible range of speakers lined up for you, including Professor Dame Sally Davis, the previous CMO for England, and Professor Dame Carrie McEwen, the chair of the GMC. We hope to see you there.

SPEAKER_03 2:04

Welcome to this episode, and today we have got Dr. Michael Farker on, who is a consultant in children's sleep medicine in London, and we will be talking about sleep shift work, burnout, and fatigue. So thank you very much for joining us. Now you initially graduated from Edinburgh University and then have completed training in Glasgow, Nottingham, Australia, and then settling in London. How did you choose and decide to get into sleep medicine?

SPEAKER_01 2:39

Well, so uh that's partly because I'm a very stubborn person. I am one of those people that got interested in a particular branch of medicine because I had a personal investment in it. So when I was a teenager, I started to get episodes of things called hypnogorbic hallucinations and sleep paralysis, which can be quite frightening things. Uh, in olden times, people used to think demons were coming and attacking them in the night. These days I think it's probably alien abduction stories. But as a teenager, they were pretty disturbing. I went to see my GP, my GP said, you're probably not going to die, but he didn't really know what they were. And then I started researching it myself. So I went to the library, found out you know all about sleep, discovered what I thought these were, and in the process of that I got really interested in sleep as a concept. And then through my career, I kept that interest. And initially it was just an interest. But the further through my career I got, the more I realized there was the possibility of turning it into a consultant job at the end. So it took a bit of stubbornness and a bit of uh carving my own path, if that makes sense. Um, but yeah, it's all just because I got an interest in sleep when I was younger.

SPEAKER_03 3:34

Oh, fascinating. And I think there's you know been more and more information and awareness brought to the attention of doctors and the general public about the importance of sleep. But I guess what are the impacts on one's health with a lack of sleep and not getting enough? Because even that small amount of consistent lack of sleep seems to massively build up.

SPEAKER_01 3:56

Absolutely. So, as you said, there is increasing awareness of the importance of sleep. So you spend out a third of your lives asleep, and we don't evolve to spend as much time doing that unless there's a really important reason for it. So, sleep is one of the absolute foundations of health and well-being, and as junior doctors are usually very aware, um, if you don't get the right amount of good quality sleep, that has lots of impacts in terms of your ability to work, how you feel, and being able to stay awake when you're trying to do your job. That concept of even a little bit of sleep having significant consequences, most adults in the UK probably get about an hour less sleep most nights than they should do. And we're all pretty good at justifying that, take a double espresso, everything's fine. But if you're meant to get seven, eight hours of sleep and you're missing about an hour of sleep most nights, which most people are, it means over the equivalent of a week you miss about an entire night's sleep, which starts to sound like a much more significant amount. When I teach, I often talk about uh sleep as a kind of the MOT for your brain and body. It's that kind of regular repair and maintenance to make sure you're functioning at your best. And if you skip that, then you probably function okay for well, but the longer you skip it, the more problems are likely to develop. And there's an increasing body of evidence now that tells us that even mild to moderate chronic sleep deprivation over the course of a lifetime plays an important factor in things like lifetime risk of cardiovascular disease, so high blood pressure, strokes, heart attacks, all the rest of it, developing some types of cancer, developing type 2 diabetes, developing obesity, increasing your risk of developing mental health problems, increasing your risk of conditions like Alzheimer's. So as we get more of that evidence base, there is much more interest in trying to really think about how we use sleep, both on a personal health but also a public health level to try and mitigate those risks as much as we can.

SPEAKER_03 5:31

Yeah, absolutely. Having read your 2017 paper, which I think it's worth reading, the for nature cannot be fooled, I think it's a good one for doctors to realise that, and it's not just sleep, it's you know, taking breaks. It's the culture previously of working through your breaks, missing them, that needs to go, especially as the intensity and the workload has dramatically increased even before COVID, and that's just kind of pushed it right over. That actually don't be a hero, take your break because you function better.

SPEAKER_01 6:00

Absolutely. And that's where, you know, so when I started doing work about thinking about how to support healthcare workers around the clock, what I was really starting with initially was, you know, if you work nights, you are going to have screwed-up sleep, you're going to be sleep-deprived, it's more difficult to sleep in the daytime when you're on night shifts, it's more difficult to work at night when you're meant to be asleep. But that piece of work very rapidly evolved into a much broader piece of work that encompasses exactly what you're talking about, which is that there is a huge problem with the concept of fatigue within the NHS. And as a culture, the NHS is an organization that has very much adopted in the past the kind of you know heads down and bulldoze through kind of attitude, that this is just something we have to do. But again, there's a significant body of evidence that tells us that fatigue really matters. You know, it impacts our ability to do our jobs, you know, our ability to analyse situations, to make decisions safely, do procedures safely, but it also has a personal cost. And again, one of the factors that really drove me to get involved in this work was the sad truth that, you know, every few months or so we lose a doctor or a nurse driving home after a night shift who crashes and dies because they've literally fallen asleep behind the wheel of a car. So fatigue has huge impacts in the NHS for both an individual but also an organizational level as well.

SPEAKER_03 7:02

Yeah, I think there's a lot of people probably listening to this podcast can probably sadly relate to either themselves or someone they know feeling tired behind the wheel or getting home or feeling like their decision-making ability is not what it normally is. And are there any particular kind of warning signs or things people should look out for? Because fatigue can kind of just creep up on you in a very subtle way.

SPEAKER_01 7:24

I think it's often really difficult because there's a huge amount of individual variation in both sleep and fatigue. And it's one of the reasons why I think this really has to be a systemic approach to things. Air traffic controllers can only work for a few hours before they must have a mandatory 30-minute break because they're just not judged capable to be able to do their job safely if they don't do that. And we don't have that same attitude to rest and breaks in the NHS. So I think rather than focusing on individuals, we should really be saying this is a systemic problem, and we should be building that in. And you kind of said yourself, the importance of rest and breaks. We've had a culture that sees rest and breaks as a luxury for a very long time. And actually, we should be flipping that around and saying, well, actually, if we're not getting rest and breaks, then we're not able to provide safe patient care. And actually, that's one of the things that the English junior doctor's contract enshrines that concept and says that rest and breaks are necessary for both the safety of the doctor but also patient safety. If you're not getting your breaks, you're not providing safe patient care, and that's the way around it should be.

SPEAKER_03 8:16

And do you think going on to night shifts in our breaks, should there be a facility that we should be having a short nap? Is that a beneficial thing to have on a night shift?

SPEAKER_01 8:25

I think yes, for many people it can be. I think there's a lot of thinking that has to go around that to do that safely. So this is talking about power naps, which are generally about 15 to 20 minutes. So they fit within a statutory 30-minute break. And the idea with that is exactly that that if you can have a short burst of sleep, then you are going to mitigate some of the impacts of fatigue that absolutely builds up over the course of a shift and even more so on a night shift. You'd have to be a little bit careful. So, one of the reasons that we would recommend short power naps is that what you're aiming for is a short enough sleep that you get refreshed when you are able to done that, but not so long that you get into the deeper stages of sleep. So if you sleep for much longer than about 15 to 20 minutes, you're likely to get into the much deeper stages of sleep. And then the issue, then obviously, is if you're needed in a hurry, your crash patients off whatever, it's much more difficult to be woken from that. So there's often a bit of trial and error for individuals to work out what the right length of paranap is for them. Not everybody can do it, but in that case, I think just even that getting into the habit of taking yourself off for one of your breaks into a quiet, dark room, set an alarm, and even you just lie back and say, right, I'm not going to sleep, I'm just going to relax and chill for 20, 30 minutes, is not a bad habit to get into. And actually, many people find that they can actually start to learn to teach themselves to do paranaps and doing that. Yeah, not for absolutely everybody, but when used appropriately, I think they are an important way to try to mitigate some of that risk that is inherent in fatigue, particularly on night shifts.

SPEAKER_03 9:43

That sounds really good. And in night shifts, is there anything we've got new doctors coming through or rotating the whole time, maybe haven't been on a night shift before? How should they manage the approach to night shift? You kind of got the before, the during, and then the after process to try and make it as smooth as transition as possible.

SPEAKER_01 10:01

That's an entire talk in itself. And I don't know if you're able to put links in the podcast, but I can give you a link to a paper that basically covers exactly that. Particularly speaking to final year medical students, one of the things I say to them in preparation for coming into a job where they're probably going to have to work night shifts for possibly the first time in their life is to really concentrate on getting their core sleep routines and habits as good as possible. If you are already coming into medicine sleep-deprived and with bad sleep routines and habits, then night shift and working rotating shifts is probably going to make that worse. So, really investing in getting your core sleep routines and habits as good as possible is absolutely worth doing. There are then a whole host of things that you can do to try and mitigate some of the consequences of that around the clock working. And if you're able to put the link, I'll send you the paper that covers that. But a lot of it is about managing at a systemic level that impact. So a lot of it is about, you know, making sure you're getting your rest and breaks, how are you cross-covering to do that, supporting each other as a team at night, thinking about things like paranaps, how to use caffeine sensibly in a way that doesn't then uh screw up your ability to get to sleep when you go home the next day, thinking about tips to get you home safely, thinking about optimizing your bedroom environment at home. You know, so if you're trying to sleep in the daytime, then it's really worth investing in things like blackout lines or good quality eye masks, earplugs, things like that. And then there's a little bit of work, as you say, about trying to reboot people's sleep to get them back into a day shift pattern. But that's a bit of work that we've done. It was actually the first bit of work that we did as part of all of the work that I do with this was building teaching of that sort into our induction programme. So I'm doing it as we're we're doing this in the first week of August. So I'm doing that session later on this week for our new starters. But I think it should be mandatory in induction actually, um, giving people enough information to be able to manage the impact of working shifts on their health, but also then to be able to provide best quality care.

SPEAKER_03 11:41

Yeah, I think that would be really useful, certainly, to have in in the induction when it's often so new to people. Maybe as a medical student, you've done a kind of ad hoc night, but you probably haven't done the whole kind of three or four in a row, potentially, and in the same kind of intensity. And on that note, I guess do you think there's enough in the teaching, either at a postgraduate undergraduate level, about sleep and the importance of sleep?

SPEAKER_01 12:05

No, absolutely not. So, as you said at the beginning, you spend a third of your life asleep. The average medical school curriculum probably has about an hour of teaching on sleep, if that's over the course of five years. And it doesn't tend to feature very heavily in postgraduate curriculums either. I don't think we need to spend a third of the time in medical school talking about sleep, but I think we certainly should do a lot more than we currently do. And I think that will change. So it that kind of shifting understanding of how important sleep is, I think will result in some changes to curricula. We've managed to get a little bit of teaching about sleep into the pediatric postgraduate curriculum, for example. But things like the Nobel Prize for Medicine was awarded a few years back to the people that looked at the cellular mechanisms of the circadian drive, the body clock. And I think one of the things that will change over the lifetime of the new medical students becoming doctors now is that recognition of how important body clock physiology is to lots of the things that we do. And so I think as that shifts, we will also see an incorporation of more sleep principles into teaching and training, but it's sorely needed in my opinion.

SPEAKER_03 12:59

Yeah, no, I think that will be a good addition to people's understanding on earth, I guess, for for the patients and for themselves. It's been in a general debate with everybody for a long time of topical conversation of burnout, and I think COVID has just exacerbated that. And I was looking at the GMC survey this year, which has they started talking about burnout in their questions in 2018, and sadly it's going in the wrong direction, which I think fits with what everybody's personal views are, but put some data to that. And two-fifths of trainees responded that they feel burnt out to a high or a high degree because of their work. What can we do on a, I guess it comes into levels, doesn't it? What can we do on a personal level or and then on a group level and what then needs to be done on a wider level to address this? Because it's a big and worrying issue for everybody.

SPEAKER_01 13:51

So I think there's a few really important points. So I agree with you that COVID to a degree has exacerbated this, but these were problems that existed in the NHS long before COVID. And actually, it's really important that COVID doesn't become the excuse for this. You know, our waiting lists were already staggeringly high pre-COVID. Um, measures of burnout were worryingly high pre-COVID. And yes, COVID may have amplified that, but this is not a COVID problem. This is an NHS problem. It's also really important that there isn't too much of a focus on saying that this is something that individuals should have to be the ones to cope with. What the burnout measures are telling us is that the NHS is fundamentally under-resourced to do the job that it's there to do. And that is a consequence of a decade and more of underinvestment and under-responding to the changing pressures of the needs of the population for health. Um, you know, so we see more patients, those patients tend to have more complex problems, and we haven't adapted our workforce to match that. And there's this real worry that you mentioned it a little bit earlier on, that many of the people that come into healthcare end up with this kind of superhero mentality that somehow they think they should just be able to cope with all this because that's their job. And that's what leads to burnout. You know, you set yourself these impossibly high standards, you're trying to live up to do the best for your patients, and you push yourself too far and fall over. So, although there are individual things you can do, and thinking about sleep and managing fatigue is what is one of those things, this has to be a systemic problem. And fundamentally, it comes down to pointing out at every possible opportunity that the NHS is not adequately staffed to safely do the job that we're here to do. Jeremy Hunt, after leaving his post as health secretary, and therefore being responsible for much of this, ended up being the chair of the Health and Social Care Committee. And last year they published a report that flat said that, that the NHS has not been invested in to meet the demand, and that that means that every member of staff is doing over and above every day of their life. You're all working at 120%, but you think it's 100%. So somebody asks you to do that a little bit more, and you know, oh, I could do that a little bit more, but you're already beyond where you should be. And that's the point that I think we need to keep making. So pre-COVID in 2019, the GMC commissioned Michael West and Denise Coya to do a report called Caring for Doctors, Caring for Patients. And that really emphasized all of these points. Michael West's summary was um, we can't go on the way we are, just loading more work and more responsibility onto doctors already struggling to cope. And the more we do that, the more the system will creak and crack.

SPEAKER_03 16:05

And the and the personalities and the characters that come into the NHS are those that will take on extra.

SPEAKER_01 16:10

There's a lot of goodwill and we often feel that the primary responsibility is to our patients. And whilst that is true on one level, you have to be really careful about that because our responsibility is to be able to provide the care that our patients need. You know, on a really simple level, at three o'clock in the morning and there's 30 people to see a needy waiting room, and then you've not had a break since you came on shift at eight o'clock. It is really difficult to prioritize yourself and say, do you know what? None of those patients are going to come to massive harm if I stop for 30 minutes. Yes, they'll wait 30 minutes longer. But if I stop, have a cup of tea and a Kit Kat, and then come back to them in 30 minutes, I will probably get through them quicker and more effectively than if I don't do that. But at that point, it is really difficult to prioritize yourself because all you see is that patient needs. So I think teaching people to understand that the patient first, yes, but sometimes that means actually you have to look after yourself to be able to look after the patient. And that's actually, if you look at things like the world's medical organizations or world medical associations, you know, the equivalent of duties of a doctor, one of them is exactly that. You know, you must be able to prioritize looking after yourself to be able to look after your patients and know how and when to do that. I don't think we teach people that nearly enough.

SPEAKER_03 17:21

Yeah, no, definitely. I think that's a really important tip. So I guess rounding this all up, we could chat for hours on all of these topics. What would be your summary of top tips for doctors in managing sleep, fatigue, and night shifts?

SPEAKER_01 17:38

So, from a sleep perspective, I would say it is absolutely worth doing a bit of reading around what good sleep routines and habits look like and really trying to invest in building as good quality foundation sleep as you can. It is, it's hard, it's not like it's you know it's like exercise to lose weight. It takes work, it takes effort, it takes commitment, but it is worth it. And particularly if you're then working a job that shifts you around the clock as you work. So really invest in your core sleep routine and habits as much as you possibly can from a sleep point of view. From a fatigue point of view, it's as you said at the top of it, it's it's all about rest and breaks. Rest and breaks are not a luxury, they're an absolute essential necessity to be able to make sure that we are delivering care to the best of our capabilities and also to make sure that we're not putting ourselves at risk of making a mistake, whether that's you know, patient-related or whether it's you know falling asleep behind the wheel of a car, driving home. So that would be my absolute line from that point of view. But the most important thing, I honestly think, is that there has to be a much better organizational recognition of all of these points. And we have to be able to have conversations, you know, to the recording this on the 1st of August, and I saw a quote this morning from the transport minister saying in relation to train strikes and train drivers that one of the problems with this is that rest days are voluntary and that people are not volunteering to work on their rest days, and this is why there's a problem with the train timetables and things. And it's just entirely the wrong message to send. You know, rest days should not be seen as this voluntary uh add-on extra. You know, we need that organizational recognition that these concepts really matter, both for our health but also to make sure we're doing our jobs.

SPEAKER_03 19:06

Excellent. Well, thank you so much for um giving up your time and speaking to us today. And I think everybody listening will really appreciate this talk and take a lot from it. So thank you very much, Dr. Farkas.

SPEAKER_01 19:18

Thank you for having me. I'll send you the link for the paper as well.

SPEAKER_03 19:20

Wonderful. That's great. Thanks. Bye.