Facing government threats that would apply federally enforced work hours due to the extent of damning evidence, the Accreditation Council for Graduate Medical Education made the following alterations. First-year residents would be limited to (1) working no more than an 80-hour week (which still averages out at 11.5 hours per day for 7 days straight), (2) working no more than 24 hours nonstop, and (3) performing one overnight on-call shift every third night. That revised schedule still far exceeds any ability of the brain to perform optimally. Errors, mistakes, and deaths continued in response to the anemic diet of sleep they were being fed while training. As the research studies kept accumulating, the Institute of Medicine, part of the US National Academy of Sciences, issued a report with a clear statement: working for more than sixteen consecutive hours without sleep is hazardous for both the patient and resident physician.
You may have noticed my specific wording in the above paragraph: first-year residents. This is because the revised rule (at the time of writing this book) has only been applied to those in their first year of training, and not to those in later years of a medical residency. Why? Because the Accreditation Council for Graduate Medical Education—the elite board of high-powered physicians that dictates the American residency training structure—stated that data proving the dangers of insufficient sleep had only been gathered in residents in their first year of the program. As a result, they felt there was no evidence to justify a change for residents in years two to five—as if getting past the twelve-month point in a medical residency program magically confers immunity against the biological and psychological effects of sleep deprivation—effects that these same individuals had previously been so provably vulnerable to just months before.
This entrenched pomposity, prevalent in so many senior-driven, dogmatic institutional hierarchies, has no place in medical practice in my opinion as a scientist intimate with the research data. Those boards must disabuse themselves of the we-suffered-through-sleep-deprivation-and-you-should-too mentality when it comes to training, teaching, and practicing medicine.
Of course, medical institutions put forward other arguments to justify the old-school way of sleep abuse. The most common harkens back to a William Halsted–like mind-set: without working exhaustive shifts, it will take far too long to train residents, and they will not learn as effectively. Why, then, can several western European countries train their young doctors within the same time frame when they are limited to working no more than forty-eight hours in one week, without continuous long periods of sleeplessness? Perhaps they are just not as well trained? This, too, is erroneous, since many of those western European medical programs, such as in the UK and Sweden, rank among the top ten countries for most medical practice health outcomes, while the majority of US institutes rank somewhere between eighteenth and thirty-second. As a matter of fact, several pilot studies in the US have shown that when you limit residents to no more than a sixteen-hour shift, with at least an eight-hour rest opportunity before the next shift,fn9 the number of serious medical errors made—defined as causing or having the potential to cause harm to a patient—drops by over 20 percent. Furthermore, residents made 400 to 600 percent fewer diagnostic errors to begin with.
There’s simply no evidence-based argument for persisting with the current sleep-anemic model of medical training, one that cripples the learning, health, and safety of young doctors and patients alike. That it remains this way in the stoic grip of senior medical officials appears to be a clear case of “my mind is made up, don’t confuse me with the facts.”
More generally, I feel we as a society must work toward dismantling our negative and counterproductive attitude toward sleep: one that is epitomized in the words of a US senator who once said, “I’ve always loathed the necessity of sleep. Like death, it puts even the most powerful men on their backs.” This attitude perfectly encapsulates many a modern view of sleep: loathsome, annoying, enfeebling. Though the senator in question is a television character called Frank Underwood from the series House of Cards, the writers have—biographically, I believe—placed their fingers on the very nub of the sleep-neglect problem.
Tragically, this same neglect has resulted in some of the worst global catastrophes punctuating the human historical record. Consider the infamous reactor meltdown at the Chernobyl nuclear power station on April 26, 1986. The radiation from the disaster was one hundred times more powerful than the atomic bombs dropped in World War II. It was the fault of sleep-deprived operators working an exhaustive shift, occurring, without coincidence, at one a.m. Thousands died from the long-term effects of radiation in the protracted decades following the event, and tens of thousands more suffered a lifetime of debilitating medical and developmental ill health. We can also recount the Exxon Valdez oil tanker that ran aground on Bligh Reef in Alaska on March 24, 1989, breaching its hull. An estimated 10 million to 40 million gallons of crude oil spilled across a 1,300-mile range of the surrounding shoreline. Left dead were more than 500,000 seabirds, 5,000 otters, 300 seals, over 200 bald eagles, and 20 orca whales. The coastal ecosystem has never recovered. Early reports suggested that the captain was inebriated while navigating the vessel. Later, however, it was revealed that the sober captain had turned over command to his third mate on deck, who had only slept six out of the previous forty-eight hours, causing him to make the cataclysmic navigational error.
Both of these global tragedies were entirely preventable. The same is true for every sleep-loss statistic in this chapter.
Chapter 16
A New Vision for Sleep in the Twenty-First Century
Accepting that our lack of sleep is a slow form of self-euthanasia, what can be done about it? In this book, I have described the problems and causes of our collective sleeplessness. But what of solutions? How can we effect change?
For me, addressing this issue involves two steps of logic. First, we must understand why the problem of deficient sleep seems to be so resistant to change, and thus persists and grows worse. Second, we must develop a structured model for effecting change at every possible leverage point we can identify. There is not going to be a single, magic-bullet solution. After all, there is not just one reason for why society is collectively sleeping too little, but many. Below, I sketch out a new vision for sleep in the modern world—a road map of sorts that ascends through numerous levels of intervention opportunities, visualized in figure 17.
Figure 17: Levels of Sleep Intervention
INDIVIDUAL TRANSFORMATION
Increasing sleep for an individual can be achieved through both passive methods, which require no effort from the individual and are thus preferable, and active methods, which do. Here are several possibilities that may not be so far-fetched, all of which build on proven scientific methods for enhancing sleep quantity and quality.
The intrusion of technology into our homes and bedrooms is claimed by many of my research colleagues to be robbing us of precious sleep, and I agree. Evidence discussed in this book, such as the harmful effects of LED-emitting devices at night, proves this to be true. Scientists have therefore lobbied to keep sleep analog, as it were, in this increasingly digital world, leaving technology out of the discussion.
Here, however, I actually disagree. Yes, the future of sleep is about a return to the past in the sense that we must reunite with regular, plentiful sleep, as we once knew a century ago. But to battle against rather than unite with technology is the wrong approach in my mind. For one thing, it’s a losing battle: we will never put that technological genie back into its bottle, nor do we need to. Instead, we can use this powerful tool to our advantage. Within three to five years, I am quite certain there will be commercially available, affordable devices that track an individual’s sleep and circadian rhythm with high accuracy. When that happens, we can marry these individual sleep trackers with the revolution of in-home networked devices like thermostats and lighting. Some are already trying to do this as I write.
Two exciting possibilities unfold. First, such de
vices could compare the sleep of each family member in each separate bedroom with the temperature sensed in each room by the thermostat. Using common machine-learning algorithms applied over time, we should be able to intelligently teach the home thermostat what the thermal sweet spot is for each occupant in each bedroom, based on the biophysiology calculated by their sleep-tracking device (perhaps splitting the difference when there are two or more individuals per room). Granted there are many different factors that make for a good or bad night of sleep, but temperature is very much one of them.
Better still, we could program a natural circadian lull and rise in temperature across the night that is in harmony with each body’s expectations, rather than the constant nighttime temperature set in most homes and apartments. Over time, we could intelligently curate a tailored thermal sleep environment that is personalized to the circadian rhythms of each individual occupant of each bedroom, departing from the unhelpful non-varying thermal backdrop that plagues the sleep of most people using standard home thermostats. Both these changes require no effort from an individual, and should hasten the speed of sleep onset, increase total sleep time, and even deepen NREM-sleep quality for all household members (as discussed in chapter 13).
The second passive solution concerns electric light. Many of us suffer from overexposure to nighttime light, particularly blue-dominant LED light from our digital devices. This evening digital light suppresses melatonin and delays our sleep timing. What if we can turn that problem into a solution? Soon, we should be able to engineer LED bulbs with filters that can vary the wavelength of light that they emit, ranging from warm yellow colors less harmful to melatonin, to strong blue light that powerfully suppresses it.
Paired with sleep trackers that can accurately characterize our personal biological rhythms, we can install these new bulbs throughout a home, all connected to the home network. The lightbulbs (and even other networked LED-screen devices, such as iPads) would be instructed to gradually dial down the harmful blue light in the home as the evening progresses, based on an individual’s (or set of individuals’) natural sleep-wake pattern. We could do this dynamically and seamlessly as individuals move from one room to the next in real time. Here again we can intelligently split the difference on the fly based on the biophysiological mix of whoever is in the room. In doing so, the users’ own brains and bodies, measured and translated through the wearables to the networked home, would synergistically regulate light and thus melatonin release that promotes, rather than impedes, optimal regulation of sleep for one and all. It is a vision of personalized sleep medicine.
Come the morning, we can reverse this trick. We can now saturate our indoor environments with powerful blue light that shuts off any lingering melatonin. This will help us wake up faster, more alert, and with a brighter mood, morning after morning.
We could even use this same light-manipulation idea to apply a slight nudge in someone’s sleep-wake rhythm within a biologically reasonable range (plus or minus thirty to forty minutes), should they desire, gradually moving it earlier or later. For example, if you have an unusually early morning meeting in the middle of the workweek, this technology, synched to your online calendar, would gradually begin shifting you (your circadian rhythm) to a slightly earlier bed and rise time starting on Monday. This way, that early-morning rise time on Wednesday won’t be as miserable, or cause such biological turmoil within your brain and body. This would be equally, if not more, applicable in helping individuals overcome jet lag when traveling between time zones, all dispensed through LED-emitting personal devices that people already travel with—phones, tablets, laptop computers.
Why stop at the home environment or in the infrequent circumstance of jet lag? Cars can adopt these same lighting solutions to help manipulate alertness during morning commutes. Some of the highest rates of drowsy-driving accidents occur during mornings, especially early mornings. What if car cockpits could be bathed in blue light during early-morning commutes? The levels would have to be tempered so as not to distract the driver or others on the road, but you’ll recall from chapter 13 that one does not need especially bright light (lux) to have a measurable impact of melatonin suppression and enhanced wakefulness. This idea could be particularly helpful in those parts of the Northern and Southern Hemispheres during their respective winter mornings where this issue is most problematic. In the workplace, for those lucky enough to have their own office, lighting rhythm could be custom fit to the occupant using the same principles. But even cubicles, which are not so different from the cell of a car, could be personally tailored in this light-dependent manner, based on the individual sitting in that cubicle.
How much benefit such changes would make remains to be proven, but I can already tell you of some data from ever-sleep-sensitive NASA, with which I worked on sleep issues early in my career. Astronauts on the International Space Station travel through space at 17,500 miles per hour and complete an orbit of the Earth once every ninety to one hundred minutes. As a result, they experience “daylight” for about fifty minutes, and “night” for about fifty minutes. Although astronauts are therefore treated to the delight of a sunrise and sunset sixteen times a day, it wreaks utter havoc on their sleep-wake rhythms, causing terrible issues with insomnia and sleepiness. Make a mistake at your job on planet Earth, and your boss may reprimand you. Make a mistake in a long metal tube floating through the vacuum of space with payloads and mission costs in the hundreds of millions, and the consequences can be much, much worse.
To combat this issue, NASA began collaborating with a large electrical company some years ago to create just the types of special lightbulbs I describe. The bulbs were to be installed in the space station to bathe the astronauts in a much more Earth-like cycle of twenty-four-hour light and dark. With regulated environmental light came a superior regulation of the astronauts’ biological melatonin rhythms, including their sleep, thereby reducing operations errors associated with fatigue. I must admit that the development cost of each lightbulb was in the neighborhood of $300,000. But numerous companies are now hard at work constructing similar bulbs for a fraction of that cost. The first iterations are just starting to come to market as I write. When costs become more competitive with standard bulbs, these and many other possibilities will become a reality.
Solutions that are less passive, requiring an individual to actively participate in change, will be harder to institute. Human habits, once established, are difficult to change. Consider the countless New Year’s resolutions you’ve made but never kept. Promises to stop the overeating, to get regular exercise, or to quit smoking are but a few examples of habits we often want to change to prevent ill health, yet rarely succeed at actually changing. Our persistence in sleeping too little may similarly appear to be a lost cause, but I am optimistic that several active solutions will make a real difference for sleep.
Educating people about sleep—through books, engaging lectures, or television programs—can help combat our sleep deficit. I know firsthand from teaching a class on the science of sleep to four hundred to five hundred undergraduates each semester. My students complete an anonymous sleep survey at the start and the end of the course. Across a semester of lectures, the amount of sleep they report getting increases by forty-two minutes per night on average. Trivial as that may sound, it does translate to five hours of extra sleep each week, or seventy-five extra hours of sleep each semester.
But this isn’t enough. I’m sure a depressingly large proportion of my students returned to their shorter, unhealthy sleep habits in the years after. Just as describing the scientific dangers of how eating junk food leads to obesity rarely ends up with people choosing broccoli over a cookie, knowledge alone is not enough. Additional methods are required.
One practice known to convert a healthy new habit into a permanent way of life is exposure to your own data. Research in cardiovascular disease is a good example. If patients are given tools that can be used at home to track their improving physiological health in respon
se to an exercise plan—such as blood pressure monitors during exercise programs, scales that log body mass index during dieting efforts, or spirometry devices that register respiratory lung capacity during attempted smoking cessation—compliance rates with rehabilitation programs increase. Follow up with those same individuals after a year or even five, and more of them have maintained their positive change in lifestyle and behavior as a consequence. When it comes to the quantified self, it’s the old adage of “seeing is believing” that ensures longer-term adherence to healthy habits.
With wearables that accurately track our slumber fast emerging, we can apply this same approach to sleep. Harnessing smartphones as a central hub to gather an individual’s health data from various sources—physical activity (such as number of steps or minutes and intensity of exercise), light exposure, temperature, heart rate, body weight, food intake, work productivity, or mood—we show each individual how their own sleep is a direct predictor of their own physical and mental health. It’s likely that, if you wore such a device, you would find out that on the nights you slept more you ate less food the next day, and of a healthy kind; felt brighter, happier, and more positive; had better relationship interactions; and accomplished more in less time at work. Moreover, you would discover that during months of the year when you were averaging more sleep, you were sick less; your weight, blood pressure, and medication use were all lower; and your relationship or marriage satisfaction, as well as sex life, were better.
Reinforced day after day, month after month, and ultimately year after year, this nudge could change many people’s sleep neglect for the better. I’m not so naïve to think it would be a radical change, but if this increased your sleep amount by just fifteen to twenty minutes each night, the science indicates that it would make a significant difference across the life span and save trillions of dollars within the global economy at the population level, to name but two benefits. It could be one of the most powerful factors in a future vision that shifts from a model of sick care (treatment), which is what we do now, to health care (prevention)—the latter aiming to stave off a need for the former. Prevention is far more efficient than treatment, and costs far less in the long run.
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