The Impact of Sleep and Brain Health on the Mental Wellness of Medical Students
Written by Kirti Veeramachaneni
Have you ever been in a hospital or clinic and been faced with a bleary-eyed medical student? Or a resident physician? Or even a physician? Did you ask them how long they had been sleeping in the past week? Or did you just assume that because they were there treating you that they knew what they were doing? Sleep is a much needed but very underappreciated necessity that society as a whole ignores but the medical education system particularly ignores. Year after year medical students, residents, and physicians go without hours of sleep that impact their own health but also the health of their patients and contributes to the growing burn-out epidemic that is plaguing medical professionals.
Healthy Sleep
So, what does healthy sleep even look like, and why am I the one talking to you about it? As a current medical student who was engaged in sleep research even before starting medical school, I have learned to prioritize sleep. This prioritization is not common among my peers as well as in the field of medicine and its associated fields. According to the National Sleep Foundation, adults generally need between 7-9 hours of sleep each night.1 This can seem like a lot – particularly for all of us workaholics and people who need all the time in the day they can get (especially those of us who engage in revenge bedtime procrastination – I am very guilty of this but more on that later).
Why do we need to spend at least a third of our day sleeping? Sleep is vital for your health – mental and physical. Memory consolidation, toxin removal, organ health, and more all depend on sleep.2,3 All of that is to say that insufficient sleep is also tied to an increased risk of hypertension, obesity, stroke, dysfunctional metabolism, impaired focus, as well as cognitive deficits and physical health problems.3-5
Emotional regulation and executive functioning are also heavily impacted by sleep.6-9 In a nasty cycle, stress can negatively impact sleep which can then make it hard for a person to properly regulate their emotions. This can impact decision-making which can then further worsen sleep. And then the cycle can continue on and on until it is somehow broken.
Sleep (or lack thereof) in Medicine
Now we ask, how much sleep does your physician and your physician to-be get?
According to a 2020 systematic review and meta-analysis, globally, medical students sleep on average about 6 hours per night and more than half experience poor sleep quality while a third experience excessive sleepiness as well.10 A 2004 study found that 66% of first and second year residents averaged 6 hours or less of sleep per night.11
In medical students, poor sleep quality and increased daytime sleepiness has been linked to emotional exhaustion, cynicism, and poorer academic efficacy.12 Medical students with worse sleep deprivation also report more symptoms of anxiety and depression as well as poorer odds of quality of life as well as perception of the academic environment.13
While the relationship between sleep and its impact on medical students have not been studied extensively, it has been examined in residents and physicians. Residents who averaged 5 hours or less in the 2004 study were more likely to report various work-related issues such as medical errors, conflict with coworkers, alcohol use, as well as noticeable weight change.11 Those with many on-call shifts tended have poorer sleep quality as well as poorer mental health, fatigue, and even physical health outcomes.14 In general, fatigue and sleep deprivation is perceived my residents to impact their personal and work lives.15
In a 2020 study of over 11,000 physicians, sleep-related impairment was found to be significantly associated with burnout, self-reported clinically significant medical error, and lower professional fulfillment.16
With the COVID-19 pandemic severely impacting the healthcare field and higher rates of burnout, sleep deprivation has been implicated in increasing burnout17 and the American Academy of Sleep Medicine issued a position statement in 2020 outlining the need to further examine the relationship between sleep deprivation, burnout, and countermeasures to this problem.18
Our society in general tends to be dismissive of sleep – just look at the way that media celebrates pulling all-nighters and people drink endless amounts of caffeine just to make it through the day. I have seen many of my classmates and friends compromise on sleep to study or work on assignments or even just have some time to themselves after a long day – a phenomenon known as revenge bedtime procrastination.
Sleep education for medical students is little in comparison to the ways that sleep can impact health.19,20 There is a need for improved education in sleep for medical students – not just for patients’ health but for those who are treating them too. As flight attendants say, secure your own mask before assisting others.
Tips for better sleep
Now that I have sufficiently scared you about all the ways poor sleep can ruin your life, how can you form healthy habits to ensure you have healthy sleep?
Taken from the resources below as well as my own personal experiences, here are some ways you can improve your sleep hygiene.
Habits Habits Habits
Your body excels at routine and your sleep absolutely relies on a good routine. In general, adults need between 7 to 9 hours of consistent sleep. Consistent means the same bedtime and waketime each day – even weekends (social jet lag, a.k.a. that groggy feeling when you wake up much later on weekends compared to weekdays, can negatively impact how rested you feel). A 30-minute wind down period is recommended to cue your body that it’s time to sleep. Activities such as getting ready for bed, brushing your teeth, stretching, and other activities that are not going to make your mind more active (i.e., TikTok, the news, trying to learn the latest gossip, etc.) are examples of what you might include in that routine. Screen time of any kind is not recommended during this period as the light can trick your brain into thinking it’s not nighttime.
Personally, I am very bad at the “no screen time” before bed rule so personally my own rule is to try to not watch or read things that will make me more active (and so I end up watching a lot of David Attenborough documentaries).
How do you spend the day?
Caffeine – I know many people who depend on caffeine to get through the day. I have bad news for you if you do… It is recommended that you do not have any caffeine after 2 pm as it can start to impact your nightly sleep if consumed after that time.
Exercise – Everyone probably hears all about the benefits of exercise… sleep is not exception to the power of exercise. However, if you are a nighttime gym person that can unfortunately be negatively impacting your sleep. For the best benefits of exercise on sleep, plan to exercise in the morning or early afternoon.
Sunlight – The sun is a powerful cue for our body’s circadian rhythm. If you work inside or long hours, try to get at least 30 minutes of sunshine a day in order to help set your circadian rhythm.
Sleep Environment – Having a sleep environment that is comfortable is vital. Make sure your room is dark and quiet. Separating at least your bed from other activities other than sleep and sex is also important in allowing your body to know that being in bed means rest.
Meals – A healthy diet is important for sleep but also meal timings. Unfortunately, this means no more late-night snacks. Large meals before bed can impact how deep you sleep and can lead to you not feeling rested in the morning.
Alcohol and Nicotine – As with everything else on this list… don’t consume alcohol and nicotine close to bedtime. Alcohol near bedtime can lead to fragmented sleep while nicotine is a stimulant which can make it difficult to fall asleep and stay asleep.
Naps
Who doesn’t love a good nap? Who hates how groggy you feel after a nap?
A concept known as sleep inertia is responsible for how you may not actually feel rested post-nap. This happens because the length of your nap and when you wake coincides with you being in a deeper phase of sleep which your body very much does not like being woken out of.
Ideally, naps should be ~20-30 minutes or about 90 minutes before early afternoon so as to not interfere with your nightly sleep. This allows you to wake up at ideal times in your sleep cycle. Of note, naps are not a substitute for nightly sleep. All the naps in the world will not rid your body of accumulated sleep debt (all the sleep you are missing at night).
What to do if you can’t sleep?
What if you are trying to sleep and can’t? It is recommended that if you have spent about 20 minutes in bed and have not been able to fall asleep, you should get out of bed and do some sort of calming activity until you feel sleepy. This means that unless you are ready to sleep, don’t get in bed (I am very guilty of not following this rule).
Personally, I have found it easier to fall asleep with the use of a weighted blanket (very nice particularly for those with anxiety) as well as a weighted eye mask, or eye mask in general (especially if you are unable to fully darken your room). In addition, there are a variety of bedtime meditations or “night casts” out there from organizations such as Headspace and Calm that I have personally found helpful in quieting my brain and getting me to sleep faster.
If you continue to have difficulty sleeping or have significant fatigue and impairment during the day, please reach out to your physician or other healthcare provider.
What does it all mean?
If you are a medical student or healthcare professional of any kind, please prioritize your sleep. The medical system is not yet set up to help you value your sleep and mental health – as such it is even more important for you to prioritize rest. Sleep is vital for your mental and physical health and poor-quality sleep and lack of sleep can have long term consequences, both personally and for your work.
Our society, and especially the medical education system, needs to work towards prioritizing healthy sleep for the health of all, but especially for our soon-to-be physicians and patients who can be impacted by sleep deprivation.
Please view the below resources for more tips on healthy sleep and for the websites for the American Academy of Sleep Medicine and the National Sleep Foundation.
Further Resources:
https://www.nhlbi.nih.gov/files/docs/public/sleep/healthy_sleep.pdf
https://www.sleepfoundation.org/sleep-habits
https://newsinhealth.nih.gov/2021/04/good-sleep-good-health
https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/sleep/art-20048379
https://www.sleepfoundation.org/sleep-hygiene/napping
1. How Much Sleep Do You Really Need? National Sleep Foundation. https://www.thensf.org/how-many-hours-of-sleep-do-you-really-need/
2. Good Sleep for Good Health. National Institutes of Health. https://newsinhealth.nih.gov/2021/04/good-sleep-good-health
3. Why is Sleep Important? National Heart, Lung, and Blood Institute (National Institute of Health). https://www.nhlbi.nih.gov/health/sleep/why-sleep-important
4. What are Sleep Deprivation and Deficiency? National Health, Lung, and Blood Institute (National Institute of Health). https://www.nhlbi.nih.gov/health/sleep-deprivation
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