To Sleep or Not To Sleep?

Most of those who know me have probably, at one time or another, heard me say something disparaging about sleep. “Sleep is a poor substitute for coffee.” “Sleep is a symptom of caffeine deprivation.” “Sleep is foolish and nonessential.” Remarks of this character tend to leave my mouth on a semi-frequent basis.

I can’t deny the necessity of sleep, and I won’t pretend to be immune to its nourishing effects. An abundance of scientific research affirms the need for sleep; restful sleep of a decent length is apparently advantageous to cognition, the immune system, and even the metabolism. I can’t argue with these findings. My quarrel with sleep is not a scientific quarrel but a philosophical one, borne of looking at the world and seeing both what is and what could be. We spend nearly a third of our lives practically comatose. This seems to me to be a bit of a waste (“design flaw” comes to mind). Although its effects pervade the body at large, sleep is generally understood to be a process of the brain. With this in mind, it’s trivially easy to imagine a brain that doesn’t need sleep. We don’t need to know everything about the brain in order to make this claim, we need only postulate that there’s no physical law ordaining all complex information-processing systems to undergo mandatory periods of rest. If we grant that no such law exists, we need only imagine a different brain in our heads than the one we happen to have. If this strikes you as too fanciful, hopefully we can agree it’s at least possible to imagine a brain needing far less sleep than ours currently does.

Given my attitudes towards sleep, medicine may be the ideal field for me. Medical students and residents, as well as our attending physicians, are no strangers to sleeplessness. Dr. Chase of House M.D. once compared medical school to “a competition to see who could stay awake the longest”. This comparison does in fact extend to the real world. A classmate shared this image with me, a few weeks into the schoolyear, captioned “Med school sure is pulling a number on my already messed up sleep…”

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Medical residents have it much worse. Residents (so-called because they used to literally live in the hospitals) can expect to work 70 – 100 hours per week, in shifts up to 26 hours in length, with a call-schedule of one in every four nights. (Actually, there are some exceptions that allow for 36-hour shifts). This might sound like a lot, but it’s actually much less than it used to be, back in the days when there were no limits on consecutive number of hours worked and no limits for the frequency of on-call duties. My sole family member in medicine, a great-uncle in B.C., once told me of a full Monday-to-Friday workweek in his residency during which he slept only four hours. These four hours came in the form of one hour on Monday and three hours on Thursday. I have no idea how many of the remaining hours were spent practicing medicine, but my educated guess would be “pretty damn close to all 116 of them.” A week quite like that is no longer kosher, but in certain specialties (pretty much anything surgical, for example), the current reality is not far from that.

Do attending physicians have it easier? Yes, but just as in residency, it depends on the specialty. I recently spoke with a neurosurgeon who reported working twelve-hour days six days a week, and being on-call one in every four nights. Call is busy for a neurosurgeon; if one is on-call, one can expect to work. Additionally, this particular doctor takes time in his evenings to review the imaging scans that will guide him through the next day’s scheduled procedures, and, as if this weren’t enough, he also likes to phone his patients on the eve of their procedures and touch base with them, answer their questions, discuss their concerns, etc. When I heard all this, I was amazed. What a stupendous amount of effort! More impressive still is the fact that he’s been in practice for a few decades, so if anything, this is the more relaxed portion of his career. While certainly more relaxed than the life of a neurosurgical resident, it’s a life far from idle. That being said, according to the stats, this individual is above average even among neurosurgeons.

Neurosurgeons are among the busiest of doctors, but they’re not the busiest and not even atypically busy (see the table below for a comparison of most major specialties). Consider neurologists, the non-surgical doctors of the brain (my top choice of specialty when I started medical school). Including the time spent administering care while on call, the average Canadian neurologist works 67.6 hours per week (actually slightly more than the average Canadian neurosurgeon). No matter how you slice it, that’s a lot of hours. Add in a half-hour lunch break and you’re looking at 14-hour days Monday through Friday, 12-hour days Monday through Saturday, or 10-hour days for the entire week. The actual distribution of time spent working will be different than that, but not necessarily in a way that’s preferable. How does one find time to work ~68 hours per week and still sleep eight hours each night? Most likely, one does not.

Table 1. Average weekly hours per medical discipline. Data obtained from CMA profiles available online. Cardiac surgery appears to be the busiest.

Medical Discipline Hours worked per week excluding on-call Hours per week spent in direct patient care while on-call Total hours worked per week
Anatomical Pathology 50.5 12.1 62.6
Anesthesiology 51.6 12.1 63.7
Cardiac Surgery 69.6 11.4 81.0
Cardiology 58.7 10.0 68.7
Dermatology 48.3 3.3 51.6
Diagnostic Radiology 45.6 5.8 51.4
Emergency Medicine 47.3 3.3 50.6
Endocrinology 51.2 6.8 58.0
Family Medicine 47.0 6.1 53.1
Gastroenterology 49.3 10.0 59.3
General Pathology 47.2

n/a

47.2
General Surgery 54.3 14.7 69.0
Hematology 48.6 8.7 57.3
Internal Medicine 47.1 11.7 58.8
Medical Microbiology 49.5 10.3 59.8
Medical Oncology 52.5 4.0 56.5
Neurology 57.8 9.8 67.6
Neurosurgery 51.5 13.1 64.6
Nuclear Medicine 48.6

n/a

48.6
Obstetrics & Gynecology 48.6 13.5 62.1
Ophthalmology 50.2 4.9 55.1
Orthopedic Surgery 57.0 12.6 69.6
Otolaryngology 52.6 6.1 58.7
Pediatrics 47.0 9.6 56.6
Physical Medicine 48.1

n/a

48.1
Plastic Surgery 58.8 10.5 69.3
Psychiatry 46.2 4.4 50.6
Public Health & Preventive Medicine 41.3

n/a

41.3
Radiation Oncology 51.4 3.3 54.7
Respirology 50.6 8.7 59.3
Rheumatology 54.6 6.8 61.4
Urology 56.8 13.3 70.1

There’s more than one way to think about sleep. I once went on a date with a girl, an athlete, who told me “sleep is a weapon.” (Apparently I don’t know better than to raise my concerns about sleep while on first dates). Something that can boost your cognition, boost your immune system, and boost your metabolism does perhaps deserve the title of “weapon” in at least some sense of the word. For an elite athlete, a weapon like that may make all the difference in competition. However, I am (assuredly) not an elite athlete, and I’ve found that although I presumably feel roughly as good as the next guy after a good night’s rest, in all my usual activities (studying, writing, even test-taking), sleep doesn’t lead to much difference in performance. In a sleep-deprived state, I can still do everything I want to, and do it roughly just as well — the only difference is I’ll feel just slightly worse as I do it. This is a downside I often don’t mind living with. Two affirmative examples from my life that suggest I’m not totally alone: my sister Christie, a law student at a top school who works constantly and tirelessly on numerous projects of human rights and social justice; and Dr. Soheila Karimi of the Regenerative Medicine Program, a prominent stem cell researcher focusing on multiple sclerosis and spinal cord injury whose lab I worked in as an undergrad (and where I plan to return f0r the next two summers). Both of these individuals sleep only a handful of hours per night (quite a bit less than me, even for all my hostility towards sleep), and in productivity, outshine me by quite a lot. Not everyone needs the full eight hours per night, and it seems plausible to me that both my sister and Dr. Karimi tolerate low levels of sleep with comparatively few side effects, but there’s obviously an element of determination and willpower at play, and I can’t help but wonder if maybe this is enough to account for their apparently-reduced sleep requirements.

Insofar as I’m deprived of sleep, it’s partly because I’m busy and feel I need the extra hours, partly because I’ll occasionally use “sleep-time” as “fun-time” (if there are six hours in a day to spare, is it better to sleep for all six? Or is it better to relax and do something fun for an hour or two, using only the remainder for sleep?), but also partly because life is short and I don’t want to forfeit any more time than I have to. Just as Damocles in the ancient tale bearing his name, each of us lives life under a precariously-dangling sword that is poised to drop at any moment. The late Christopher Hitchens spoke and wrote about living life as if he was always operating on the margins of a potentially great harvest of future knowledge, living life as if he hadn’t yet done anything like “enough”. This resonates with me. In Unweaving the Rainbow, Richard Dawkins writes

After sleeping through a hundred million centuries we have finally opened our eyes on a sumptuous planet, sparkling with colour, bountiful with life. Within decades we must close our eyes again… Who, with such a thought, would not spring from bed, eager to resume discovering the world and rejoicing to be a part of it?

To put it the other way round on Richard — who, with such a thought, would even want to go to bed in the first place??

Christopher Hitchens also said “It will happen to all of us that at some point that you’ll get tapped on the shoulder and told, not just that the party’s over, but slightly worse: ‘The party’s going on, but you have to leave.'” I don’t know when the day will come that I’ll be asked to leave the party, but I know there are things I want to do before that day comes, and in this context, life appears to be an emergency. A long emergency, but an emergency nonetheless. (This idea is also developed by Sam Harris in his talk Death and the Present Moment.) Is it reasonable to spend one third of an emergency in a slumber? I’d prefer not to, but it appears we humans may have to. Thoughts of this sort form the basis of my annoyance with sleep.

I asked my great-uncle how he survived the near-sleeplessness of residency. His response was brilliant: “I wasn’t always smiling, but I was happy to be there.” When you’re passionate about something — be it the rights of our oppressed fellow citizens, or the eradication of grievous illnesses, or something else entirely — the need for sleep can take a backseat. Given the brain’s ability to change itself, and given the ability of psychology to affect change all throughout the body, I can’t help but wonder if maybe this passion is enough to literally reduce a person’s requirements for sleep. This would explain people like my sister and Dr. Karimi, it would explain people like my great-uncle John and other medical residents both past and current, and it would explain people like the neurosurgeon discussed above. I used to fantasize (if that’s the word) about a future pill that would eradicate or somehow fulfill the need for sleep. (This would probably not be forbidden by the laws of physics and so probably not impossible in principle, but probably too complicated to ever be attained in reality.) Maybe we don’t need pharmacology for this — maybe the right motivation can suffice, at least to a certain degree. I haven’t yet attained the truly legendary levels of sleeplessness that certain acquaintances of mine have reached, but a career in medicine is a privilege for which I’ll happily forfeit a few hours’ sleep if and when it comes to that.

Happy holidays!

-GM

PS None of this is actual medical advice — just my thoughts!

Touching Brains

When life is busy, it can be hard to stop and appreciate the significant moments as they occur. This is hard even when life is not busy — busyness just makes it more difficult. When life is moving fast it’s hard enough to just keep up, nevermind appreciate the moments as they occur. Busy or not, life is always in motion; the moment always fleeting, always running away from us. In Unweaving the Rainbow, Richard Dawkins writes it feels to him as though “the present moves from the past to the future, like a tiny spotlight, inching its way along a gigantic ruler of time.” If we apply this analogy to life in medical school, the spotlight accelerates to a breakneck speed, careening down the ruler like a runaway freight train. Avoiding academic failure requires some form of running alongside the train; pausing to drift at its side for a moment’s contemplation is easier said than done. Learning to drift in this way is a skill that requires diligent effort and discipline.

It occurs to me that many people — medical students or otherwise — feel that they’re on the losing end of the race with the runaway freight train. Most people I talk to feel there aren’t enough hours in the day to accomplish all they hope to. Medical school only exacerbates these sentiments, as our schedules are packed with courses and extracurriculars and riddled with exams. For example, today’s Neuroscience midterm marks the sixth exam in just slightly more than two weeks. In this time there was the Cardiovascular System final and the Respiratory System final, midterms in Clinical Reasoning and Population Health, a two-station Objective Standardized Clinical Exam (OSCE), and the above-mentioned Neuroscience midterm. We don’t get time off for exams; these were all scattered amongst the usual 9 – 5 schedule of coursework. This fast pace makes it hard to stop and, as they say, “smell the roses”. This is unfortunate, as big events are happening all the time! In the past four days, for example, I was honoured to participate in my first surgery (obviously a very minor role, but still exciting), clinically examine strangers for the first and second times, and perform Christmas carols alongside several classmates for the patients of the Children’s Hospital. These moments are all worthy of reflection. I could probably write about any of them, but instead I’ve chosen a different topic: somewhere in the past weeks’ busyness was my first hands-on experience with the human brain.

Part of the curriculum of our modular courses, the ones that teach us about the various organ systems, is to learn the relevant anatomy of the systems. We’re in a 4-week neuroscience course right now; neuroscience entails neuroanatomy. Our education in anatomy includes hands-on lab sessions with human specimens that have been generously donated to our program (this thought alone is grounds for significant reflection). Our first neuroanatomy session was roughly two weeks ago. The supervisor of my upcoming research project was one of the instructors. Anxious not to appear incompetent, I had been up late into the morning hours cramming my brain full of as much neuroanatomy as it could hold (a situation that only now strikes me as ironic.) We entered the lab to find rows of tables, each with a skull on one end and a large bucket on the other. The class had been split into groups of six, and each group was given one skull and 1.5 brains — one full brain, and one single-hemisphere (my group was awarded a left hemisphere). The brains had been placed into the buckets and were afloat in a preservative bath. My proximity to the bucket nominated me for the task of reaching in and removing the brains (I was feeling fairly eager, so this worked out well). Armed with our printed instructions and under the guidance of several circulating instructors, we set to work on the task of hands-on study.

Before I carry on here, a quick word on the brain. The brain sends electrical impulses throughout the body; these impulses control the body. That, in a sentence, is the nervous system. One special type of cell, the neuron, is responsible for both the generation and the conduction of these signals, both inside the brain and out. There are roughly one hundred billion (100 000 000 000) neurons in the human brain. Most of these brain-dwelling neurons send signals to one another, forming the complex circuitry of the brain. Some send signals through the base of the skull into the spinal cord, itself made of neurons, which projects neurons to all the other sites of the body. Whether current does or does not flow from one neuron to another is the basis of the brain’s computational abilities. The site of connection between two neurons, through which a signal may pass, is called a synapse. Each neuron in the brain is linked up to about 1000 other neurons, making for a total of one quadrillion synapses (a million billion, also written 1015 or 1 000 000 000 000 000) in the average human brain. This is a staggeringly large number. It’s not surprising that the brain is so complex, given its remarkable capabilities. What is surprising is the ordinary appearance of the brain.

I’m not sure what I expected of the first meeting between my hands and a brain. I hadn’t given it enough forethought to have any specific expectations, but in retrospect I was anticipating the awesome complexity to be somehow indicated by the experience. This expectation was not met. Holding a brain in the palm of my hands was definitely a thrill, but the magnificent complexity I knew to be present was not able to be deduced by mere observation. Had I not been told it was so, I would have had no idea I was cradling the most complicated object in the known universe. This is because the brain, like so much of the world, doesn’t look like what it really is. This vast network of a hundred million billion connections, through each of which electricity either does or does not flow at every given millisecond, whose circuitry controls the body and produces the mind, appears to be scarcely more than a folded-up piece of meat.

This relates to a fact about the limitations of our sense organs. Our sense organs, powerful as they may be, evolved to detect a limited range of phenomena — specifically, medium-sized objects moving at medium speeds — and even within these constraints, quite a lot of what goes on is unavailable to us. Vision, our sense for detecting electromagnetic radiation, allows us to see only the tiniest fraction of electromagnetic radiation that exists in the world. Our sense of smell picks up only a small fraction of molecules that exist.  The model of the world created in our brains is powerful, extremely useful for survival, and often tremendously beautiful, but it has many notable limitations. Certain things are simply beyond what we can expect of a brain built by natural selection. The realm of the microscopic was unavailable to our ancestors and so unavailable for the action of natural selection, therefore we’d expect events on this scale to be beyond what we can probe with sensory experience. The complexity of the brain itself is realized on a microscopic scale, so it’s unsurprising that this affair is hidden to casual observer. In short, evolution wouldn’t be expected to build a brain capable of appreciating the brain. The world we experience is beautiful, but the true world is much more beautiful than we can appreciate by sense alone. Thankfully, we have science to take us beyond the realm of sensory faculty.

Returning to the earlier topic of mindfulness: not every day will contain dramatic milestones, but every day contains something worth appreciating and reflecting on. It’s up to us to be mindful and watch for these things. The path to appreciation, to happiness, always leads through the present moment, because the present moment is all we really have. As author Marianne Williamson puts it, “No matter what time it is, it is always now.” Life is ultimately the sum of a long series of present moments. In his talk Death and the Present Moment, neuroscientist and philosopher Sam Harris elaborates on this point:

“The past is a memory; it’s a thought arising in the present. The future is merely anticipated, it’s another thought arising now. What we truly have is this moment…and this. And we spend most of our lives forgetting this truth, repudiating it, fleeing it, overlooking it, and the horror is that we succeed. We manage to never really connect with the present moment and find fulfillment there, because we are continually hoping to become happy in the future. And the future never arrives.”

Thank you all for reading. Please comment below! I wish you all the best with your future happiness and mindfulness.

– GM