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!

2 thoughts on “To Sleep or Not To Sleep?

  1. Happy to be here says:

    Very interesting post, GM. The need for sleep probably varies from person-to-person, but certainly some require less than others. Do you think sleep requirements vary with age?

    Liked by 1 person

    1. Yes, sleep requirements decrease with age! The National Sleep Foundation has published a chart of age-specific recommendations. https://sleepfoundation.org/sites/default/files/STREPchanges_1.png I’m not sure I agree with the recommendation of 7-8 hours for older adults — based on what I’ve read, 6 hours is probably most appropriate — but overall a reasonable document that clearly shows the relationship between sleep requirements and age.

      You’re absolutely correct that sleep requirements vary from person-to-person! Most people require somewhere between 7 and 9 hours per night. There are people whose requirements actually fall outside this range, but this is not a large portion of the population, and requiring less than 7 or more than 9 hours of sleep per night can actually be an indication of disease. Whatever your sleep requirements may be, the best current medical knowledge would advise you to try to satisfy them. The aim of the piece — not to be confused with actual medical advice — was to explore the idea of undershooting the requirements in service of a good cause, and speculating as to whether the requirements might be flexible in service of such a cause. Thanks for your comment!

      Like

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