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Habit formation

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It’s that time of year when many consider aspirational goals for the next calendar cycle. New Year’s resolutions don’t work for everyone, but they do work for some, and nearly everyone at some point in their life considers how to make positive changes via new habits. Therefore, while this blog is prompted by the beginning of the new year, these reflections are valid all year long and support positive change in any domain and at any time.
Resolutions are goals, and goals are achieved by habits. Without habits and systems, goals are useless. So, to support you in whatever goals you have, here are what some writers (and deep ponderers of habits) have to say about things.

In order of literary appearance, here are synopses of three popular books on the topics:

In 2012, Charles Duhigg published The Power of Habit, a widely acclaimed book that delves into the psychology research and data behind how habits are formed and embedded into daily routines. Duhigg highlights several key insights:

  1. The Habit Loop: Habits are reinforced through a cycle of cue → routine → reward → cue. Environmental conditions often serve as powerful cues, while rewards—no matter how small—enhance the longevity of a habit. A lot of emphasis in placed in this book and others around modifying one’s environment to prime for good habits and to help achieve goals.
  2. Spillover Habits: Some habits, referred to as “spillover” or “keystone” habits, have a disproportionately positive impact across multiple areas of life. For example, regular exercise often leads to improved sleep, better dietary choices, and increased productivity.
  3. Habits Beyond the Individual: Duhigg extends the concept of habits to organizations and societies, emphasizing that workplace cultures are largely shaped by the values and habits their systems encourage and reinforce.

Through these points, The Power of Habit sheds light on how both individuals and groups can harness the power of habits to drive meaningful change.
You might not guess it from the title, but Gretchen Rubin’s 2015 book Better than Before is all about habit formation. Packed with practical tips and supported by nods to the science behind them, the book dives deep into building better habits—and also into breaking bad ones. Beyond the sheer volume of tips and tricks, Rubin highlights two particularly important points:

  1. Bad habits matter: Tackling harmful habits is just as critical as creating and sustaining good ones.
  2. Habits shape identity: Building an identity around a habit can significantly improve long-term retention. For example, seeing yourself as “someone who exercises regularly” reinforces consistency more than merely setting a goal to go to the gym more often.

Rubin also earns credit in my book for emphasizing the importance of the foundational practices of good sleep, a healthy diet, and regular exercise. These are essential not just for achieving goals but for overall well-being—and the science backs her up (PMC4426706; Harvard Health; PMC6971834). I’d go one step further: these pillars aren’t just foundational—they’re mutually reinforcing. They shouldn’t be treated as à la carte options. For instance, establishing a regular exercise habit can naturally improve sleep quality and promote healthier eating patterns. When we pay attention to all of these areas, we create a positive feedback loop that strengthens our physical and mental health, in addition to positioning us to achieve our goals and sustain meaningful, fulfilling careers. While Duhigg introduced the idea of spillover habits, Rubin takes it a step further and specifically makes the case for good sleep, good diet, and regular exercise as key spillover habits to latch onto to make other habits more likely to stick.

Finally, we have James Clear’s Atomic Habits, an ongoing blockbuster since its debut in 2018, which reliably reclaims the spotlight every January as people set their New Year’s resolutions. Like Charles Duhigg in The Power of Habit, Clear emphasizes a habit loop of cue, craving, response, and reward. However, he takes the concept further by focusing on the systems that support habits, rather than just the goals they aim to achieve. Goals, Clear argues, simply set the direction; it’s the systems you put in place that determine success. His memorable mantra encapsulates this idea: You don’t rise to the level of your goals; you fall to the level of your systems.

Clear’s core principles include:

  1. Habits compound over time: Whether good or bad, the effects of habits snowball as they accumulate.
  2. The 1% Rule: Small, incremental improvements in habits—what I call “sustained micro-growth”—lead to disproportionately large positive changes over time.
  3. The Four Laws of Behavior Change: To create a habit, make it Obvious (clear cues), Attractive, Easy, and Satisfying.

While many of the ideas in Atomic Habits echo those in The Power of Habit, Clear’s book is widely considered more accessible and practical. It’s packed with actionable strategies that emphasize starting small and manageable. For example, Clear highlights how schedules, existing habits, social networks, and environmental cues can be leveraged to build systems that make good habits stick. His emphasis on consistency over ambition—focusing on small, repeatable steps rather than grandiose efforts—makes his advice particularly effective for sustainable growth. In essence, Atomic Habits is about the small actions (“atomic habits”) that form the building blocks of larger systems. These systems, in turn, create meaningful and lasting change. While it’s difficult to summarize this book in one go, this idea—that small changes which are sustained over time lead to big results—is at the heart of Clear’s philosophy.

Do busy doctors need to read all three books to support their New Year’s resolutions or any career or health goals they set this year? Absolutely not. The key themes shared across these books can be distilled into these actionable insights for those genuinely interested in making meaningful changes:

  1. Focus on systems, not just goals: While setting clear goals is important, creating systems to support those goals is what leads to sustainable success.
  2. Cultivate insight: Pay attention to what feels rewarding or painful to help you prioritize and pursue only what is truly meaningful to you.
  3. Address bad habits: Identify and tackle the habits that sabotage your growth or derail the changes you want to make.
  4. Optimize your environment: Adjust your physical and social surroundings to align with and support the growth or change you’re aiming for.
  5. Start small: Consistency matters more than scale. Focus on doing something small, and keep at it all year long—duration beats intensity.
Focus on systems, not just goals: While setting clear goals is important, creating systems (self reflection, habit formation, and environmental optimization) to support those goals is what leads to success.
Bend in winter

Sleep for Doctors, Part 1: A Call to Action

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Most winters, I teach a course on sleep for medical students. To complement lectures on sleep waves and the fundamentals of sleep-disordered breathing, my course emphasizes the science around sleep (quantity and quality). The students are, for the most part, young and energetic—still mostly unaware (at the lived experience level) of the profound toll that chronic sleep disruption or deep deprivation can take on their vitality. Yet, they already sense, with a tinge of foreboding, that such exhaustion is their inevitable fate, at least during the gruelling early years of training. Thus, they find the topic both intriguing and personally relevant. They are eager to explore how sleep – a lifestyle factor that touches nearly every facet of health – can dramatically influence not only their scholastic performance but also their overall well-being, health, and even their longevity.

In contrast, the reception from doctors in training (residency and beyond) is often less enthusiastic. And I get it: when you’re in the thick of it, battling the relentless demands of the profession with no immediate escape, a lecture on the virtues of rest might feel misplaced or even tone-deaf. But every doctor, regardless of their educational or career stage, stands to gain from a deeper understanding of the health benefits of sleep and the strategies for optimizing rest. As sleep researcher Matt Walker puts it (@sleepdiplomat): “Sleep is not an optional lifestyle luxury; it is a non-negotiable biological necessity.” Similarly, this critical truth was highlighted this way by a research team(1): “The challenges surrounding discussions of sleep, fatigue, and medical education stem from an ironic biological reality — physicians share the same physiology as their patients, including an absolute need for sleep and endogenous circadian rhythms that govern alertness and performance.”

This blog post on sleep (and the ones that follow) are a call to action to take sleep seriously. The evidence is clear: many healthcare workers(2-5)* — and a significant number of their patients — are not getting sufficient sleep to optimize their health and performance.

Action steps that every doctor can start to take now to be better rested tomorrow:

  1. Become or remain educated on the long and short-term health impacts of insufficient sleep (see Sleep For Doctors, Part 2 for a list of these impacts).
  2. Embrace good sleep as an essential element of a healthy lifestyle, for patients and for healthcare workers alike.
  3. Reflect on your own sleep habits to get clear about how regular your sleep patterns are, and whether you are getting enough and sufficiently high quality sleep. How sleep sufficient or insufficient are you? If you are sleep insufficient, can you take a few minutes to atively imagine how your life and health could be improved by prioritizing regular, restorative sleep? (see Sleep For Doctors, Part 2 for more around how much is enough sleep, and what constitutes high quality sleep.)
  4. If you are a doctor in a training program, consider: (a) asking your program leadership to review and discuss the data around sleep insufficiency and physician well being and patient outcomes, and (b) inquiring about the steps they are taking to promote healthier sleep habits for trainees.
  5. As an attending physician, particularly if early in your career, it’s crucial to take ownership of your sleep habits. Protecting your rest will ultimately be up to you — your job will not do it for you. Employers often expect more, sometimes with fewer resources, year after year. Get clear on how you want to spend your career time and energy, and how your achievement and career management can be enhanced by safeguarding healthy sleep habits. It’s ok to work hard when you’re at work or when you are otherwise expected and compensated to do so, but don’t invite work into bed with you. And if you’re on call, consider adjusting your pre and post call schedules to help buffer the impact of potential sleep disruptions.
  6. For doctors at every stage: How can you incorporate sleep education and counselling into routine clinical practice? This has the potential to profoundly improve the lives of our patients, transforming health outcomes on a large scale—this is a vital opportunity we cannot afford to overlook.
  7. If you are involved in patient safety, the findings of this study(6) — which identified a dose-response relationship between sleep-related impairment and self-reported clinically significant medical errors — are nothing short of compelling. As the authors suggest, “strategies to mitigate wellness factors could reduce medical error.” A well rested workforce is not just good for employee well being, it is also essential to optimize the outcomes and experiences of patients.

In the following post (Sleep for Doctors, Part 2), I highlight some of the key data featured in my course, including a discussion of how much is enough sleep. While the findings are sobering, my hope is that they will inspire greater urgency in prioritizing sleep regulation for better health — not just for the benefit of our patients, but for our own well-being as well.

Thank you for tuning in, and here’s to good sleep in 2025!

  • Several factors which contribute to insufficient sleep among healthcare workers, including rotating shifts and long working hours, are related to sleep impingement or sleep cycle alterations. Whether insomnia is an additional contributing factor remains unclear. Most of the existing research on insomnia among healthcare workers stems from studies conducted during the COVID-19 pandemic, raising questions about how applicable these findings are in non-pandemic times. This is a critically under-studied area of physician health.

REFs:

  1. Buysse DJ, Barzansky B, Dinges D, Hogan E, Hunt CE, Owens J, et al. Sleep, fatigue, and medical training: setting an agenda for optimal learning and patient care. Sleep. 2003;26(2):218-25. https://pubmed.ncbi.nlm.nih.gov/12683483/
  2. Coelho J, Lucas G, Micoulaud-Franchi JA, Philip P, Boyer L, Fond G. Poor sleep is associated with work environment among 10,087 French healthcare workers: Results from a nationwide survey. Psychiat Res. 2023;328. DOI: 10.1016/j.psychres.2023.115448
  3. Gohari A, Baumann B, Jen R, Ayas N. Sleep Deficiency: Epidemiology and Effects. Sleep Med Clin. 2024;19(4):509-18. DOI: 10.1016/j.jsmc.2024.07.001
  4. Mansour W, Knauert MP. Adding Insult to Injury: Sleep Deficiency in Hospitalized Patients. Sleep Med Clin. 2024;19(4):607-23. DOI: 10.1016/j.jsmc.2024.07.008
  5. Scott H, Naik G, Lechat B, Manners J, Fitton J, Nguyen DP, et al. Are we getting enough sleep? Frequent irregular sleep found in an analysis of over 11 million nights of objective in-home sleep data. Sleep Health. 2024;10(1):91-7. https://www.sciencedirect.com/science/article/pii/S235272182300253X
  6. Trockel MT, Menon NK, Rowe SG, Stewart MT, Smith R, Lu M, et al. Assessment of Physician Sleep and Wellness, Burnout, and Clinically Significant Medical Errors. JAMA Netw Open. 2020;3(12):e2028111. DOI: 10.1001/jamanetworkopen.2020.28111
NH lighthouse

Sleep for Doctors Part 2: The science of sleep and why every doctor should care

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Sleep impacts health and well being in many ways. This blog post addresses these impacts in two parts, with part I focused on specific health outcomes and part II focusing on the work-related impacts of poor or insufficient sleep for doctors.

Part I: Insufficient good quality sleep – increasingly recognized under the term “Insufficient Sleep Syndrome” (ISS), and recently identified as a possible major noncommunicable disease(1) – is associated with a wide range of significant health impacts:

  1. Cardiovascular Health:
    • Increased risk of hypertension (2) – this is so real and so prevalent that, in this author’s opinion, sleep data should be queried in all patients on anti-hypertensive medications or in those creeping towards that need.
    • Higher rates of cardiovascular disease(3), so much so that healthy sleep now stands alongside a healthy diet, regular exercise, and tobacco avoidance as a foundational pillar of heart health according to the American Heart Association(4)
  2. Metabolic Health:
  3. Mental Health:
    • Increased symptoms of anxiety, depression, and other mood disorders (5-7)
    • Possible links to addiction and substance use disorders(8)
  4. Pain Perception:
    • Higher acute pain sensitivity and increased pain scores (9)
  5. Headache Disorders:
    • Higher risk of triggered migraines, potentially mediated by an accumulation of adenosine during sleep deprivation
  6. Accidents and Injuries:
    • Increased risk of both fatal and non-fatal accidents (10,11)
  7. Immune Function:
    • Potentially reduced vaccine efficacy(12,13)
  8. Neurological Health:
    • Likely increased risk of dementia(14,15), potentially due to impaired clearance of beta-amyloid protein during sleep(16) and its accumulation during sleep deprivation(17)
  9. Cancer Risk:
    • Higher risk of colon cancer(18)
  10. Mortality:
    • Slightly increased all-cause mortality risk(19)
    • Higher cancer-associated mortality rates for some cancers(20)

    Note: Cancer studies often highlight a “Goldilocks zone” for sleep duration, with short and long sleep times both have been associated with increased mortality rates. However, this author has not seen any data that the latter is causal; rather, cancer can be associated with hyper-somnolence, and cancer progression may drive increased sleep time. The case for insufficient sleep and poor cancer outcomes seems more clear cut, and founded on data which implies a causal relationship.

Research on the impact of sleep insufficiency on fertility (and possibly on the outcomes of treatments for infertility) (21-23), and its connection to functionality in individuals with autism spectrum disorder (24,25), highlights the importance of assessing sleep quality. Prioritizing strategies to improve sleep may be an important component of care plans for these patients, although more research is needed in these domains.

Beyond the specific health impacts listed above, emotional processing, cognitive performance(26) including attention and focus, and stress management are all impacted by sleep. For the latter, high stress and poor sleep can be mutually reinforcing, setting up a negative feed forward cycle often called the sleep-stress cycle(27). The figure below provides a snapshot of the emotionally impacts of insufficient sleep.

From the American Psychological Association’s, Stress in America™ 2013 survey (https://www.apa.org/news/press/releases/stress/2013/sleep)

Finally, the discomfort caused by hyper-somnolence is not a medical condition in itself, but it can be a genuine source of suffering, comparable to pain from other causes. This symptom can significantly impact quality of life, much like any form of pain.

Part II: Beyond specific medical conditions, poor or insufficient sleep can affect doctors in other vital ways. Sleep impairment among healthcare workers is linked to several serious professional consequences, including increased risk of medical errors and reduced work performance. In one study (29), interns working traditional schedules with extended hours made more serious medical errors than those on schedules with reduced work hours. Further, these impacts were reversible: reducing the work hours of medical interns led to increased sleep and reduced attentional failures(28). Both studies, published over 20 years ago, provide evidence linking sleep deprivation with performance, including the occurrence of medical errors, among healthcare professionals. It’s time we pick up the conversation again, and make sleep protection a part of every physician training program.

Other aspects of work performance also are measurably impaired. Below is a clear and concise summary of this impact, quoted verbatim with full credit to the authors, and with their references included, from this highly important piece(30): “Emergency physicians working night shifts take longer to intubate,22 display an increased propensity for error as the shift progresses,23 and exhibit a significant decline in cognitive performance after working 5 consecutive night shifts.24 Sleep-impaired physicians in training exhibit deficiencies in functional cognition,25,26 concentration,27 working27 and visual memory,28 operative dexterity,29 vigilance,30,31 and ability to discern arrhythmias on an electrocardiogram.17 One night of sleep deprivation in physician trainees led to reduction in scores on the examination of the American Board of Family Practice equal to the average difference in scores between first-year and third-year residents.32 Sleep-related impairment also results in impaired decision-making,33,34 including reduced capacity for risk-benefit analysis35 and increased risk-taking behavior.35,36 For instance, sleep-deprived residents responding to a case vignette select more risky treatment options.37  …and sleep-related impairment … among physicians are associated with increased unsolicited patient complaints,38…”

Finally, sleep-deprived doctors report significantly higher levels of burnout and reduced professional fulfillment(31). (Note: that study relied on subjective reports of sleep quality and sleepiness symptoms(32); while these scores have been correlated with total sleep time at least in one study(33), whether doctors – who have potentially endured years of sleep insufficiency – retain a reliable degree of subjective sensitivity to sleep deprivation is unclear). Multiple factors may contribute to a pro-burnout effect of sleep insufficiency. First, sleep deprivation can trigger a negative feedback loop of impaired cognitive performance, which in turn prolongs work hours as doctors struggle to complete their tasks, leading to more sleep insufficiency. Moreover, sleep deprivation hampers emotional processing which, if left unaddressed, can contribute to burnout. Here’s a plea worth heeding from a review that eloquently underscores the connection between sleep disruption and physician burnout: “Interventions should be directed not only at individuals but also at the entire health system”(34).

Thank you for tuning in, and here’s to good rest and good sleep for 2025 (and beyond)!

REFS:

  1. Chattu VK, Sakhamuri SM, Kumar R, Spence DW, BaHammam AS, Pandi-Perumal SR. Insufficient Sleep Syndrome: Is it time to classify it as a major noncommunicable disease? Sleep Sci. 2018;11(2):56-64. IPMID: 30083291
  2. Calhoun DA, Harding SM. Sleep and Hypertension. Chest. 2010;138(2):434-43. DOI: 10.1378/chest.09-2954
  3. Wang SS, Li ZX, Wang XY, Guo S, Sun YJ, Li GH, et al. Associations between sleep duration and cardiovascular diseases: A meta-review and meta-analysis of observational and Mendelian randomization studies. Frontiers in Cardiovascular Medicine. 2022;9. doi: 10.3389/fcvm.2022.930000
  4. Lloyd-Jones DM, Allen NB, Anderson CAM, Black T, Brewer LC, Foraker RE, et al. Life’s Essential 8: Updating and Enhancing the American Heart Association’s Construct of Cardiovascular Health: A Presidential Advisory From the American Heart Association. Circulation. 2022;146(5):E18-E43. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001078
  5. Babson KA, Trainor CD, Feldner MT, Blumenthal H. A test of the effects of acute sleep deprivation on general and specific self-reported anxiety and depressive symptoms: An experimental extension. J Behav Ther Exp Psy. 2010;41(3):297-303. DOI: 10.1016/j.jbtep.2010.02.008
  6. Neckelmann D, Mykletun A, Dahl AA. Chronic insomnia as a risk factor for developing anxiety and depression. Sleep. 2007;30(7):873-80. DOI: 10.1093/sleep/30.7.873
  7. Weissman MM, Greenwald S, Nino-Murcia G, Dement WC. The morbidity of insomnia uncomplicated by psychiatric disorders. Gen Hosp Psychiatry. 1997;19(4):245-50. DOI: 10.1016/s0163-8343(97)00056-x
  8. Ostos-Valverde A, Herrera-Solis A, Ruiz-Contreras AE, Mendez-Diaz M, Prospero-Garcia OE. Sleep debt-induced anxiety and addiction to substances of abuse: A narrative review. Pharmacol Biochem Behav. 2024;245:173874. DOI: 10.1016/j.pbb.2024.173874
  9. Woelk J, Goerlitz D, Wachholtz A. I’m tired and it hurts! Sleep quality and acute pain response in a chronic pain population. Sleep Med. 2020;67:28-32. DOI: 10.1016/j.sleep.2019.10.017
  10. Garbarino S, Durando P, Guglielmi O, Dini G, Bersi F, Fornarino S, et al. Sleep Apnea, Sleep Debt and Daytime Sleepiness Are Independently Associated with Road Accidents. A Cross-Sectional Study on Truck Drivers. PLoS One. 2016;11(11):e0166262. DOI: 10.1371/journal.pone.0166262
  11. https://www.rospa.com/getmedia/25999a67-6e67-4a8c-b32d-13b5c1090010/Driver-Fatigue-Factsheet-2022-updated.pdf
  12. Spiegel K, Sheridan JF, Van Cauter E. Effect of sleep deprivation on response to immunization. JAMA. 2002;288(12):1471-2. DOI: 10.1001/jama.288.12.1469
  13. Spiegel K, Rey AE, Cheylus A, Ayling K, Benedict C, Lange T, et al. A meta-analysis of the associations between insufficient sleep duration and antibody response to vaccination. Curr Biol. 2023;33(5):998-1005 e2. DOI: 10.1016/j.cub.2023.02.017
  14. Robbins R, Quan SF, Weaver MD, Bormes G, Barger LK, Czeisler CA. Examining sleep deficiency and disturbance and their risk for incident dementia and all-cause mortality in older adults across 5 years in the United States. Aging (Albany NY). 2021;13(3):3254-68. DOI: 10.18632/aging.202591
  15. Sabia S, Fayosse A, Dumurgier J, van Hees VT, Paquet C, Sommerlad A, et al. Association of sleep duration in middle and old age with incidence of dementia. Nat Commun. 2021;12(1):2289. DOI: 10.1038/s41467-021-22354-2
  16. Nedergaard M, Goldman SA. Glymphatic failure as a final common pathway to dementia. Science. 2020;370(6512):50-6. https://pubmed.ncbi.nlm.nih.gov/33004510/
  17. Shokri-Kojori E, Wang GJ, Wiers CE, Demiral SB, Guo M, Kim SW, et al. beta-Amyloid accumulation in the human brain after one night of sleep deprivation. Proc Natl Acad Sci U S A. 2018;115(17):4483-8. DOI: 10.1073/pnas.1721694115
  18. Chen J, Chen N, Huang T, Huang N, Zhuang Z, Liang H. Sleep pattern, healthy lifestyle and colorectal cancer incidence. Sci Rep. 2022;12(1):18317. DOI: 10.1038/s41598-022-21879-w
  19. Gallicchio L, Kalesan B. Sleep duration and mortality: a systematic review and meta-analysis. J Sleep Res. 2009;18(2):148-58. DOI: 10.1111/j.1365-2869.2008.00732.x
  20. Donzella SM, Deubler E, Patel AV, Phipps AI, Zhong C. Sleep and cancer mortality in the Cancer Prevention Study-II. Cancer Causes Control. 2024;35(12):1541-55. DOI: 10.1007/s10552-024-01910-3
  21. Zhao F, Hong X, Wang W, Wu J, Wang B. Effects of physical activity and sleep duration on fertility: A systematic review and meta-analysis based on prospective cohort studies. Front Public Health. 2022;10:1029469. https://pmc.ncbi.nlm.nih.gov/articles/PMC9669984/
  22. Poster presentation / abstract: https://www.fertstert.org/article/S0015-0282(17)30888-9/fulltext
  23. Info sheet from the University of North Carolina’s fertility center: https://uncfertility.com/fertility-blog/the-link-between-sleep-and-fertility/
  24. Elkhatib Smidt SD, Gooneratne N, Brodkin ES, Bucan M, Mitchell JA. Sufficient sleep duration in autistic children and the role of physical activity. Autism. 2022;26(4):814-26. https://pmc.ncbi.nlm.nih.gov/articles/PMC9010343/
  25. Devnani PA, Hegde AU. Autism and sleep disorders. J Pediatr Neurosci. 2015;10(4):304-7. https://pmc.ncbi.nlm.nih.gov/articles/PMC4770638/
  26. Alhola P, Polo-Kantola P. Sleep deprivation: Impact on cognitive performance. Neuropsychiatr Dis Treat. 2007;3(5):553-67. PMID: 19300585
  27. Kalmbach DA, Anderson JR, Drake CL. The impact of stress on sleep: Pathogenic sleep reactivity as a vulnerability to insomnia and circadian disorders. J Sleep Res. 2018;27(6):e12710. PMID: 29797753
  28. Lockley SW, Cronin JW, Evans EE, Cade BE, Lee CJ, Landrigan CP, et al. Effect of reducing interns’ weekly work hours on sleep and attentional failures. N Engl J Med. 2004;351(18):1829-37. DOI: 10.1056/NEJMoa041404
  29. Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, et al. Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med. 2004;351(18):1838-48. DOI: 10.1056/NEJMoa041406
  30. rockel MT, Menon NK, Rowe SG, Stewart MT, Smith R, Lu M, et al. Assessment of Physician Sleep and Wellness, Burnout, and Clinically Significant Medical Errors. JAMA Netw Open. 2020;3(12):e2028111 doi:10.1001/jamanetworkopen.2020.28111
  31. Trockel MT, Menon NK, Rowe SG, Stewart MT, Smith R, Lu M, et al. Assessment of Physician Sleep and Wellness, Burnout, and Clinically Significant Medical Errors. JAMA Netw Open. 2020;3(12):e2028111 DOI: 10.1001/jamanetworkopen.2020.28111
  32. Yu L, Buysse DJ, Germain A, Moul DE, Stover A, Dodds NE, et al. Development of short forms from the PROMIS sleep disturbance and Sleep-Related Impairment item banks. Behav Sleep Med. 2011;10(1):6-24. https://pubmed.ncbi.nlm.nih.gov/22250775/
  33. Hanish AE, Lin-Dyken DC, Han JC. PROMIS Sleep Disturbance and Sleep-Related Impairment in Adolescents: Examining Psychometrics Using Self-Report and Actigraphy. Nurs Res. 2017;66(3):246-51. PMID: 28448375
  34. Stewart NH, Arora VM. The Impact of Sleep and Circadian Disorders on Physician Burnout. Chest. 2019;156(5):1022-30. DOI: 10.1016/j.chest.2019.07.008.
Canary Island waves

Sleep for Doctors Part 3: How to get the sleep you need

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This installment of Sleep for Doctors transitions from understanding why sleep is important to exploring how to optimize it. Without further ado, to achieve the sleep you need to live the life you want, these steps are key:

  1. Determine the optimal number of sleep hours that your individual body needs. Most people are not the average value (of any parameter!). The average sleep need for an adult in normal conditions hovers around 7 hours per night, but it is safe to assume that your need is not exactly that average value. Seven hours is a ballpark, but we can do better than ballparks, and everyone can become aware of their individual sleep need. This need is a measurable, durable, genetically-influenced trait. To determine your optimal sleep time, try a multi-day experiment inspired by the study on Optimal Sleep Duration(1). Go to bed when you feel naturally tired and allow yourself to wake up without any external interruptions—such as alarms, lights, noise, or other disturbances—relying solely on your circadian rhythm. Or even better: allow for a 10 to 12-hour time in bed to avoid any pressure for early arousal, and then recording and averaging the number of hours that you slept. This needs to be done in a non sleep-deprived state (note that achieving a well rested state can take several days of liberal sleeping), and in an environment with an evening schedule oriented around rest and sleep. Once you do this (admittedly lengthy) self-test, you will know your Optimal Sleep Duration value for life.
  2. Do a just-right amount of tracking of your sleep patterns…just enough to know if you are hitting your sleep need target on a regular basis. Overly vigilant tracking can create sleep anxiety(2), but light touch sleep journaling for a week or so every so often (up to a few times a year, as needed) is a healthy check-up activity for most people.
  3. Make sleep a priority. Prioritize sleep when you design your schedule, daily routines, and lifestyle. If you are not meeting your bedtime goals to get the sleep you need, do an inventory of what’s getting in the way of achieving this goal. If it helps, set a go-to-bed alarm, or plan backwards from your goal bedtime to anticipate what you need to do – and when – to get to bed on time. Or do both: many people benefit from a T-minus 45 minute alarm clock…this way they still have time to wrap things up, get ready, and turn off the lights at the desired time for sleep, all without a big rush or bolus of stress before the body and mind are meant to wind down. With that in mind: what is your bedtime goal and how would you plan your evening tonight to meet this goal? If you can’t imagine this, you’ll often miss your bedtime target and the opportunity to optimize your health and achievement-potential. In sum: getting to bed on time is the first step to getting to sleep on time, and getting to bed on time takes planning and commitment.
  4. The process of putting kids to bed can be (very) disruptive to the sleep pattern of adults. There is no easy answer here. Some parents have found it helpful to consult with a child sleep coach; this can be life changing, but best to ask around for recommendations or referrals as this is an unregulated professional group. A common theme that emerges in this type of coaching is that ritualizing routines around bedtimes helps everyone in the family, and should start an hour or so before bedtime if the target bedtime is to be reliably met.
  5. To thwart off or combat chronic insomnia, pro-actively manage your environment. Much of that falls under the concept term of what many call “sleep hygiene”. Specific tips for that are posted below.
  6. For short term relief of the discomfort of fatigue, power napping (ideally not more than 30-40 minutes), rest, and/or the judicious use of caffeine can help.(3) While these measures can reduce the sensation of sleepiness and the acute propensity to fall asleep, they do NOT fully eliminate impairments in psychomotor function that come with sleep deprivation.

Getting the sleep you need reflects a real commitment to your health, well being, and short-term and long-term performance. While the discomfort of hyper-somnolence typically abates quickly after establishing a restorative sleep pattern, most other rewards will be slower to reap (delayed gratification alert!). While delayed rewards are less habit reinforcing compared to immediate rewards(see the Habit Blog post), the long game is worth playing (see Sleep for Doctors, Part 2). For many, understanding the benefits of sleep and cultivating an identity centered around health can serve as its own reward, reinforcing positive sleep habits.

Here are some so-called sleep hygiene tips, largely inspired from the Sleep Foundation website(4) with my additional comments included:

  • Stick to the same sleep schedule as much as possible every day, even on weekends.
  • Practice a relaxing bedtime routine to make it easier to fall asleep quickly; a myriad of apps and other streaming platforms can support this practice; if music – including white or pink noise – or story telling is helpful for you, the podcast Meditative Story may be worth checking out.
  • Choose the **best mattress, pillows** and **bedding** for you…items that are comfortable and support your sleep needs. Warning: This research has a high potential to become a rabbit hole. Tip: Set specific time limits for conducting research and testing products to stay focused!
  • Minimize potential disruptions from light and sound. If watching TV / netflix / the like (and for some this includes reading) makes you blow through your bedtime or overly activates your mind, then consider shifting these activities to the weekend, or setting a timer for how long you will watch or read. Potentially painful, I know, and I do not enjoy saying this.
  • Many experts advise optimizing your bedroom temperature, with the ideal temperature for sleep reported to be between 65-68°F (18-20°C). If you are an outlier who needs to feel warm to fall asleep, then you do you. But consciously consider and experiment with the environmental conditions that optimally promote sleep for you. Our core body temperature drops as melatonin levels rise throughout the night (reaching their nadir and peak, respectively, around 4am); however, it is not clear that lowering your body temperature before that time facilitates sleep onset or that heating your body to mitigate this drop interferes with sleep.
  • Beware of light at bedtime: Disconnect from electronic devices like phones and laptops for half an hour or more before bedtime to aid falling asleep.
  • Beware of light during sleep: avoid all sources of blue light in the bedroom if possible – this includes from phones, computers, ipads, heaters, humidifiers, etc. Night lights should only be used if needed for safety (and truly: safety first); if indicated, then soft white light versions are best. Leave your phone in another room, or if it must be in the room with you: turn it over, remove all (sound, light, and vibrational) notifications, and consider a do-not-disturb setting (careful though if you are on and off call: if you have frequent call nights, try other methods for eliminating phone disruptions on non-call nights). Even when light does not wake you up, it disrupts your circadian rhythm in (readily measurable!) harmful ways.
  • Appropriately regulate your intake of caffeine based on your needs and the effects of caffeine on your body. The bioavailability of caffeine is close to 100%, and while peak levels occur one hour after ingestion, physiological effects typically being within 15 minutes of consumption. ****The half-life of caffeine can vary widely among individuals due in part to genetic features which regulate its metabolism.(5) Medications can further impact caffeine metabolism; ciprofloxaxin, for example, can substantially lengthen the half-life of caffeine.(6) For people who are sensitive to the sleep-disrupting effects of caffeine, it is advisable to avoid consumption for at least several hours prior to bedtime; for some, caffeine intake may need to be limited to the first half of the day to avoid sleep disruption at night. Caffeine blocks adenosine (the sleep pressure signal that accumulates during wakefullness) and additionally acts directly a stimulant.(7) When caffeine is metabolized and cleared from the system, adenosine levels, which are not affected by caffeine and continue to accumulate throughout wakefullness, are then felt in full force; avoid the temptation to continually caffeine spike throughout the day to deal with the primary problem of sleep dept.
  • Appropriately regulate your intake of alcohol if you consume it. Click this here to read a short blurb that nicely and succinctly summarizes the impact of alcohol-before-bedtime. For those who consume alcohol (even minimally) and are not getting enough restorative sleep after drinking, then an adjustment of consumption habits may be needed: earlier, reduced, or more infrequent consumption all can help.
  • Burn enough energy in the day: exercise and movement, and the avoidance of prolonged sitting, promote healthy sleep habits and good sleep. Most sleep experts recommend exercising early in the day, or at least not close to bedtime, for the best effect.
  • Chamomile (in tea or other forms) may reduce sleep latency, but the ritual effect (Pavlovian dynamics are real) also may contribute to its sleep promoting effects. So go ahead and drink up before lying down(8), but avoid large-volume intakes as bladder pressure is a potent stimulant*, and for those with an overactive bladder it is prudent to completely avoid liquids before bedtime.
  • If you often feel compelled to work on or finish something important—whether for work or life—at times when you know you should be going to bed, and especially if this habit is affecting your sleep time or quality, consider this a gentle but urgent nudge to reflect on why this pattern persists. In my coaching experience, many clients find that the time before bedtime is often their first quiet moment to work on a project that requires focus and concentration. While the temptation to do deep work after hours is understandable – and let it be known that the author of this blog has no hilltop of righteousness to stand on in terms of this issue – the real challenge lies in understanding why your daytime schedule doesn’t allow enough space for essential or otherwise important projects for your career (or life), and how this can be improved. This is a time management issue that often leads to collateral damage in sleep regulation. Even if you are an owl and work best at night: if you have a lark work schedule, adjustments will be needed to be ensure that doing work at a time that feels natural for you doesn’t come with health and next-day functionality costs.

For those struggling to fall asleep due to a racing mind, I include mention of relaxation strategies which may promote sleep, leading with the caveat that data are limited to support these measures. There is an abundance of online testimonies, but as the saying goes: anecdotes are not data. That said, some patients find that brain tapping, breathing-drumming regimens(9), the so-called military technique(10), and other meditative activities (which often include breath work) can slow the mind and foster a transition to sleep. As long as they aren’t stressful explorations, I’d say have a go. Finally, while this intervention is not on the internet, I have sometimes encouraged doctors to do a “let it go” exercise before sleep…say goodnight to whatever is racing though your mind. Good-night busy clinic schedule tomorrow, I’ll meet you in the morning. Good-night stressful day at work today. Good-night anxious brain that wonders if the lecture I prepared for the morning is good enough. Good night world events or family dynamics or unexpected bills or babysitters that suddenly quit. Breathe in, say good night, and exhale. Good-night to it all, sometimes one by one, breath by breath. No need to count sheep, but yes to reflecting on nature, and saying your good-nights, and gently controlling the breath. (It can sound ridiculous, but when one is awake at 2am with an active mind, and entering an anxiety-can’t fall asleep-anxiety spiral, it sometimes doesn’t sound so crazy after all; anecdotally, it works best to do this activity at bedtime, if thoughts are already racing then, and not wait for a 2am wake-up call from your brain).

If these measures on your own aren’t doing the trick, consider insomnia-focused cognitive behavioral therapy(CBT)(11,12). If the idea of CBT makes you feel weak in the professional knees (because this is therapy you prescribe but can’t imagine needing for yourself) or makes you start to minimize or dismiss your sleep issues, then address these emotional responses in whatever way you need to to allow yourself to move forward with interventions that will sanely, reasonably, and effectively help you achieve healthy sleep patterns. You deserve to feel and be well rested.

As always, thank you for tuning in, and here’s to good resting and good sleep for patients and healthcare workers alike!

  • I once heard a podcast interview (sometime, somewhere…no memory of the source for attribution, but if you are aware of the interview please DM me, and credit will be added to this post!) in which a medical trainee purposefully liquid-loaded before bedtime so that accumulating bladder pressure would help him wake up and get out of bed in the early morning hours, and overpower the desire to stay in bed due to insufficient sleep. I immediately thought “that’s brilliant…and that’s insane”. Houston we have a problem with our workplace culture when doctors are chronically medicating or otherwise manipulating their physiology to overcome the discomfort of sleep starvation. Let’s address that (see blog post Sleep for Doctors, part 1)!

REFS:

  1. Kitamura S, Katayose Y, Nakazaki K, Motomura Y, Oba K, Katsunuma R, et al. Estimating individual optimal sleep duration and potential sleep debt. Sci Rep. 2016;6:35812 https://www.nature.com/articles/srep35812)
  2. Newspaper article (The Guardian in the UK) https://www.theguardian.com/lifeandstyle/2019/jun/07/sleep-apps-backfire-by-causing-anxiety-and-insomnia-says-expert)
  3. Farquhar M. Fifteen-minute consultation: problems in the healthy paediatrician-managing the effects of shift work on your health. Arch Dis Child Educ Pract Ed. 2017;102(3):127-32 https://ep.bmj.com/content/102/3/127
  4. Informational website (Sleep Foundation): https://www.sleepfoundation.org/how-sleep-works/how-much-sleep-do-we-really-need
  5. Informational website (UK-based News Medical): https://www.news-medical.net/health/Caffeine-Pharmacology.aspx
  6. Healy DP, Polk RE, Kanawati L, Rock DT, Mooney ML. Interaction between oral ciprofloxacin and caffeine in normal volunteers. Antimicrob Agents Chemother. 1989;33(4):474-8. doi: 10.1128/aac.33.4.474
  7. Review paper: doi: 10.7759/cureus.15032
  8. Shinomiya K, Inoue T, Utsu Y, Tokunaga S, Masuoka T, Ohmori A, et al. Hypnotic activities of chamomile and passiflora extracts in sleep-disturbed rats. Biol Pharm Bull. 2005;28(5):808-10. https://pubmed.ncbi.nlm.nih.gov/15863883/
  9. Youtube video: https://www.youtube.com/watch?v=A5dE25ANU0k
  10. Informational website (Cleveland Clinic): https://health.clevelandclinic.org/military-sleep-method
  11. Informational website (Sleep Foundation): https://www.sleepfoundation.org/insomnia/treatment/cognitive-behavioral-therapy-insomnia
  12. Walker J, Muench A, Perlis ML, Vargas I. Cognitive Behavioral Therapy for Insomnia (CBT-I): A Primer. Klin Spec Psihol. 2022;11(2):123-37. https://pmc.ncbi.nlm.nih.gov/articles/PMC10002474/).