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/).