Up all night to get lucky?
Why sleep deprivation could be sabotaging your success and putting patients at risk
Sleep deprivation is a recognised part of life for medical students, many of whom carry their bad sleep habits into their days of being junior doctors and beyond. Many choose to give up sleep in favour of pulling an “all nighter,” often as a last minute attempt to study for an exam or finish an essay. Others simply have schedules that are too busy to accommodate sleep. An article published by Science News discussed that in order for people to fit everything into their “have it all” lifestyles, with burgeoning social lives, careers, and extracurricular activities, sleep is often sacrificed: “Sleep is regarded by some as unproductive, wasteful downtime. People who would rather hit the hay than the dance floor are told that only losers snooze and that they can sleep when they’re dead.”
A lack of sleep has wider implications, however, including an impact on the ability to perform a variety of tasks. Worryingly, it has been reported that people often underestimate their degree of sleep related impairment, which could lead to unsafe decision making and poor performance, and raises the issue of patient safety from tired junior doctors working on the wards.
The all nighter
The all nighter can be defined as foregoing sleep altogether in favour of other activities, commonly study. We conducted a quick and informal poll on the networking site doc2doc (http://doc2doc.bmj.com/forums/medical-education-cpd_student-bmj-1_ever-pulled-nighter), asking for a few of the reasons for staying up all night. Students said “the fear of not being able to answer a question in an exam” provided motivation for studying overnight before examinations. Other reasons included not wanting to leave the study zone: “Sometimes takes me a good while to get into a topic and then stopping for the night seems like a waste.”
Overall, however, the feedback about the repercussions of an all nighter was negative. “I have pulled all nighters and each time I do, I pretty much regret it, as although I do learn a lot that night . . . I simply feel awful the next day.” This can affect the quality of study the following day, with another respondent saying that he was usually “too tired to do anything productive.”
Despite the intention of an all nighter primarily being to improve academic performance, studies have shown the opposite effect. A paper in the University of Minnesota Undergraduate Journal of Psychology found that “the average amount of sleep a student receives per night does seem to be (positively) tied to the student’s GPA [grade point average, the measure of student’s academic success in the United States].” The same paper reported that the quality of sleep did not seem to matter, inferring that the most important factor was the length of time spent asleep. Importantly, even short term sleep deprivation can have negative effects on performance. Students tested for vigilance and the ability to perform mathematical calculations experienced declining test scores over just a seven day period with as much as five, and in some cases seven, hours sleep a night.
Errors in clinical judgment
The risks associated with sleep deprivation are evidently much worse for doctors than for students, as poor performance has a direct impact on patient outcomes. A 2004 BMJ article reported just how tired doctors were, finding that “70% of specialist registrars in one hospital . . . slept for an average of two hours per night while contracted to work, and most had problems with sleep in the day time.” The study reported that “in the United States, interns working a traditional schedule of 77-81 hours per week caused 36% more serious medical errors than when working an average 65 hours per week.” The study found that the longer the sleep deprivation, the more dangerous the behaviour, as “risk increases exponentially over the course of the night and increases further still over consecutive nights.” Another study on junior doctors in New Zealand had similar findings, reporting that “30% of participants scored as excessively sleepy (Epworth Sleepiness Score >10), 24% reported falling asleep driving home since becoming a doctor, 66% had felt close to falling asleep at the wheel in the past 12 months, and 42% recalled a fatigue related clinical error in the past 6 months.”
Can you cheat the system?
Some students use stimulants to try to beat sleep, but they are not necessarily effective and are potentially a health risk. A report by Veasey and colleagues stated that there are health risks associated with regular use of central nervous system stimulants to improve performance after sleep loss, such as caffeine, modafinil, and dexamfetamine: “Potential health risks with regular use of any of these drugs should preclude consideration as countermeasures for chronic sleep loss in physicians in training, and caffeine does not correct mathematical calculation decrements with sleep loss.”
Napping can help lessen the after effects of sleep deprivation, according to Veasey and colleagues, “Naps as short as 15 minutes can significantly ameliorate the performance decrements if provided at 2-3 hour intervals during 24 hours of sleep deprivation.” Despite this, the authors found that “the effects of chronic partial sleep loss appear to be cumulative.” You can’t out-run the need for a full night’s sleep—eventually poor habits will catch up with you, and not necessarily at the most convenient time. Ultimately, according to Veasey and colleagues, “the most effective countermeasure for sleepiness is sleep.” 1
How to avoid having to “pull an all nighter”
Meir Kryger, professor of medicine, Yale University, USA
Staying awake all night before an exam is a terrible idea. In spite of your wanting your brain to be awake, and any caffeine or other products that you may have ingested, your brain is trying to sleep. Research has shown that learning is impaired and next day performance is compromised. You will actually learn little to increase your exam score and the cognitive impairment you experience will degrade your ability to answer questions on topics you actually do know about. The figure shows that a single night of zero hours sleep results in significant neurocognitive impairment.
You can avoid pulling an all nighter by planning. Create a schedule and aim to finish your studying a day early—the pressure and stress of the “unfinished business” of preparing for the exam will be gone the day before the exam. Many all nighters are self induced: what you do during the day before the big exam may give you insomnia, which can lead to your being awake the entire night. Avoid coffee after lunch, and avoid studying, electronics (computers, video games, texting, stimulating music), and stressful discussions (with worried classmates whose anxiety may be infectious) in the hour before your planned bedtime. Crucially, turn off your smart phone and make sleep a priority.
How to approach friends who are putting their health at risk through their study habits
Meir Kryger, professor of medicine, Yale University, USA
If you notice that a friend is seriously sleep deprived because of study habits, it is time to act. You may need to intervene quickly to prevent injury. It is possible that your friend could be as impaired as though he or she had been consuming alcohol. You would never allow a friend to drive when over the legal limit, and, likewise, when sleepy.
When the situation is less severe it is still important to help. Approach your friend privately and indicate your concern. Tell him or her that you believe that the sleepiness could harm both themselves and the public (for example, vehicle crashes) and their patients (for example, medical errors). How would a patient respond to a doctor with the smell of alcohol on his or her breath, or a doctor with droopy eyelids because of lack of sleep? Tell your friend the behaviours you are concerned about: “You fell asleep at rounds yesterday,” “You didn’t respond when asked a question by the professor,” “You prescribed the wrong dose of amoxicillin.” Remind your friend that short changing sleep does not help learning; instead it becomes a barrier to learning. Remind your friend that they have a professional duty and their unprofessional behaviour could potentially harm their patients. Be honest if you need to tell your friend they look ill and that everybody is noticing their poor performance. They, like you, must make sleep a priority.
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not peer reviewed.
- Saey TH. Science of slumber: dying to sleep: getting too little sleep can impair body and brain, and could even be deadly. Sci News 2009;176:28-32. doi:10.1002/scin.5591760920.
- Veasey S, Rosen R, Barsanksy B, Rose I, Owens J. Sleep loss and fatigue in residency training: a reappraisal. JAMA 2002;288:1116-24. doi:10.1001/jama.288.9.1116.
- Lowry M, Dean K, Manders K. The link between sleep quantity and academic performance for the college student. Sentience 2010;3:16-9. www.psych.umn.edu/sentience/files/Lowry_2010.pdf.
- Murray A, Pounder R, Mather H, Dame Black C. Junior doctors’ shifts and sleep deprivation. BMJ 2005;330:1404. doi:10.1136/bmj.330.7505.1404.
- Gander P, Purnell H, Garden A, Woodward A. Work patterns and fatigue-related risk among junior doctors. Occ Env Med 2007;64:733-8. doi:10.1136/oem.2006.030916.
- Kryger MH, Avidan A, Berry R, eds. Atlas of clinical sleep medicine, 2nd edn. Elsevier, 2014.
Cite this as: Student BMJ 2013;21:f5769