This side effect of the pandemic is harming doctors most

Doctors have plenty of reasons to lose sleep during the pandemic. Whether it’s stressing about getting infected or carrying the virus home to their families, adjusting to new virtual care procedures, or weathering financial uncertainty, new evidence suggests doctors are suffering the effects of severe sleep deprivation.

Research shows that physicians who get insufficient sleep are more likely to experience long-term physical and mental health problems. Sleep deprivation is also linked to burnout, increased patient safety incidents, poorer quality of care, and reduced patient satisfaction. Here’s why it’s happening now more than ever, and what to do about it.  

Sleep loss: the evidence

Prior to the coronavirus pandemic, there was already evidence that doctors and other healthcare workers were getting less sleep than the general public, according to a literature review published in Current Treatment Options in Neurology in 2020. Research examining how the outbreak has affected the sleep quality of medical staff is only now beginning to be published, the authors noted.

In the review, researchers pooled healthcare workers’ sleep-quality data during the pandemic, and sought to corroborate those findings with data collected from the Sleep Disorders Center of the IRCCS San Raffaele Scientific Institute, in Milan, Italy. One of these studies examined 1,563 medical staff members, finding that more than one-third were experiencing insomnia during the pandemic. That study pointed to drivers such as long hours in isolation, concern about being infected, a perceived lack of “psychological support” from social media, and very strong uncertainty regarding effective disease control.

Overall, researchers found that poor sleep quality among medical staff, which was already prevalent prior to the pandemic, had worsened during the COVID-19 outbreak. They concluded that, given the relationship between sleep disorders, cognitive disorders, and mental health, early detection of sleep disturbances among health care workers taking care of COVID-19 patients should be prioritized.  

Another study, published in Sleep Medicine: X in 2020, examined insomnia and physicians’ stress levels during the COVID-19 outbreak. Using the Athens Insomnia Scale to examine the sleep quality of a cohort of 268 physicians from different medical settings, researchers found that more than two-thirds (68.3%) of their subjects were experiencing insomnia and a vast majority were experiencing stress (93.7%). 

Evidence suggests that this problem is occurring across the globe. For example, a 2020 study published in BMC Research Notes, looked at sleep disturbances in a cohort of Saudi physicians during the outbreak. Researchers found that more than 43% of subjects experienced sleep disorders that were exacerbated by the pandemic. To mitigate this, hospital administrations should provide staff with sufficient breaks and employ more healthcare workers to ensure that staff aren’t working too many hours, they concluded. 

The fallout

Such widespread sleep deprivation can wreak havoc on another already-harrowing problem: physician burnout. Several studies, including a review published in Contemporary Reviews in Sleep Medicine in 2019, have linked sleep problems to burnout and ill effects on physician health. The review authors concluded that sleep deprivation contributes to burnout by leaving doctors in a state of chronic energy depletion, and by activating the hypothalamic-pituitary-adrenal axis and increasing levels of bodily stress.

Numerous studies have examined the effects of physician burnout on patient safety and healthcare worker safety, many of which were included in a review published in Medicina in 2019. After analyzing 21 studies, the review authors found that most of those studies demonstrated an association between staff burnout and a decline in patient safety levels. 

More recently, JAMA Network published a study that monitored the effects of sleep deprivation on clinically significant medical errors. Using physician wellness survey data on roughly 7,500 healthcare workers collected between 2016-2018, researchers found that moderate, high, and very high levels of sleep impairment were associated with increased odds of self-reported clinically significant medical error, by 53%, 96%, and 97%, respectively, when compared with low sleep-related impairment levels. These increased risks were still apparent even after the researchers adjusted their findings to account for burnout levels. They concluded that, not only is sleep deprivation associated with increased risks of burnout and decreased feelings of professional fulfillment, but that it’s independently associated with increased odds of clinical errors, which puts patients in danger. 

Getting doctors on the sleep train

In response to this growing body of evidence, the American Academy of Sleep Medicine (AASM) published a statement describing the “pressing need” to examine the role of sleep quality in physician well-being and burnout. The authors identified factors linked to sleep disturbances and burnout among physicians, including: high work demands, reduced control over schedules, increasing lengthy bureaucratic tasks, strained doctor-patient relationships, and financial stressors. Citing various studies on the subject, the authors urged researchers and policy-makers to explore possible mitigation options.

In the statement, Indira Gurubhagavatula, MD, associate professor of medicine at the VA Medical Center at the University of Pennsylvania and chair of the AASM Public Safety Committee, listed measures that healthcare employers could take to address this issue. These included: providing opportunities for rest breaks (ie, designated napping areas); offering counseling services for those who are dealing with stress-related insomnia; and ensuring that staff are educated on the importance of sleep for good health

On a similar note, the lead author on the aforementioned JAMA Network study, Dr. Mickey T. Trockel, suggested putting a limit on the length and frequency of extended shifts, lowering the number of successive night shifts or on-call nights, mandating rest breaks during longer shifts, and providing healthcare workers with melatonin supplements before night shifts. 

Some of the barriers to addressing this problem were uncovered in the findings of a review published in Current Anesthesiology Reports in 2020. Authors studied the history of physician burnout, along with present and future interventions. Aftering analyzing more than 150 articles, they found that most studies evaluating possible interventions—including stress management, exercise, self-care, better feedback and mentorship, peer-support programs, and mindfulness—were either of low quality or lacked long-term follow-up.

The authors concluded that, due to the quality of the evidence, “no specific interventions could be recommended,” and acknowledged that burnout is a “multifactorial problem requiring a multi-factorial solution.” They also noted that much of the literature focuses on “increasing resilience” among physicians, which places blame on the individual while failing to acknowledge systemic institutional problems. 

In short, while the evidence highlights sleep deprivation among healthcare workers, further research is needed to comprehensively address the issue. Mitigation will likely involve a combination of personal protection measures and concessions from institutions, which will need to offer more support to medical staff. Perhaps the deleterious impacts of the COVID-19 pandemic will prompt healthcare decision-makers to explore solutions.