Sleep Reform for Physicians

Part 1: Self-Advocacy

My phone chimed on the bedside table, and I pulled the bright screen to my face. It was 3:17 a.m., and a patient with severe pneumonia and graft versus host disease needed a third pressor. I put the order in on my laptop next to me and rolled over.

It was day five of seven of home call as a fellow, and my role was to work all day then cover the Bone Marrow Transplant Unit overnight, along with hematology oncology needs across several other hospitals and patient calls from their homes. Because the pandemic had ramped up the volume, from 5 p.m. to 7 a.m., I would get anywhere from 20 to 50 pages.

By the end of the day, I needed to steal sleep wherever I could. I decided to stay at a local hotel that night to cut out my commute. I pulled the white duvet over me, and just as I closed my eyes, my phone chirped again. Another patient wanted an order for Pepto Bismol. Five minutes later, it was a call from the lab: GNRs growing in blood cultures. I navigated to the patient’s chart to confirm he was on antibiotics with broad enough coverage.

My nose was running again, a virus trying to take hold on my immune system that was compromised by chronic sleep loss. All week, I’d only gotten one to two hours of sleep each night. 

As the midnight hours dragged on, the pages continued. A patient needed a blood transfusion. Another had a critically low potassium. One had a heart rate of 44. Several patients called from home with symptoms and asked if it was safe to go to the ER. Could they take aspirin? What could they do for severe heartburn?

By 6:12 a.m., my brain was foggy, my eyes burned, and yet it was time to start my way to the hospital. I sat on the edge of the bed and waited for my body to stand as my stomach turned with nausea.

A wave of heat rose to my face and my throat tightened. Inside my head, a voice was growing louder. It was the one I rarely listened to: my own. This is not just a difficult call week, this is unsafe. It is completely unethical. This isn’t how humans should be treated.

I swallowed hard, and within moments I knew what I needed to do. The patients I was caring for that day in the hospital had a full team: An intern, a resident, and my attending physician. They would be fine without me, but if I kept going like this without sleep for the sixth consecutive day, I was worried I might collapse from fatigue or make a critical medical error.

Deep down, I knew that if I wasn’t going to advocate for myself, no one was going to do it for me. So I pulled out my computer and slowly crafted an email:

Dr. R,

Because of Covid, overnight call has been incredibly busy. Patients are afraid to go to the ER, and they often call with updates in their symptoms multiple times overnight requesting advice. I’m also receiving a higher volume of calls from the ERs.

Last night I received more than 45 pages, and despite staying in a hotel and lying down at 6:30 p.m. on, I received just over 2 hours of fragmented sleep.

The ACGME says home call “must not be so frequent as to preclude rest,” and I believe this week the volume of calls has truly precluded rest.

This fellowship is very important to me, and I want to perform at a high level. I do not think it is good for patient care or for my health to work all day in addition to all night without rest, especially when my daytime responsibilities are supportive in nature. With this volume of overnight call, I find it reasonable to be excused from daytime duty hours. I’m willing to find any workable solution. 

Thanks again for your support.
 

The old familiar thoughts crept in as I stared at the text: Don’t be difficult. Just don’t complain. If you send this, you’ll look weak. They’ll think you can’t cut it.

I sat there for a moment just staring at the screen. It wasn’t the first time I’d drafted a similar email. In residency, I crafted one to a psychologist when I had suicidal thoughts but never had the courage to send it. I knew that if I waited another moment, this text would sit forever in draft email purgatory, too.

I took a deep breath and quickly hit send. Immediately after, my stomach dropped as I gazed into the dark room, convinced I’d just made a career-ending mistake.

Thankfully, my attending’s reply came within minutes and was a single line. “I agree completely.”

Relief washed over me as I collapsed on the bed, and I slept for the next ten hours. When I woke up to cover the overnight services again, the hospital was still full, my phone still chimed continuously, and home call was still incredibly hard. But something in me had shifted. I had finally put the truth in writing, and it hadn’t ended my career. It was as if a knot had loosened, just a little, when I thought it was impossible to untangle.

Over the next years, I kept working to loosen the knot. It happened through taking a deep dive into the data on sleep deprivation, continuing to have conversations and build relationships with program leadership, and addressing barriers to make changes in our program that I’d previously thought impossible. I advocated for myself and others trainees, and in doing so, I learned that my efforts weren’t a detour from being a good doctor but a part of becoming one. 

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Stay tuned for Part 2.

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