What is it about sleep that is so special?

            Six months into my 3^rd year rotations and I continue to be amazed everyday with the unique ability of most humans to work through and ignore obvious physiologic signals trying to say that enough is enough, you need some rest! The current culture within Western medicine is centered around strength and fortitude, and more often than not, I hear individuals feeling the need to “brag” about the number of hours that they have been continuously awake, functioning, and “performing” the necessary medical tasks required.  Despite the work hour restrictions placed on resident physicians, the truth is they work long hours on irregular cycles, and inevitably, share amongst other residents/interns, a periodized schedule of night shifts.  Throw in the fact that the hospital is by no means a stress-free environment and one can quickly see that modern health care, as is carried out in most academic medical centers, is made for anything but health. Perpetuating the perception that working more means you are a better physician or that acknowledging fatigue and distress simply means your are too weak for this job is only doing the health care industry more harm. Stepping down from the soap box, I hope this evolving insight will provide a little context for the main topic of this post: SLEEP!

            The realization that sleep is an absolutely essential component of health is nothing new. I love hearing the hard charger’s mantra “I’ll sleep when I’m dead,” because the reality is, acute sleep deprivation WILL KILL YOU before dehydration or malnutrition stop your organs in their tracks. To put it in another way, you can survive longer without food and water (considering you are not completely exposed in Death Valley during the summer months) than you can without sleep.  For years, epidemiologists have been tracking, though numerous retrospective and cohort studies, the strong associations between sleep deprivation and shift work to nearly every pathologic disease process including: metabolic disturbance, cardiovascular disease and even cancer. So we know we need sleep to be healthy, but why suddenly does it seem like every holistic, functional and traditionally trained family doctor is urging his or her patients to make sleep a number one priority? Just as with most pathologic “disease” treatment within the current system, there isn’t a problem worth treating until it is incredibly DISABLING or LARGE ENOUGH to warrant the serious interventions we have studied and KNOW to be effective. As far as sleep is concerned, Americans have gradually been sleeping less over the past 50 years, such that, as a whole, we are now sleeping between 1.5-2 hours LESS every day. When you consider that the average individual needs from 7-9 hours per night, 2 hours of lost sleep from the average of 8 hours is a 25% reduction. That might not seem like a lot, but the scary reality is that due to the nature of our sleep cycles, cutting hours of sleep isn’t as simple as first grade subtraction.  One may disproportionately lose a greater fraction of restorative, deep, slow wave sleep in addition to compromising REM sleep, and establish irregular intervals of early stage 1 and 2 sleep. While this post is not meant to focus on the scientific and technical aspects of sleep, I do want to make it clear that when it comes to sleep 8-2 ≠6.

            So yes, since chronic disease is disabling millions of Americans and we are now aware that most Americans are sleeping significantly less than they should, sleep has become a problem worth treating. And of course, what do we turn to when it comes to treating insomnia or poor sleep: PILLS. Doctor Kirk Parksley has become one of the most prominent researchers, clinicians and advocates for recognizing insomnia and poor sleep as one of if not THE most important public health concern facing our nation- even more than the DIABESTIY EPIDEMIC that seems to get more media attention than the NFL in April. Poor jokes aside, the treatment of choice for insomnia and disturbed sleep is a class of drugs affectionately called the “Z drugs.” Structurally similar to the anti-anxiety/sedative drugs known as benzodiazepines, the “Z-compounds” which include: Ambien, Sonata and Lunesta are more selective for certain receptors such that they induce more sustained “sedation/hypnosis” than the traditional anxiolytic medications. Parsley comments; however, that the “sleep” induced by these “Z compounds” is entirely anything but actual sleep. The brain wave patterns (EEG) and overall polysomnography observed for people using these drugs resembles that of an unconscious zombie knocked out with a sledgehammer. The normal sleep architecture and pattern is non-existent and the idea of actually getting restorative slow wave sleep is entirely fictitious. To make matters worse, due to their chemical and structural “differences” from the benzodiazepine drugs, the “Z compounds” are considered to have no potential for dependence, abuse or addiction. If you ask Dr. Parsley or other clinicians specializing within the field of sleep medicine, they would laugh you off of the face of the Earth if you believed the chemists and pharmaceutical companies explanation of the drug's mechanism of action, risks and benefits. Working within the field of military medicine, and more specifically with  the Navy Seals, Dr. Parsley has commented in numerous blog posts, videos and podcasts the struggle to get soldiers off of their absurdly high routine dosages of ibuprofen, acetaminophen and Ambien. I have provided links to some of his best articles, his current sleep promoting supplement and a TedTalk regarding this growing problem below.

1.  Sleep Cocktails: http://www.sleepcocktails.com/

2. How we are wired to sleep; Part 1 of 3: http://robbwolf.com/2015/06/01/how-we-are-wired-to-sleep-and-why-we-have-sleep-problems/

3.  America’s Biggest Problem: https://video.search.yahoo.com/video/play;_ylt=A2KLqIIBB9lVGEAAvnEsnIlQ;_ylu=X3oDMTByZWc0dGJtBHNlYwNzcgRzbGsDdmlkBHZ0aWQDBGdwb3MDMQ--?p=Ted+Talk+Kirk+parsley&vid=2f2c30842bea0c0d6bd16679473cbf33&turl=http%3A%2F%2Ftse2.mm.bing.net%2Fth%3Fid%3DWN.A4obMSH3byr2mf3zehcCeg%26pid%3D15.1%26h%3D168%26w%3D300%26c%3D7%26rs%3D1&rurl=https%3A%2F%2Fwww.youtube.com%2Fwatch%3Fv%3D7s9C_8-OoxI&tit=America%26%2339%3Bs+biggest+problem+|+Kirk+Parsley+|+TEDxReno&c=0&h=168&w=300&l=1042&sigr=11bsa82ov&sigt=11n4t4ags&sigi=12lumiqq9&age=1410188665&fr2=p%3As%2Cv%3Av&fr=yhs-mozilla-002&hsimp=yhs-002&hspart=mozilla&tt=b

So now that we know that these medications are clearly not the answer, what exactly should the average American focus on to improve their sleep? Rather than try to re-invent the wheel, I will provide you with links to some of the best resources, education, advice and programs for improving sleep. Obviously, there are hundreds of ways to go about improving sleep hygiene from modifying your daily habits to taking supplements, and I have tried to provide a selection of resources from some of the best practitioners and researchers currently available across this spectrum. In my next post I will share my own experience and experiment with sleep during a few weeks of night shift work during my pediatric and obstetric rotations. Enjoy the reading and watching, but more importantly get some better sleep!

Reference and Resources

1.  Sleep Habits for Shift Workers

“Surviving the Night Shift” Nom Nom Paleo:  http://nomnompaleo.com/post/55156756199/surviving-the-night-shift

2.  Sustainable Behavior and Habit Change

“Dan’s Plan” Dan Pardi

https://www.dansplan.com/company/company-information/our-team

3.  Alternative Medication for Insomnia

“Sleep Cocktails” Dr. Kirk Parsley and Robb Wolf

http://www.sleepcocktails.com/pages/product

4. Understanding Sleep

“How Much Sleep Do You Need?” Guest Post by Dan Pardi- Chris Kresser’s Revolutionary Health

http://chriskresser.com/how-much-sleep-do-you-need

5. Sleep Hygiene

“Sleep” Guest Post by Evan Bran- Paleo Mom

http://www.thepaleomom.com/2015/02/guest-post-evan-brand-sleep.html

A Poet Reborn

Sometime in seventh grade (~2003/2004), I remember writing somewhere around 40 poems in 2 weeks for 2 english/reading/literature classes. From English sonnets, to free verse, haiku's, it was simply too much for a middle school mind to handle. Fast forward over 10 years and it seems the seeds of the poet planted by my amazing grandfather have finally be watered and are starting to grow. There has been nothing better than writing a thoughtful poem after a long day at the hospital, or better yet, on the walk into work in the crisp summer morning. I have provided a few of my more mindfully oriented pieces below and will continue to add at least one poem each week. Maybe a weekly Saturday poem is just the thing to share with the welcoming world.

Photograph

 6-3-2015

What is a photograph but a poem without words

Cursed without a voice, but blessed by the majesty of sight

The colors dancing upon my eyes, speaking a different language

Shadows, contours, reflections whisper in my ears

It takes more than silence to keep a picture from speaking

 a thousand words

Compassion

6-25-2015

Gratitude

We share our thanks

Positivity

We share our optimism

Caring

We share our thoughtfulness

Truth

We share our honesty

Acceptance

We share our understanding

The recipe for compassion is rather simple

All it takes is a little belief

Into how beautiful

The human connection

Can truly be

The Flame

7-16-2015

We all carry a single torch

At the center of our being

It is our eternal flame

Forever burning

Even after our physical form

Has passed

Nurture your fire with friendship

Let the light show you

What it truly means

To be nourished

Give from your source

And receive the gifts from all those

Willing to connect

Eternal being is not the same as

Always giving

Or

Perpetually receiving

We must seek to be

The wick when another is burning out

The light when a torch goes dim

The strength when only smoke remains

Blessed we are

To have courage

To let our fires burn

Under the care of another

Let vulnerability and compassion

Be the sustenance

To your flame

And you will never be worried again

By the question

Of when your embers

Will finally go out

Pediatric Medicine for Adults?

         Having recently completed a 6 week rotation for Pediatrics, in which I saw numerous children from the 2-hour newborn to the 18 year-old needing a sports physical, I was quite impressed with the depth of knowledge required to be a pediatrician. I often joke with my brother's girlfriend, who is a veterinary technical assistant, that being a doctor should be simple, you are just responsible for one species. When it comes to taking care of kids, however, the idea that they are all Homo sapiens somehow is just too hard to believe. Developmentally complex, children can be categorized by certain physical and cognitive milestones, but in reality, this is just a snap shot reflection of the person they currently are, and may have no bearing on the adult they will become. Nurturing and caring for our youth is something near and dear to my heart. Having grown up with all younger cousins, I literally saw the growth of my relatives from diapers, to tricycles and rec soccer, to finally graduating high school and moving on to college. If I were to tell you that the most important part of their physical maturation was constant oversight from a pediatrician via well child checks, sports physicals, the occasional visit during a tough cold, or getting comfort for some bumps and bruises and that really weird rash, you might think this to be a grand overstatement. But take a closer look and what you might find instead is a relationship of trust whereby the pediatrician or family physician nurtured the growth of a child by being a positive presence, someone who cared.

         After observing several visits with UVa general pediatricians, it became very obvious that the majority of our discussions revolved not around an illness or presenting complaint (even if there was an acute problem), but on how a kid was doing in life. What sports did they play, were they involved in dance or art, how much were they sleeping, did they have any problems with their diet- too much candy, food intolerances, not eating enough vegetables, binging on ice cream and Chinese food, how was life at school, did they have close friends, if they had siblings what was their relationship like, did they get to travel to another state or country, what did they want to do when they grew up, what was the coolest thing they had done in the past week? Taking a history was so far removed from asking about quality, duration and onset of pain, or reciting a laundry list of questions for a complete review of systems. Even when these components where required as part of our visit, it was accompanied by discussions about total well being: social, spiritual, physical, and emotional.

         As vulnerable as I have become during my years of medical school, I often tell people that I see a psychologist every 2-4 weeks for an hour at a time to simply talk about my life, review my well-being and make sense of any thoughts or doubts that are going through my head. While this relationship works for me, what I encourage of everyone is to find that person in your life with whom these types of discussions can occur, completely safe, secure and free of judgment. It certainly does not have to be with a trained psychologist or even a family member or friend, the arrangement and sense of true acceptance are all that matters. In thinking about the pediatric visits, it became clear to me that maybe this dynamic was being shaped without even the child, family or doctor being aware of the development. Through thoughtful and meaningful interaction over a period of time, the pediatrician could become a trusted presence in a child’s life such that the cultivation of positive well-being and the adoption of self care practices could actually develop. We all want to be happy, healthy and at peace with our true nature. Sometime illness, negative thoughts, and unexpected life events can cause upheaval in this balance. While I always want to know that I have people in my life that I can turn to when times are difficult, I ultimately want to know that I have the tools and personal resiliency to face any challenges, all the while with my support team waiting in the wings to catch me should I stumble.

         Being a pediatrician can be so much more than simply being the kid doctor. As physicians of adult patients, it can be rather difficult to see where we fit into the patient’s idea of wellness and day to day self-care practice. Often we get derailed by discontinuity or lack of communication/connection with our older patients, yet this is not an excuse. A recent Ideas and Opinions piece from the May 19^th, 2015 issue of Annals of Internal Medicine entitled “Balloon Animals, Guitars, and Fewer Blood Draws: Applying Strategies From Pediatrics to the Treatment of Hospitalized Adults” sought to showcase how we can improve care in the hospital for adult patients by utilizing a pediatric approach. While the article was creatively original as well as practically relevant to our current health care system, it got me to thinking: “What if we combined the pediatric approach with the holistic model of personal well-being and applied this in the outpatient, functional environment, away from the hospital? As I have said many times before, the hospital is all too often the home of sick care while true preventative holistic medicine conducted at the home is healthcare, so why not spend more energy changing the way we care for adult patients outside the home, than continuing to reform and revamp an institution that routinely fails to provide health and vitality to the majority of people seeking aid. I am never one to discredit the value of hospitals, and certainly do not want to come across as someone who views the thoughtful Annals article as misguided, I merely want to suggest an alternative use of our time, energy and resources. Sure, my kind of hospital would look a lot like the one described by Michael R. O'Brien, MD; Marjorie S. Rosenthal, MD, MPH; Kumar Dharmarajan, MD, MBA; and Harlan M. Krumholz, MD, SM, but I also see something more, a new frontier for medicine, a replacement for the hospital when one needs just a little more care than what is realistically achievable while living strictly at home. Just maybe, with the help of a few friends and many years of hard work, we might just see the creation of a new healing institution that truly embodies what it means to provide Healthcare.