5. Understanding and Optimizing Sleep

Sleep science and sleep hygiene are discussed to optimize routine, brain and body recovery.  Reading and References: Peak Performance, Essentialism, Think Like a Monk.

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So one of the really important strategies for preserving brain power and optimizing our time and routines, as well as our overall function and performance in daily tasks, is going to be through good sleep and sleep hygiene. And just like understanding the dimensions of time, space and routine, we've got to understand our chess pieces or our basics of sleep, before we understand how to improve our sleep, hygiene, and good good sleep health. So just to start with some sleep basics, each person has an optimal sleep cycle based on their age and genetics, right, and that refers to when you go to sleep, as well as how long you sleep, and this will change with age, then one of the really important concepts that we're going to discuss is that a little bit of sleep is not a badge of honor. Many of us grew up in surgical training programs, where sleep was a little sleep was considered a badge of honor, right? Oh, you stayed up all night long when you were on call, or alternatively, oh, you went to sleep, or you got to go home? Well, you missed out on these cases or these opportunities because you weren't awake and in the hospital. But I would say the opposite. Not giving yourself the time to sleep, and sleep in a healthy fashion is a failure of self respect and a failure of priorities. And what we're going to talk about is how little sleep reduces productivity reduces the quality of that productivity. And while early in our surgical training and surgical careers, we may we may have been under the false assumption that being exposed to more and staying up and seeing more may have been a better education, we may have been much better educated if we will route well rested and intent on shorter periods of time in the hospital or in hospital based activities. There are both mental and physical benefits to sleep, the mental benefits for sleep are first understand that this is where our thoughts and emotional experiences are assessed, consolidated and retained. There's a incredible body of literature based on this. And we also know that sleep will help with impulse control as it affects decision fatigue. The physical benefits of sleep allow us to shift from catabolic states to anabolic states, driven by once again testosterone in HCG to help our muscles and our brain and our other physical structures recover over the course of an evening. And there's some data to say that 20 to 30 grams of protein intake prior to sleep may improve protein synthesis overnight, I would tell you, there's very little data to support that. But there's definitely some circumstantial data to indicate that that may be helpful. So why is it really important for our brain to recover? So the prefrontal cortex is the front of our heads, right? That's 30% of our cortical mass is the part of our brain that works, quote, unquote, hardest during wakefulness. And this is measured by the highest metabolic rate on functional MRI studies. But even when we are relaxed, or sleeping, this part of our brain is consuming 20% of our metabolic energy. And this is due to a concept called the default mode network. And this is basically the physical structures are in the midline of our prefrontal cortex and post cingulate cortex, the node basically connecting the limbic system to our cortical system. And this is the area where baseline neural activity and memories are stored, where we generate a relation to self or who we are based on the experiences and the thoughts we had. And importantly, a lot of this association, and the default mode network occurs during sleep. And so just to get some sleep basics sleep goes through, we have four phases of a sleep cycle, and then REM rapid eye movements. And so in stages three and four of not non rapid eye movements. This is where mental and physical processes actually slow down. This is where we experience a physical restoration in our muscles and in our brain. And then during rapid eye movements, or REM sleep, our brain is incredibly active. This is where we achieve mental restoration. This typically happens in 90 to 120 minutes cycles, once again based on the individual and their genetics. And our REM cycles tend to accumulate by the end of the night. So typically, we have one or two cycles early in the night and then can have more dense or important REM cycles later in the evening. So the science of sleep, we already talked a little bit about sleep can improve self control, and we talked about this through decision fatigue, but there's a number of other studies that basically basically show well rested individuals have better self control in better outcomes in a variety of studies. We also know that anabolic anabolic hormones are increased during the first hour of sleep and associated with REM sleep, particularly testosterone and human growth hormone, increased Protein Protein Synthesis, to facilitate physical repair. While it's never been shown that protein intake prior to sleep can improve these outcomes, it is certainly been shown that protein synthesis does increase in this period. So feeding yourself protein before bed may help. We also know anecdotally that sleep disorders are associated with testosterone deficiency in men once again may not necessarily be causal, but we certainly see this association and for HGH, 75% of HGH is released during sleep at night. And most people experience a burst between 10pm and midnight based on circadian rhythms, and the sun more so than their own sleep cycles. So getting to bed early can actually help tremendously, with HGH release and physical recovery during sleep. And lastly, REM sleep or the duration of REM sleep increases with each sleep cycle, and it's maximized in the seven to nine hour range. So to achieve those mental benefits of REM sleep, you really want to be asleep for seven to nine hours. So that concept of Oh, maybe I should get a little bit more training or stay up a little bit later or work a little harder at the expense of sleep is actually counterproductive, productive, because your your ability to assimilate that information and incorporate what you just stayed up to learn is ineffective, and inefficient. And it brings us to the concept of sleep deprivation. And there's a number of important studies here. One by Wagner at all in nature, took 100 volunteers give them either eight hours of uninterrupted or interrupted sleep, and then gave them basically in a number puzzle with a with a hidden code within it. And the uninterrupted sleep cohort was able to find the answer more than twice as often as the sleep deprived group. And they were able to conclude that the brain encodes and restructures information while we are sleeping. And a similar study in PNAS looked at a single session of REM sleep, and were able to show that this enhances the integration of unassociated information. And there's a classic study of Tetris insomniacs, where the skills of the game were better incorporated in subjects who slept versus those who did not despite similar hours of active play. So really, when we're sleeping, and when we're undergoing REM sleep is when our brain is pulling together information and data in ways that we wouldn't normally consciously doing it. This is when our subconscious is at its highest. And so it's generally assumed that for demanding and motivating conditions, sleep deprivation has little impact, right? And we like to think this in medicine, right? When we're doing complex skills, or something that's really interesting, or something we haven't seen before something that's variable. Sleep deprivation may have a little impact. But what's important to recognize is that the more and more we do a task, and while it may be complex and interesting this time, the next few times we do it, it becomes less complex, less interesting, and it is much more vulnerable to sleep and sleep deprivation issues. So Dr. Charles Eisler is a professor of sleep medicine at Harvard. And he has equated sleep deprivation to blood alcohol intoxication. And has basically shown the with even moderate amounts of sleep deprivation, you'll have lack of focused attention, increase the visual and auditory distractions, you'll engage in risk taking behaviors have uninhibited mood and mood behaviors, loss of memory, poor insight into your own self performance and less effective communication, the equivalent to a blood alcohol level of 0.1%, which is pretty intoxicated. Very interestingly, from army data at 36 hours of, of continuously being awake, critical tasks and innovative thinking deteriorates. And this has been seen in Battlefield studies, in studies of from the fire and other battlefield issues. And if you look at some of our major world catastrophes, Chernobyl the challenger incident, a number of plane crashes, they all had a decision making that was potentially impaired by sleep deprivation France Since, while they weren't necessarily the exact cause of the incidents, the Chernobyl incidents was preceded by poor decision making in the early morning two or 3am. The Challenger incident once again, a decision made early in the morning or late at night to proceed with launch in poor weather conditions. Were not necessarily the cause of these terrible events, but certainly contributed to them. And when we think about sleep and medicine, particularly, we know that fatigue can affect performance, and performance of physicians and this can happen in patient care. This can happen in self injury where car crashes are much more common. F and sleep deprived individuals coming off shifts, and it can also affect mood and burnout. And while we said that sleep varies among individuals, and is genetically determined, it does not change with age, and it cannot be trained. But physicians don't believe that, and we don't believe it by our actions. Very few physicians are really aware of their own fatigue, and how that impacts their behaviors and their outcomes. And interestingly, things like caffeine or adrenaline are getting pumped up. They can help with alertness, but they don't really help with any of the underlying physiology of sleep and sleep deprivation. Importantly, as many of us know, from firsthand experience, sleep deficits can be restored by extended sleep on sleeping days. So for instance, you had a long call shift you worked really hard this week, well, you can make up for it on the weekend and restore yourself to normal thoughts and a normal non deprivation deprived state. Interestingly, individuals have very little ability to determine how sleepy they are, or if they have fallen asleep. And this was shown in a paper in the Academy of Medicine, where individuals were more likely to perform critical tasks when tired, and they were less likely to use countermeasure strategies to avoid fatigue when they were tired. So it's important to recognize when we are potentially sleep deprived, because those symptoms or signs may not be readily apparent to us. And we can potentially try to avoid really critical decisions, or we can rely on others to help us make those critical decisions. And we should be planning for restorative sessions where we can get our mind right, get our sleep back to cycle and get ourselves back to effective decision making. There's a couple of studies that are specific to sleep and surgery. There's kind of a classic paper in Lancet 1998, where it was a surgical laparoscopic simulator study, where basically surgeons who did not sleep and made 20% more errors and took 14% longer to complete tasks on a laparoscopic simulator. And a study of anesthesiologists or anesthesia residents latency latency response was greater in those who were sleep deprived, it probably didn't translate into clinically significant outcomes. But you could measure differences in latency of response. And so how should we fight fatigue? And how should we fight sleep deprivation? Well, the first thing is preventing it right? So optimize our scheduling, know your own circadian rhythm, your own chronotype as we talked about in time awareness and time management and one of the earlier podcasts, scheduled rest periods. And for all the physicians and residents out there follow the acgme recommendations, there's a reason those recommendations exist. They're based on the best available scientific literature about sleep, sleep deprivation, patient outcomes, and decision making that was available when they were created. And new data has come about but they haven't changed the recommendations that much. Hence, why the recommendations themselves haven't changed. We can certainly fight fatigue by improving our sleep habits and we're going to get into how to do that. naps of 15 to 30 minutes are excellent to combat fatigue. And importantly, strategic stimulant use. So whether that's coffee soda, a little bit of caffeine, light therapy, meaning getting outside seeing the sun, or even social interactions, seeing colleagues, friends, picking up the phone and talking to someone will actually help overcome some of the downsides of fatigue. And so when we think about sleep, hygiene, sleep hygiene actually starts with proper waking starts with how you start your day evolves into your daytime habits and lastly, into your sleeping routine. How do you put yourself to bed but I think really important here is that you don't want to Turn sleep or sleep hygiene into an ideology. Right? It's not an exact science, you want to come up with routines, but you don't want to put too much weight in this. If you do, it can create anxiety and stress that are counterproductive, especially if you fail to meet your ideal sleep routine. So how do we start with proper waking? Well, first thing I'd say is start with a good wake up plan or routine allow your mind to wake up slowly. As we talked about in prior episodes, this helps preserve mental function for the more important decisions you're going to need to make throughout the day. But it also allows you to ease into your day, I'd recommend waking up early. Now, obviously, I am a lark and not an owl. So I enjoy waking up early in the day. But a good point here is many people think they're owls who are not. And many people who are not als will also stay up late for useless reasons, I really want them to see that Netflix show, I just wanted to read a little bit more about this. But you'll refuse to wake up in the morning for good reasons. So for instance, I'm going to stay for an hour and binge this other show. But I'm not going to set my alarm an hour earlier so that I can go to the gym and workout. That doesn't make a lot of sense if you really think about it. And if you wake up early, it will facilitate you going earlier to bed that evening. The other really important thing that we've talked about already is don't look at your cell phone, your brain was not made to go from zero to 60 miles per hour, it's not ready to process tons of information within minutes of waking up. So when you add together an alarm and a phone, you create a state of overwhelming stress, anxiety and pressure for your brain. And it sets a poor tone or poor intention for the rest of your day. So in the opposite, start your day with intentional tasks. Right? Give yourself a little bit of extra time in the morning. So if you wake up and you've timed your alarm and your wake up so that you just have enough time to get to work. You're setting an intention for the day that you're going to rush through your tasks, you're going to struggle to meet your goals. Give yourself 510 1530 extra minutes in the morning, enjoy your coffee, watch the sunrise, do yoga or mindfulness to get your body and your mind set an intent on well being for your day. Throughout the day, you really want to take advantage of circadian rhythms which are based on sun and sunlight. So get if you can natural light throughout the day, really hard in the hospital really hard for surgeons. But try to get as much natural light as you can limit blue light at night right these are from our screens and our computers and our laptops. Once again tough with our lives, but when you can exercise exercise vigorously, even if it's 15 minutes or half an hour doing vigorous cardio. Getting a little bit of sweat going helps facilitate that circadian rhythm and helps you sleep better at night. You want to limit your caffeine later in the day, particularly five to six hours before bed. We all have different tolerances for caffeine and metabolize it at different rates. But I would say safely no caffeine after dinner that will help you sleep better. You want to limit your alcohol in addition, and while alcohol may hasten sleep onset, it can disrupt sleep at later stages or later cycles for a variety of reasons. Simply, it can make you get up in the middle of night to have to use the bathroom and disrupt your sleep cycle. You also want to be conscious of what you're eating so high quality fats and proteins. These are animal fats nuts, avocados, for instance, prevent the need to eat prior to sleep which we typically fill with carbohydrates and higher calorie treats which are not good for us for a variety of reasons. So you want your digestive system relaxed, you want your brain relax, going into sleep. So eat a good dinner full of high quality fats and proteins. And you want to avoid if possible, stressful physical and mental activities after dinner. Try to fill that part of your evening with the more mundane, such a routine for the next day. If you journal it's a great time to journal or write. It's a nice time to read. It's a nice time to spend time with your kids and your family. And while mid afternoon naps are totally acceptable, you couple of key points here you don't want to nap for more than 30 minutes. It will put you into a deeper stage of sleep and will make it more challenging later to fall asleep and can also make it more challenging for you to wake up and be productive after that nap. And mid afternoon nap has been shown in a variety of clinical settings to be as effective as caffeine, or more effective in some circumstances for achieving good outcomes and fighting, fighting off fatigue and poor decision making. And then the last Part of sleep hygiene is that you want to end your evening with a routine that facilitates restful sleep. And to go back to the morning, when we wake up before our bodies are ready, Melatonin is high and it sets us up for sleepiness throughout the day. So getting good restful sleep and getting to bed early prevents that melatonin kind of sagginess the following day. So how do we set the mood for sleep? Well, we talked about routine, we talked about time and space. So your bedroom should be set up for sleeping, it should be dark. It should be calming, minimize your electronics, you want to sleep in sleep clothes, right? We work in our work clothes. So have a sleep routine, sleep clothes that you sleep in. All of this works to set a tone and set an intention and condition ourselves for quality sleep. We really want to minimize electronics. Remember bed is for two things, sleeping and sex. Good Book is a very reasonable thing to bring into your bed. But you don't want to be eating, you want to minimize the amount of TV you're watching in bed. And remember that TV and phones emit blue light, which really can affect circadian rhythm and stimulate our brain. There's really good science out there about this. But they're looking at one study that looked at ebook readers. Subjects after just five days of reading with an E book versus a paper book, they, they felt less sleepy, they had longer sleep latency. And they had a 90 minute delay in there melatonin release. And there are a number of if you like your electronics at night, or if you like reading via electronic and night rather than a book, you can now get apps some of which are free. These apps change all the time, but some of them are night shift red shift red moon. And what they do is they filter out the blue light that comes from your screens, and helps facilitate a more healthy sleep pattern. Other things you can do to get for good sleep hygiene is reduced the next day's anxieties. So you can create a to do list I would say no more than three things that you want to do, either as priorities throughout the day, or three things that you want to do before you even pick up your phone in the morning, I'm going to do a, b and c before I delve into the work day, pick up your clothes the night before you can do mindfulness exercise is a great time to visualize, particularly for surgeons, if you're gonna do a big case, the next day visualize what you think is going to happen in the operating room. Meditate, there are great sleep meditation, practices and apps. And it's a great time to journal. I've started creating a diary, or I have kind of three steps. The first is a gret, I write a piece of gratitude from the day, I do my to do list of 123 things that are priorities for the next day. And then I write very brief diary of things that happened through the day. I don't write a lot, or typically bullet points, but things that were particularly insightful or memorable from the day. Sometimes it's something I did with my children. Sometimes it's something I learned from work or an experience I had. But this process not only allowed me to reflect on my date and learn and internalize my day. But it also sets my mind up because it knows after I do this, I'm going to bed. And the last thing I'd say is aim to sleep between eight and 10pm. At night. This is when our HGH impulses are the highest it maximizes our REM sleep for later in the night, seven to nine hours from now. And obviously this is based on your individual schedule and how you wake up and your own cycle. But these are really important things to consider. And in the book essentialism, Greg McCown talks about protecting the asset. And our best asset is ourselves. And in the beginning of this podcast, we talked about our brain and brain power is a great asset, what our entire body and it can be considered the asset. And the real challenge for many of us, particularly in the fields we are in is not working overly hard. How do we step back and allow our body and mind to recover and rest so we can be maximally efficient the next day? And one of the great points that Greg McCown brings about is, we know the 10,000 hour rule from Malcolm Gladwell his book, right? Yes, purposeful time is important. But one of the secondary outcomes from those original studies was that the second most distinguishing feature between the expert violinists and all others with the amount of sleep they got, experts slept more at night, experts nap during the day, they were fully charged, they were ready to work and perform when it was their time. And so these are all ways we can protect our assets. And the last thing I would say is talk about these things with your colleagues in medical and medical rounds. We should be talking about these things in Grand Rounds. in corporate realms bring about them in in meetings and board meetings. Right, but greater creativity, enhanced productivity, all happened with improved sleep hygiene. In addition, it actually improves health care costs. And all of those things can affect the bottom line. So if you don't buy into the mindfulness portion of good sleep hygiene and the kind of soft data about brain power and efficiency, maybe the fact that this will improve your fiduciary outcomes through better creativity, productivity and lower costs, maybe this is the reason to consider good self self sleep hygiene, for yourself and for your colleagues. So to wrap up this episode, what I would say the important points here are brain power is under appreciated and often underutilized. We should learn to recognize and try to avoid decision fatigue through good habits and good routines. We want to learn how to tap into the power of the subconscious. How can we use that use that loose processing in our brain to help us achieve better solutions than we could through powering through conscious thought. And sleep is a key to our maintaining our brain power. Right? We talked about myelination in that transition from type two to type one learning, but the streamlining of our processes and the streamlining of our routines occurs at night. And sleep deprivation influences our ability to make quality decisions. And lastly, protect our asset protect ourselves by understanding brain power, and sleep. Thanks for listening. And so in the first few episodes here we discussed time space routine as the first dimensions that we need to understand and master and how brain power and sleep are part of optimizing those dimensions. In the next few episodes, we're going to talk about the dimensions of self, particularly physical and mental well being how do we generate our concept of self purpose in life, burnout, and we'll touch on meditation and a variety of others. Thanks for listening