Turi McNamee says that shelling out $1.6 billion to let doctors sleep more is too expensive in our current straitened circumstances. Au contraire, I think it's a bargain.
I am a gold medalist in the macho Sleepless Working Olympics. I once worked a 60-hour shift without sleep. (Yes, that's 2.5 days without any shuteye.) One stormy February, I put in 468 hours, almost 120 hours a week for four weeks straight, sleeping an average of less than 4 hours a night. I have enjoyed all the exciting side effects of prolonged sleep deprivation, like uncontrollable "microsleep" which once almost caused me to walk into the path of a cab, or the hallucinations that set in after 48 hours or so--not fun hallucinations, either, just long conversations with co-workers who turned out to have left the building hours or even days before. I was essentially dreaming with my eyes open.
So I know whereof I speak when I think about interns training on gruelling regimens. And you know what I learned on all those sleepless nights?
Well, actually, not much. It turns out that adequate sleep is crucial to memory formation. But I did manage to process and retain one fact: when you have not had enough sleep, you. are. stupid.
Your attention span shortens. Your decision making process slows down to a crawl. Your emotions fray--towards the end of that fateful February, I burst out crying when I learned that the delivery of a hot-swappable backup drive had been delayed. In fairness, that drive was the only thing between me and going home to sleep.
That's probably the most pernicious problem: on the margin, you start making decisions based on how quickly they get you back to bed. If wretches have hung that jurors might dine, how many patients have gotten shoddy treatment that interns might sleep? The answer is surely not, as we might hope, "none".
The value of a human life is generally placed at $5-7 million by regulatory agencies. If letting doctors sleep more saves only 230 lives a year, it's worth it. Moreover, since you can't learn well when you're tired, we might save many more, by training up doctors who actually remember what they learned as interns.
I understand that against this, you have to set the benefits of continuity of care. But there's a funny thing: if continuity of care were really that great, attendings would only have four days off a month, instead of the sybaritic five or more that McNamee is deploring. Most doctors I know work really hard. But they don't work a lot of 36 hour shifts, and they don't think that two weekends a month off is the height of decadence.
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My experience with sleep deprivation came after giving birth. Newborn babies don't sleep for long; and neither do their parents (or mostly their moms, truth be told.)
I'm convinced sleep deprivation, in this instance, is a crucial biological feed-back loop. Caring for a newborn is not intellectually stimulating; it's boring. Particularly in those crucial first few weeks as the child's senses awake and the begin learning to respond. The mother's sleep deprivation-induced stupidity allows her to be the warm body (with attached food source) in those first early months. (And mom's who couldn't stand the sleep-stupidity of the first months were already deselected from the herd, since their babies didn't survive.)
But dammit, by five months, those babies ought to start sleeping at least one 7-hour stretch in the night. Anything else is a threat to your sanity.
And I don't particularly want my health-crisis being handled by some insane, sleep-deprived resident.
I don't know the specifics of the plan, but I do concur with Megan. I can't imagine that there are many people here who haven't been sleep deprived to the point of hallucinations. Studying for tests, having a sick kid, being in the service, jet lag - I'm guessing the most people here have gone past 48 sleepless hours, if not a lot more.
And, yeah, you hallucinate.
I'd go a step beyond saying that you're stupid - I'd say you're dangerous.
Doubly so if your job involves providing direct care to other human beings.
One way or the other, even if it's simply tracking their rest periods and penalizing them if they don't, care-givers have to be rested.
We do it with truck drivers and pilots.
Doubly so if your job involves providing direct care to other human beings.
Exactly.
As a computer programmer, I'm around twice as productive on the days that I'm well rested (8+ hours of sleep) vs. days that I'm not (5 or less hours of sleep). That's not even counting the time dedicated debugging + fixing defects that turn up in the code written when I was tired and couldn't think of all the corner cases.
These days, I don't even bother coding the hard (kernel-type) stuff when I haven't gotten enough sleep. I'll catch up on administrative tasks or write documentation.
A-HA! That explains why we can never follow your documentation...
;)
I'm an aerospace engineer by education, and a code monkey by vocation. I second Stan's observation. Our company caps overtime at 64 hours per week, as in total hours worked. You need a waiver to go above that. Really, that's about as much productive time as you can work in a week.
In my opinion, in an 80-hour week, you spend hours 60 through 80 fixing what you'd screwed up in hours 40 through 60. So you may as well have gone home at 40 and saved yourself the aggravation.
I remember my pre-med friends in college all attempting to justify the sleep deprivation thing with some version of "well, if you can't stay awake for two weeks at a time, maybe you just aren't TOUGH enough to be a doctor!" Now that they are all doctors or residents, they admit that the whole thing is a sick function of hospitals not having enough funding to hire enough residents, and it needs to stop. I think this is one of those things people will look back on in 20 years (or hopefully 5-10) and wonder how people were ever stupid or crazy enough to let it happen.
One of my Jewish friends became Orthodox during his residency for the confessed purpose of being able to rest at least one day a week. No joke.
Your pre-med friends actually had a point the first time.
I grew up in a doctor's family. Let me assure you there is a reason for the ridiculous training they get: because that's how their life is going to be.
Sure, there are specialties where you can work 9-5 and take Thursday off for golf. And if that's what floats your boat -- go for it. But there are also plenty of medical specialties where you will spend the first 20 years of your practice working 80 hour weeks, staying up with a critical patient for 2 days straight, working Christmas Eves and Thanksgiving Days, etc. THIS is really the life of a good doctor.
Doesn't that sort of beg the question of why, exactly, those doctors are working such long hours? I'm with Megan as to whether someone who has been up for 2 days straight can possibly be a "good doctor," and I simply don't WANT a doctor who has been working 80 hour weeks for 20 years. I get it that there are some medical procedures where you simply have to power through because if you stop to take a nap in the middle of say, separating conjoined twins (to take an extreme example) your patient is going to die on the operating table. But if a doctor can't take a few days off to recuperate after something like that, then there is something wrong with the system.
People have varying degrees ability to cope with these kinds of work hours. I can't, or don't want to, and therefore have self-selected into a subspeciality that doesn't require 80 hrs/wk for 20 years. But I know very good pediatric surgeons who can and do work these kinds of hours all the time. It's like being a marathon runner; some people can do it, and most can't. Pediatric surgeons generally like what they do and don't want to do anything else; why deprive them of a job they love, that's helpful in a societal sense, and that they are perfectly capable of doing?
You may not want a doctor who has been working 80 hour wks, but I bet you do want a doctor that has seen hundreds of patients with problems just like yours. You want a surgeon who has done hundreds of procedures just like the one you are about have done to you. There is a balance in medical training of seeing and doing as much as possible as quickly as possible to develop the necessary experience base, without compromising safety and learning. The tricky part is that the balance is different for each trainee.
Running a marathon is a poor analogy. Nobody can run a marathon without training (except, of course, for poor Pheidippides, and we all know what happened to him). But sleep deprivation isn't something you can train for, even if rote training can get you through sleep deprivation. So, unless you are saying that what hospitals currently do is a system of selection -- which doesn't seem to be the case since there are lots of cheaper and less ethically problematic ways to find out who works better with less sleep -- then this argument doesn't hold much water.
Functioning without sleep is like functioning while drowning -- it doesn't improve with experience. It always surprises me that so many doctors think it does, given that there is so much medical research on this very subject to the contrary. (Or is this one of those things where everyone is so tired they don't keep up with the research literature?)
When my wife and I were in the height of our newborn-induced sleep-deprivation, there was a classic exchange between us:
Me: Wow, this is really hard.
Her: Yeah, it is so hard when you can't get enough ....err... that thing you get at night.
She wasn't trying to be funny, but she really couldn't come up with "sleep". I'm not sure if I could have either.
Forget doctors -- parents who are sleep deprived definitely increase the risk of doing something stupid/dangerous to their baby, but we can't avoid that problem.
http://www.daybydaycartoon.com/2008/01/24/
I've thought this was crazy since I heard about it.
This is one of the primary reasons I don't feel sympathy for the business people who say they deserve huge salaries because they work 120 hours a week. Perhaps their company should pay them less and hire more employees. Their sleep deprived decisions can't be helping.
"If letting doctors sleep more saves only 230 lives a year, it's worth it."
Only if one of those lives is me or one of my friends or loved ones. Otherwise this is just more creeping government intrusion into the free market.
I don't really believe that - I just thought I would say it before somebody else does.
As someone who has sleep apnea and other sleeping difficulties I certainly appreciate the value of a good nights sleep.
Why we continue to try and train doctors with this sleep deprived fashion is just ... stupid.
Megan, I didn't quite understand your last paragraph about continuity of care. This is my biggest concern with the new duty hours currently under consideration by the ACGME. I understand that people make mistakes when they are overtired. But I have also seen mistakes made because of multiple "hand-offs" of patients, and I fear that the number of mistakes won't decline under the new rules, they'll just be made for a different reason.
Attendings in my division work two weeks straight at a time, including weekends. Although we do not take in house call, we are available by pager 24/7. It is not as bad as being a resident or fellow, because we are not on service as frequently, and we don't get that many calls overnight. But we do this for continuity of care. PICU attendings work 24/7 for one or 2 week blocks for the same reason. Continuity matters immensely to both patient health and satisfaction, and attending work schedules reflect this.
This is a good argument for paid paternal and maternal leave, too. Those first few weeks are brutal, sleep-deprived, and really not good for productivity.
This is also a good argument for digital medical records which automatically update based on the procedure. If you automatically have an electronic record of everything that is done to you which is easily displayed without having to decipher crappy handwriting, fewer mistakes are inclinded to happen. If we make the medical record process more streamlined and cut out the sleep deprivation issues we get double to bonus.
And as someone who is going to have twins in the fall I am NOT looking forward to the sleep deprivation, so thanks everyone for reminding me of that little gem.
Is this the Kate who's a friend of Megan's (and a longtime commenter?) If so, congratulations! (and if not, still congratulations!)
Don't worry, Kate. As Megan noted, your hippocampus won't work well without sleep, so you'll barely remember the worst of the sleep-deprivation later. And congrats. :)
As a mother of almost-three-year-old twins, I can assure you that you DO remember the sleep deprivation -- and mine were pretty good, for twins. (Key concept: attempt concurrent schedule at all costs! Wake a sleeping baby up if you have to, to keep them together.)
I'm also a computer programmer, so I've put in the insane hours in my time, and been so tired I couldn't safely drive myself home from the office. IME, tired people are most prone to mistakes of omission; you might be capable of tackling any given problem head-on, but you forget about all the downstream consequences, or you overlook the existence of a secondary problem. That's highly relevant to medicine, where one worries less about the surgeon falling asleep than about the surgeon failing to notice an abnormally low platelet count on the pre-op bloodwork.
Omission errors are also the most difficult to detect and enforce systematically in an application -- it's a psychological problem, not a technical one. Put in too few error checks, and users screw it up, but too many errors lead to users ignoring warnings and clicking through on autopilot. I'm pretty skeptical of how electronic medical records are the Ultimate Solution to Everything, but biological sleep requirements aren't very solvable either.
In 2004 I worked on my final (hopefully electoral campaign). From March to Election Day I only took 3 official days off. Most of the campaign we worked 80-100 hours a week, and it was rough but it was doable. Then in September we transition to 100+ hours a week. There were weeks I was working more than 130 hours, which left roughly 36 hours off (to sleep, do laundry, etc).
Megan is absolutely right; it completely wrecks your mind. The brain simply cannot function normally or even competently at that level of sleep deprivation. The fact that none of us were seriously injured (given the long car trips) is miraculous in hindsight. I would think that letting doctors sleep more is an absolute bargain at any price.
It's funny that we require doctors to be massively sleep-deprived but would fire them if they showed up to work drunk.
Especially when a bunch of those same doctors ran a study showing how being sleep deprived has similar cognitive impairment on say, driving abilities, as intoxication.
I work as a night shift labor and delivery nurse (one of the specialties where doctors are expected to work nights as well as regular office hours).
A significant portion of my job, as well as the residents' job, is to make sure the attendings can sleep as much as possible, whether they are at home or in the hospital.
A significant portion of the residents' duties has nothing to do with their "training," but rather saves the hospital from having to hire more staff. We have physicians' assistants at certain times to cover routine admission of patients, and surgeons to assist with scheduled cesarean sections, but they cost much more than residents.
The low cost vs. extraordinary workload benefits the health care industry economically, but I'm not sure it benefits the patients or improves doctor training.
No offense, but this lady is out of her mind. Physician residency programs, especially in internal medicine, overwork their residents to an astonishing degree. And why shouldn't they? They do lots of necessary work that full doctors won't, plus they get subsidized by the government for each resident. Plus, they aren't afraid that disgruntled, overworked residents will leave, due to the contractual nature of the match process, the difficulty of paying back student loans and the fact that residency programs will blacklist those who leave.
She even admits it in the 2nd comment:
" Before the duty hour restrictions, resident hours truly were appalling. "
For those who don't know, these work hour restrictions are 80 hours. Even if strictly observed, ask yourself what working 80 hours at your job would be like. Then imagine you're doing a doctor's job.
And that's the thing -- they aren't strictly observed. Residency programs, especially high-prestige ones, explicitly instruct their residents to under-report their time, because the school can't afford not to. There's just too much work to be done. Some programs run up to 100 hrs -- and yes, it did used to be worse.
At the end of the long, long day, ask yourself this. Most people work 33-40 hours a work doing things that aren't particularly life-threatening. Residents, especially at internal medicine residencies, like the one this lady runs, work 80-100 hours and make decisions that decide whether or not people live. Are these the people who should be exhausted and tired?
Let's pretend this isn't medicine. Let's pretend it's a different field, where employees work 80-100 hours, their employment is legally determined by a computer matching system, if they leave their employment they are blacklisted by the employer's cartel, those who simply protest are ostracized and encouraged to underreport their times, these employees have a quarter of a million in debt, and the government bribes the employer to retain these employees.
Someone says "gosh, maybe we shouldn't make them work that hard" and one of these employers (which is what Turi McNamee is) comes out and says "no no, I disagree, look how much that would cost!" Would this merit a civil response? Or would we simply laugh her out of the room as a cartoon of an exploitive employer whose employees have little option of exit?
I start my third year medical clerkships in one month. I would rather get kicked out med school than approach a patient when I think I'm significantly impaired. But as much as everybody talks about how doing no harm is the utmost value in medicine, I'm really not sure if someone can say "Listen, doc. I am happy to make up (even double) all of these hours. Or make me change the bedpans right now. But I simply cannot help interview, examine, or administer treatment at this moment." My fear is that this might be perceived as being lazy or irresponsible, rather than being self-aware of one's limits. I also wonder if I'd even be able to cover everything that we're meant to learn, if I demand 6+ hours of sleep every night. And of course, third year clerkships are just practice mode, in comparison to the challenges of being an intern/resident.
I also wonder if I'd even be able to cover everything that we're meant to learn, if I demand 6+ hours of sleep every night.
Well, given the documented (in the primary post) interference of sleep deprivation with memory formation, I wonder if you wouldn't be learning more if you got enough sleep.
Re:
"I understand that against this, you have to set the benefits of continuity of care."
Certainly. But the nurses with whom the doctors are working perform fixed shifts of shorter duration. Given that in a lot of cases, nurses have at least as much to do with the continuity of care as the doctor, it seems strange that people would insist on it in the case of the doctors, but not the nurses. It becomes even weirder when you realize
The reason is: the nurses can leave their jobs if it becomes too rough. Residents can't.
Couldn't resist, posted a few snippy questions at the True/Slant post.
Broken sentence above was supposed to read:
"It becomes even weirder when you realize that because the nurse shifts and doctor shifts are out of synch, continuity of care becomes even more strained because of the additional hand-offs that are imposed."
Actually, their shifts being out of synch IMPROVES continuity of care, the same way overlapping schedules everywhere does.
You might as well forget this.
For one, doctors are put on the Marine "grind" track with respect to education anyway - my biologist-to-be daughter has caught professional bio educators admitting that biologists have no business in premed classes, which are run "as game shows." They conserve the actual education for bio majors.
And "who gets into the office earliest or leaves latest" is a very real game - in the absence of any real measurement of productivity, it will most likely become the game of choice in a corporation.
There was a December 11, 2006 article in Business week about Best Buy consciously destroying that aspect of corporate culture. Not sure how that turned out, but discouraging the lazier metric-constructors among us can't be a bad thing.
When Ernest Rutherford ran the Cavendish lab he toured the building at six in the evening, telling people to down tools. "If you haven't solved your problem by six o'clock, you need to go home to think about it."
I'm finishing an anesthesiology residency in 18 days, so I have a bit of perspective on this.
80 hours sounds like an immense burden until you realize that you can go over it just by working 7a-7p from Mon-Fri and then being on call Saturday. That's a tough schedule, but it's by no means a recipe for sleep deprivation. (Just give up a social life, and you'll be fine.)
Call, as opposed to shift work, persists because of some simple facts:
1. Physicians are, mostly, paid to treat patients, not to be there. Emergency medicine is an exception.
2. Working at night is not as nice as working during the day, so night workers are normally provided with extra pay to induce them to take the job.
3. However, unless we start scheduling patients to have surgeries at night, the patients and the income will stay with the day shift.
4. So now you have people doing the less-pleasant job who get almost none of the pay. Recruitment is, to put it mildly, an issue.
5. As a result, physicians have a choice: give up a hunk of income - a big one - to people who don't contribute much to your practice, in order for them to cover nights, or split the nights up among yourselves. The latter is almost always the decision that is made.
Physicians like time off as much as anyone else. Unfortunately, while you can shut down most businesses for the weekend, you can't ignore patients from 5 pm Friday to 7 am Monday. With call, everybody takes a turn in the barrel. With shift work, the maximum duration at the hospital gets smaller, but the hours to be covered haven't changed: you trade fewer long spans of time in the hospital for more short ones, and thus you lose your weekends off.
Furthermore, if you push procedurally-oriented residents (e.g., surgical specialties) onto a shift schedule, their learning suffers because (when working nights) they don't get to do as many surgeries. They miss out on educational conferences, teaching rounds, etc. I think the 30-hour rule is a good attempt to address everything, and while it's a long way from perfect, it's also worth repeating that you're not always awake for those 30 hours - if you have nothing to do, you can go to sleep. (The three rules of surgery, as taught to me when I was a third-year med student: eat when you can, sleep when you can, and don't @&*^ with the pancreas.) You're also supposed to have 10 hours off between appearances at the hospital - if, for some reason, you're there until 10 pm one night, it's actually against the rules to come in before 8 am.
The president of the CMA suggested that women entering the medical profession cut productivity:
http://www.nationalpost.com/news/story.html?id=1610272
Directly related to women refusing to work the long hours that male doctors have traditionally done.
This seems to be another instance where women entering fields that were predominantly male exercise a socializing effect; the expectations of ridiculous hours and workloads are changed.
An anecdote. Went to my GP last week to discuss results of a diagnostic test. (joys of socialized medicine; took 4 months to get the test) My GP wants to retire, and has been trying unsuccessfully to get a young doctor to take over his practice. He said the problem is that he has 2500 patients, and if he could get it down to around 1500, which someone would be willing to take on, he could find someone.
In other words, newer graduates aren't willing to shoulder in insane demands that a previous generation of doctors would.
So the issue may sort itself out naturally.
The only issue is who is going to do the doctoring. More doctors would be required, and that would not fit in the 'cut medical costs' mode that is current.
Derek
When I was a freshman in college, I once pulled an allnighter writing a term paper and studying for two finals. I finished the finals at 10 a.m. and drove 120 miles to my parents home that same afternoon for the Christmas break- microsleep nearly killed me at one point during the drive as I nodded off and the car ran off the road shoulder and within a few feet of plowing directly into a bridge abutment.
I have driven late at night a few times since, but I have never done so beyond the point where I know that I can nod off, and during my 2nd year in college, I attended a talk given by a surgeon who described the life of an doctor, including the long hours as an internist. That talk and the experience of the previous year changed my career plans, and I abandoned plans to go to medical school. I would not want to be in the care of anyone in the condition I was that afternoon, and I certainly wouldn't want to have someone's life in my hands while in the same condition.
, I attended a talk given by a surgeon who described the life of an doctor, including the long hours as an internist.
It's sort of amazing what doctors do in terms of sleep deprivation. They of all people should know better.
But I did manage to process and retain one fact: when you have not had enough sleep, you. are. stupid.
It's also very very bad for you. You should never put yourself in a situation where you cannot get 7 hours sleep in every 24 on a regular basis. IIRC some studies found it was the equivalent of smoking a pack of cigarettes every day.
My wife is an RN and has given me numerous examples over the years of watching over the interns and residents like a hawk and saving them from their mistakes. For the most part, the point of these positions is to provide them with experience - much of the real work is performed by the nurses. I don't think the high volume of hours is really that valuable.
I'm an internal medicine resident. I agree with the main point that people need sleep to work effectively and that if you work too long you will become counterproductive. However, just because work-hour restrictions are good, does not meant that these particular new ones are good. An over 100 hour week or 48 hour day I think is clearly dangerous, but the 80 hour week and 30 hour day are tough but doable. I haven't seen the exact new rules but I understand it will stop 30 hour straight calls and mandate only 4 days in a row for night float. It is really a logistical nightmare, and for a smaller program like mine I really don't know how it can be done. As other people have pointed out hand-offs reduce patient safety too. We have to have some hand-offs but now we're going to need 2 separate hand offs in a day. The 80 hr. 30 hr. system is a reasonable system. There's no need to reduce it more. Also residents will just break this system like they do the old one anyway. We don't need administrators or attendings to tell us that you don't punch out when the clock says 5, but when all the day's work is done and you can hand off a reasonable set of tasks for the night team to follow up. If the rules said to leave at 3 PM everyone would still actually go home at the exact time they do anyway.
I'm a paramedic who frequently works 12-hour shifts that turn unexpectedly into 24-hour ones. Get called into work on short notice. Have to switch from day shift to nights for a week and then go back the next. In other words, there's lots of potential for sleeping difficulties.
My days are rarely as complicated as a doc's. From hours 24-36 without sleep, I'm a little slower cognitively. It actually helps in a way, as calmness and considered decision-making are really important in EMS, and I'm excitable. But after hour 40, I'm a mess. Strangely apathetic. The only patients you'd want me treating are Pol Pot and Hitler.
Ok looked at the suggested rules, now.
16 hour day- Is this an issue? Do any residents have non-overnight shifts that are "officially" over 16 hours? And if you're working a 14 hour shift and you're already 2 hours over finishing up work, are you going to stop because you're over your ACGME limit?
5 hour nap for overnight shifts - How are you going to do this? Bring in an extra resident for just 5 hours? Double the number of residents overnight everywhere? And if there's a code or the other resident is just really busy, you're going to just lie down and take your mandated nap? I think this requirement basically forces you to give up overnight calls and move to a night float system. I don't know how it can work otherwise.
No new patients can be admitted after 16 hours on call. Again, how exactly do you work this with an overnight call system. It forces you to do a night float system.
Overnight call no more than every 3rd day- Ok
Night float no more than 4 days in a row.-So after basically requiring you to switch to a night float system, they make it even more difficult to do a night float system. And in any case more days in a row at night should make it easier to get used to working nights, not the opposite.
At least 1 day off each week without averaging - Meh. It woul suck to go 3 weeks between days off, but does that really happen often.
One 48 hour break per block - I'd like it, but is it really useful to fight sleep deprivation.
First year residents not to be on duty without attending in house. - that would be great if you could get it to work.
The hardest I ever worked was producing a Master's thesis film project at USC. I worked about 140 hours in 8 days. That involved doing things like driving a 5-ton truck on a winding mountain road at 4 am, and then waking up to start the production at 6 am. It involved lots of long late-night drives. At one point I was driving someone else, and he told me to pull over so he could drive. All of this while keeping a crew of 25 volunteers (only 2 of the crew were paid) fed and happy and working in the middle of the desert.
It took me at least a week to recover. These are a couple of things that I think should be part of the debate: working in a hospital isn't quite as physically difficult as, say, construction. But doctors are on their feet for most of that time, and sometimes making difficult decisions. It's not just a lot of work - it's a lot of hard work. And when you work hard for an extended period of time, you need some time to recover. I've also worked on elections, and one nice thing about elections and film productions: they have deadlines. In the case of elections, absolute deadlines (except in Minnesota). There is a clear ending to them. After the Tuesday after the first Monday in November, you can sleep as much as you want. But if you're a resident, you're going to be doing insane hours for a long time.
I have to agree with the comment above about how "but it would be expensive/complicated/etc..." to implement. So what? We KNOW that it's dangerous to let people make decisions while sleep deprived. Endless studies have shown this. We don't let pilots or truck drivers work without adequate sleep. Doctors shouldn't work without adequate sleep. If they need to change the way they schedule night work, then DO IT. Instead of complaining about how hard it would be, they should sit down and figure out a solution. Doctors are smart. I'm sure they can come up with something.
I have friends and family who are doctors and the sleep deprivation is a very real problem.