Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

Night owls


When patients say they often feel drowsy during the day, discuss a sleep routine that fits with their schedule. And remember to screen for sleep apnea. 

A 50-year-old ICU physician told me that he’d been working variable shifts for years. He’s a natural night owl, and if he goes to bed at nine at night in anticipation of a shift at seven in the morning, he’s up in a few hours and has difficulty falling back to sleep. His best sleep is always in the morning from six to nine, but he rarely gets to sleep during that time. He hasn’t tried any specific behavioral interventions to improve his sleep, and experiences daytime sleepiness during sedentary activities. With variable shifts, he hasn’t been able to establish a set exercise program. In recent years, he’s gained weight, and his wife has observed apnea and snoring.  


We discussed improving his sleep with two approaches—acknowledging that there’s a mismatch between his natural circadian rhythm and the demands of shift work, and evaluating and treating him as needed for sleep disordered breathing.  



Addressing the timing of sleep 

I referred him to my colleague in behavioral sleep medicine for cognitive behavioral therapy for sleep. I explained that blocking off time now to learn the tools to strengthen his sleep drive will help him to make the best of the time he has available to sleep.


We discussed that even if he works the day shift, there’s a mismatch between his natural circadian timing and the demands of work, so he’s a shift worker, and must pay attention to enforcing his sleep/wake rhythm. His care plan includes reducing light exposure in the evening and increasing bright light exposure in the morning, timing the bright light exposure to best shift his circadian rhythm, as well as small doses of melatonin hours before his bedtime. I also suggested setting an alarm to get ready for bed in the evening to stay on schedule for transitioning from doing household and work-related tasks to activities that will prepare for and promote sleep. We also discussed considering when he can fit in exercise as this should also improve sleep quality. 


Addressing sleep apnea 

I ordered a home sleep study for a sleep apnea evaluation; sleep apnea is common, affecting 17% of women and 34% of men in the U.S., and weight is a prominent risk factor for it.


If you’re not getting good sleep, consider making it part of your professional development plan. This may include gauging how your work schedule fits your natural sleep schedule, adjusting your sleep hygiene, and being evaluated for sleep disorders like sleep apnea or chronic insomnia when needed. 










This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.