9. Sleep and Learning…

April 28, 2015

On June 6, 2014, the lead article of the BBC News website reported on the role that sleep has in learning.  Basically, researchers in the U.S. and China, writing in the journal “Science”, by using advanced microscopy techniques, had demonstrated that mice undergoing training forged significantly more inter-neuronal connections if allowed to sleep, than did mice who were sleep-deprived.   Which raises a question I have had about our whole educational paradigm.

Even in my own neurophysiology courses in the early 1990’s, I learned that shifting items from very short-term memory to long-term memory actually involves the production of new proteins in the relevant parts of the brain.  As I recall, building up those proteins can take almost two weeks.  Why then, I wondered, have we developed an educational system that purports to pump several hours of new information into us every day, when that to which we are exposed in just the first hour won’t begin to be remembered until about 24 hours later, and when intense exposure cannot speed up the process of forming new proteins in the brain?

Regarding the role of sleep in learning, ironically I developed extremely severe insomnia in my first year in law school.  In what I would now characterize as a state of chronic panic over needing to learn fifty or sixty pages of densely compacted new information each evening, I would force myself to read on at a rapid pace despite my exhaustion.  Whereupon, in act of cortical rebellion, my brain did a strange thing.  I would discover that I had, without realizing it, been reading the same paragraph over and over again for an hour.  Redoubling my efforts and flogging my weary brain I would read on into the night and finally fall into bed at five in the morning, my head swimming with the stuff I had been reading.  My roommate would try to wake me for our 8 o’clock class, but to no avail.  I was nineteen, naive, and unable to interrupt what became a dismal daily cycle and lasted the whole winter of my first year in law school.  I barely scraped through in that eight o’clock course I never attended.  By luck, In June that final exam came last, and I had nearly a week to read my virgin Criminal Law text before I had to sit for the exam.

By the time I went to medical school, five years had passed, two of them in the Army in Germany.  I was married and had a daughter, and in the last half-year of pre-med, after the Army, I was able to figure out how to study.  Or, now that I think about it, was it merely that I got a good night’s sleep snuggled next to my wife every night?

Yet, especially in the first two years of medical school, the pedagogical strategy was still to give the proverbial, “drink of water from a fire hose”.  Some of the teachers used the same intimidation techniques I had met in law school. In the final two years, sleep deprivation was specifically accomplished by placing students on night-call for the Emergency Room, the delivery rooms, the medical wards and the Operating Room.  However, at least the book and classroom load was reduced in those “clinical” years.

During my internship and a year of surgical residency, once again the “teaching'” establishment employed sleep deprivation, in the form of a 36 hours on, 12-off daily schedule, with time off from Saturday at noon to Monday morning three weekends a month.  Moreover, with an annual salary of only $3,000, and with a wife and three kids to feed,  I had to use one of my weekday “off” nights and one Sunday a month to moonlight in the E.R. at another hospital.  At 30, I was able to survive on this regimen, but it could not possibly have been the most effective way to form useful and lasting knowledge.  In the intervening fifty years, some have also questioned whether sleep-deprived young doctors in training can think clearly and perform adequately on the wards, in performing surgeries and deliveries, and in responding to emergencies.

Why doesn’t the training and educational system conform more to the neurophysiology of how we actually learn and remember?  True, a limbic component (in the academic case both fear and the exhilaration of learning) is one way to accelerate and enhance memory formation, but at what expense?

It wasn’t until I returned to a three-year residency in psychiatry at the age of 56 that I encountered a “humane” teaching program, and that wasn’t because the medical establishment wished it so.  At the state hospital , the doctors, including residents, all belonged to the Union of American Physicians and Dentists, which subscribed to the eight-hour work day, (for which more than a dozen union factory workers died in the early 20th Century).  If the state wanted to put us on night call they would have had to pay us time and a half for anything over eight hours, and double time for holidays.  So it was cheaper for them to hire non-union contract doctors for night and weekend coverage and we residents only worked forty hours a week.  Another thing that had changed:  we were paid between $37K and 40K per year.  I was single and my kids were all grown up.  Given that I needed to spend nights and weekends hitting the books, it was a good thing I could live on the salary and  didn’t have to take on an additional moonlighting job.

The process of memory formation being what it is, why are medical schools and law schools organized around sleep-deprivation methods?  Is it that the training for these professions is also a rite of passage, a form of hazing that each initiate must learn to endure?  In both cases the student certainly learns that he or she can persevere through chronic and severe deprivation of proper rest, far beyond what one would otherwise have believed possible.  It is not dissimilar to what one learns about endurance on a physical level during military basic training, where techniques of bullying and intimidation are also famously employed, but in that case only for a period of eight to sixteen weeks.

I recall that as a child of seven or eight years I learned a similar lesson of great value:  that despite fatigue and the aching of my legs, I could actually persist in climbing a sizable mountain in Vermont, due to the encouragement and cajoling of the counselors at the farm camp I attended there.  Reaching the top of Mount Haystack, a couple miles from Wilmington, I stood amazed that I had been able to walk up it despite my certainty that it could not be done, at least not by my body.

In law, and much more so in medicine at a time when there still existed the principle of “continuity of care”, the work by its nature demanded that one perform it when it was needed, often in the middle of the night and for prolonged periods of time.  Those students who had never climbed Mount Haystack or had never been through military basic training, as I had, may have benefitted from the endurance aspects of medical training.  But certainly that particular lesson could have been learned within the space of a month or two at most, and did not have to last nearly a decade.

From time to time I have wondered if it were not a form of child abuse, being passed, as are the other kinds, from generation to generation, the abused becoming the abuser.  Or whether it was a selection process, weeding out all those who were not obsessive workaholics willing to sacrifice self and family on behalf of the afflicted.  Selecting those who somehow needed the opportunity to become rescuers of major proportions.  Selecting those who, throughout their careers, would allow themselves to be abused and exploited without rebelling or even complaining.