Sleep 2023.03.15 Flynn-Evans

March 19, 2023

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00:00And now I have the great pleasure
00:03of introducing today's speaker,
00:04doctor Erin Flynn Evans.
00:06Doctor Evans is a research psychologist
00:08at the NASA Ames Research Center
00:11in California, where she leads
00:12the Fatigue countermeasures lab.
00:14She holds a PhD from the University
00:16of Surrey, UK, and an MPH from
00:18Harvard School of Public Health.
00:20She was also certified as an
00:23RPSGT from 2002 to two 2012.
00:26Prior to joining NASA,
00:27she was an instructor in medicine
00:29and the Division of Sleep Medicine.
00:31Brigham and Women's Hospital and
00:33Harvard Medical School and also as a
00:36pivotal team in the duty our changes.
00:38Doctor Roslyn Evans has extensive
00:41research experience examining the
00:42short and long term effects of sleep
00:45loss and circadian desynchrony in
00:47occupational settings including
00:48among astronauts, airline pilots,
00:50physicians and other shift workers.
00:53She's involved in both lab based
00:55and field based research.
00:56Her lab based research has focused
00:58on examining the effects of light
01:00and circadian neuroendocrine.
01:01And neurobehavioral responses in
01:03humans and how these outcomes relate
01:05to the development of countermeasures
01:07for shift work or field research has
01:10involved integrating these measures of
01:12fatigue and associated countermeasures
01:13into complex operational setting.
01:15And she has also received the
01:17NASA Honor award for her research
01:19and for her management,
01:21along with the NASA Superior Accomplishment
01:23award. She's also very active
01:25with the American Academy of Sleep
01:27Medicine and Sleep Research Society.
01:29She's a member of their extensive.
01:31Extrinsic circadian rhythm
01:33disorder guidelines,
01:34task force and Public Safety Committee.
01:36She also serves as a member of
01:39the Impairment Advisory Board
01:40and the National Safety Council
01:41with her very unique experiences
01:44of working with the astronauts,
01:45pilots and her work on circadian disruptions,
01:47shift work and fatigue mitigation.
01:49It is with great delight and
01:51enthusiasm that I would like to
01:52hand it over to doctor Flynn Evans
01:54to share her experiences with us
01:56and thank you again for joining us.
01:59Oh, well, thank you so much for that
02:02introduction, Dr. Papa. That was.
02:06I feel, I hope I can live
02:08up to that introduction.
02:10That was amazing.
02:11So thank you so much for the
02:14invitation to speak today.
02:16I I did speak actually a couple
02:19of years ago to this group,
02:22and during that talk I discussed
02:26my work in Space Flight,
02:29studying sleep and circadian
02:30rhythms and astronauts.
02:32So this is a little bit different.
02:33And today I'll be talking
02:34about some of the other.
02:35Work that we do specifically around
02:38managing sleep loss and circadian
02:40misalignment and shift work,
02:42so I don't have any.
02:45Financial relationships with
02:47ineligible companies and I am sure
02:50I'll leave this here for a moment so
02:53you can text for your CME credit.
02:57And hopefully. That's enough.
03:00All right.
03:01So to begin,
03:02you may wonder just why someone from NASA
03:06is here to speak about best practices.
03:10Firstly,
03:10alas and circadian misalignment
03:12and shift work.
03:13And so I thought I'd just start with a
03:16couple of slides describing what NASA
03:18does and then where I fit into that puzzle.
03:21So I'm sure that you've heard
03:23of Johnson Space Center,
03:24where we have Mission Control for astronauts.
03:26I'm sure that you've heard
03:27of Kennedy Space Center,
03:28where we do many of our
03:30launches and landings.
03:31For our space missions,
03:32but we actually have 10 centers at NASA and
03:36these centers all have distinct functions.
03:39We have some,
03:40we have Goddard Space Center,
03:42which is focused on
03:44astrophysics and astronomy.
03:46We have Glenn Research Center,
03:48which is focused on aeronautics,
03:49Langley Research Center.
03:51We have JPL,
03:52which I'm sure you've also heard of,
03:54where we do most of the Mission
03:56Control work for our Mars Rovers.
03:58And then I work up here in the California.
04:01Bay Area at NASA Ames Research Center.
04:04And you know, I'm probably biased,
04:07but I do think our center is the best,
04:09especially for research because it
04:12operates much like a university campus.
04:15So we are a government agency,
04:17but we are sort of the the research
04:19test bed for all of the work that
04:22happens around the rest of the agency.
04:24So we have people at NASA Ames who
04:26are doing work in molecular biology,
04:29who are doing work in materials.
04:31Engineering.
04:32And then in human systems integration,
04:35which is where my lab falls.
04:37And in my lab,
04:39my lab is the fatigue
04:41countermeasures laboratory.
04:43I didn't name it,
04:44and I'll get in a minute into what,
04:47how I feel about the word fatigue.
04:49But in my lab,
04:50we do Space Flight research again.
04:52That's what I spoke about
04:53a couple of years ago.
04:54And then we also do aeronautics work
04:57and mission operations support and with
05:00aeronautics and mission operations.
05:03Much of the work that we
05:04do here is both research.
05:06So we do studies to characterize
05:09problems and to better understand how
05:12people cope with the types of shift
05:16work schedules that they have to do.
05:19And then we also deploy countermeasures.
05:22And so sometimes that's a very
05:24formal process where we're
05:25doing a research study in step testing
05:27the effectiveness of a countermeasure,
05:29but sometimes that's just taking the
05:31knowledge that we've learned from a study.
05:33And deploying the countermeasure
05:36broadly across a particular population.
05:39And so the majority of what I'm going to
05:42talk to you about today really is based on
05:45the work that we do in these two areas.
05:48So overall today, I just want to
05:51quickly cover shift work biology.
05:53I only have a couple of slides here.
05:55I know I'm talking to a a Sleep
05:57Medicine group.
05:58And so I think that you're all very
06:01knowledgeable in this area already.
06:04But to make sure we're on the same page,
06:06I'll cover a couple of basics and
06:08then I'll talk about some of the
06:10short and long term health outcomes
06:11that are associated with shift
06:13work and I'll spend the majority
06:15of time talking about mitigations.
06:17So what is fatigue risk management,
06:20how do we implement it and how can
06:23that potentially be translated
06:25to patient populations?
06:27Much of the work that I'll talk about
06:30today comes from a task force that I
06:33was involved in that was sponsored by
06:35the American Academy of Sleep Medicine
06:38and the Sleep Research Society.
06:40This was an amazing group of
06:43researchers and clinicians that came
06:45together with the ultimate goal of
06:48trying to understand how the length
06:51of a shift would impact alertness,
06:54performance, health, and safety.
06:56But as we.
06:57Really got into this as our working
07:00group met.
07:01You know we we were scheduled
07:02I think for 8 hours a day.
07:04We ended up being at the ASM offices
07:07for something like 12 hours a
07:09day because we had lots and lots
07:11of discussion about this topic.
07:14We really came to the conclusion,
07:16which I think probably will
07:18resonate with many of you,
07:19that when it comes to shift work the
07:21answer is almost always it depends
07:23because you can't really apply A1 size
07:26fits all recommendation or strategies.
07:28Every population to every occupation,
07:31you really have to look at the
07:34characteristics of a work group,
07:36the characteristics of the
07:37individuals within that work group,
07:39and then the potential consequences of any.
07:43Accidents or incidents that may come from.
07:47Excessive sleepiness within a population.
07:50And so this.
07:52Article is really, you know,
07:56a nice, I think,
07:57summary of what I'll talk about here
08:00it I'll give you the Cliff notes.
08:02The article goes into more detail
08:04on all of these topics if you're
08:07interested in further reading.
08:09So to begin shift work,
08:11it is a term that can be very
08:14difficult to define.
08:15I think we all sort of know what
08:17shift work is,
08:17but when it comes to putting down
08:19a definition,
08:19if you ask 20 people,
08:21you'll probably get 20 different definitions.
08:24I just grabbed this from dictionary.com,
08:26but I I really actually like this definition,
08:29which is just a system of employment
08:31where an individual's normal work
08:32hours are in part outside the
08:34period of normal day working and
08:36may follow a different pattern
08:37and consecutive periods of weeks.
08:39And I like this definition in
08:41particular because I think a lot of
08:43times when we think about shift work,
08:45many people are thinking about
08:47night work or rotating shift work.
08:49And in reality, we have many people in
08:52many different occupations who have to
08:54work what many would classify as day.
08:57But where those shifts start maybe
08:59at 5:00 in the morning or where maybe
09:01those shifts end around midnight,
09:03you know, is that really a daytime?
09:06You know, it's partly daytime,
09:07but it's really kind of shifted.
09:09Outside of what the normal human
09:12diurnal pattern would allow,
09:14you know with a sort of entrained
09:16circadian rhythm.
09:17So when I talk about shift shift work,
09:20I am thinking more globally about these
09:23more nuanced types of shifts as well.
09:26And then, you know,
09:28just thinking about shift work
09:30and what the issues are,
09:33you know, first I think you know,
09:35you need to understand the biology
09:37of shift work.
09:38So what is happening in the body when
09:41we're working against our biological clock?
09:43And then what are the consequences that
09:47follow misalignment between our sleep
09:49wake timing and our circadian timing?
09:52For example,
09:53what are the consequences
09:55of peripheral misalignment?
09:57Peripheral clock misalignment and then,
10:01you know, finally,
10:01what can we do to mitigate that?
10:03We're probably never going to
10:05eliminate shift work.
10:06We're going to continue to have people who,
10:09you know, demand to have their
10:11packages shipped overnight.
10:12We're going to have people,
10:14you know,
10:14who want to travel to Europe.
10:16You really have to have pilots
10:17who are able to fly overnight
10:19to be able to accomplish that.
10:21And so in thinking about shift work,
10:25what we're really trying to do is mitigate.
10:28The consequences of shift work
10:29both in the short and long term,
10:31so that we can continue to
10:35operate in this 24 hour society.
10:38Now I know probably everyone here
10:40is familiar with the two process
10:43right model of sleep regulation,
10:45but I, I you know,
10:46I think it's really important to just
10:48start with the basics and thinking about
10:52how shift work influences our bodies.
10:54So of course we have the homeostatic Dr.
10:58which I've plotted here in light blue,
11:01which in an untrained individual of course
11:03builds up over the course of the day
11:05and then we have the circadian drive for.
11:08Make, which is in the darker blue,
11:10which sort of counteracts
11:12that homeostatic Dr.
11:13and then with shift work,
11:15you know, of course we all know the
11:18consequences of shift work are,
11:20you know,
11:21we continue to stay awake potentially
11:23through that biological night.
11:25Certainly that's the case for night work.
11:28And we may have a much elevated homeostatic
11:31sleep pressure happening at that time.
11:34And then when shift workers then
11:35try to sleep during the day,
11:37even though they may be going to sleep.
11:38The time when they have a very
11:40high sleep pressure,
11:41they're sleeping at a time
11:43when the circadian drive to
11:45be awake is opposing their ability to sleep.
11:47And so of course that leads to sleep
11:51fragmentation and potentially and
11:53typically sleep of insufficient duration.
11:55And so that compounds the problem because not
11:58only do we now have a circadian misalignment
12:01issue with sleep with shift work,
12:03we also have a sleep loss
12:06problem with shift work.
12:07And then, you know, of course it gets worse.
12:10You know, I, I'm sure many of you are
12:12working on a peripheral oscillator
12:14systems and are probably much more
12:16knowledgeable about, you know,
12:18each of these individual areas.
12:20But I am. But really when it
12:23comes to circadian Physiology,
12:25we're not just thinking
12:26about the sleep wake cycle.
12:28You know,
12:29the sleep wake cycle is important
12:31and we want to make sure that
12:33people who are engaging in shift
12:35work are able to get enough sleep.
12:37To manage their awake time,
12:40we want to make sure that they're able
12:42to stay alert during their awake time.
12:44But we also have these downstream clocks,
12:48all these peripheral oscillators and
12:50virtually every body system that
12:52are receiving information from the
12:54Super cosmetic nucleus that are,
12:56you know,
12:57then coordinating other aspects of
12:59biological function which can lead to
13:02symptoms that are not always clinical,
13:04sometimes subclinical symptoms
13:05that can make shift.
13:07Workers, you know,
13:09Colin Stack or or feel
13:11uncomfortable or or in,
13:13you know the worst case scenario over
13:16years of shift work can lead to chronic
13:19conditions and and clinical conditions.
13:22And so we have to think about the
13:24big picture when we're thinking
13:26about shift work and mitigations,
13:28you know,
13:29promoting alertness and performance on the
13:32job and sleep at home is really important.
13:36But I think we also have to think.
13:38This future of how do we ensure that
13:41shift workers health is preserved to
13:43the best that it can be as they're
13:46engaging in potentially a life of shift work?
13:50So breaking that down a little bit more,
13:54you know when I think of these
13:57longer term consequences on the
13:59short term I'm thinking of.
14:01You just what are the immediate effects?
14:04You know what what are we dealing with on a
14:07given shift during a given sleep episode?
14:10And then in the long term, you know,
14:13what are the potential consequences
14:15in a person's life?
14:17Are they going to be able to?
14:20Maintain work for you know,
14:22their entire.
14:24You know, we're typical working lifespan.
14:27Are they going to make it to retirement
14:29able to work or are they going to
14:32develop some sort of chronic condition
14:33that is going to prevent the,
14:36that's going to take them out of
14:38the workforce prematurely.
14:39We need to protect against these
14:41things as well and certainly
14:42against like say premature death.
14:46There are many consequences of shift
14:48work both in the short and long term.
14:50But I just want to hit on a couple of
14:53them here, just as probably a reminder.
14:56So in my lab, I think probably the
14:58biggest focus that we have is on
15:00this reduced cognitive function
15:01in the short term on the job.
15:03Again, the populations that I work with,
15:06you know, specifically,
15:08you know, the astronauts,
15:10pilots and then people who are
15:11working on different missions at
15:13NASA really want to know how can I?
15:15Stay awake and alert on the job and
15:19particularly because, you know,
15:20many of the occupations that I work
15:22in are safety sensitive occupations.
15:25You know,
15:26the management in those groups
15:28want to make sure that everyone
15:30is going to stay safe and that the
15:32populations of people who say who
15:35are traveling around the country on
15:37airplanes are also going to stay safe.
15:39So we're really concerned about
15:40making sure that, you know,
15:42sleepiness is managed,
15:44that accident risk is reduced.
15:47But we also have other short term
15:49conditions that are made that maybe
15:51you know garner less attention
15:53but are equally important.
15:55So you know in the short term
15:56we we see increased burnout and
15:58poor behavioral health,
16:00so increased risk of depersonalization
16:03among hospital employees towards patients,
16:06increased risk of anxiety and depression.
16:08And then again kind of going back to
16:10something you mentioned previously,
16:12we also see an increase in
16:14subclinical conditions.
16:15This can lead to more sick calls.
16:16Long shift workers,
16:17so GI distress,
16:18headache,
16:19reduced immune function all come in
16:22the short term with insufficient
16:24sleep and circadian misalignment.
16:27And then in the longer term we have,
16:29you know,
16:30some pretty serious consequences that
16:32can come with years of shift work.
16:34Again,
16:34I'm sure there are people on this
16:36call who are working in this space.
16:38I know many of my current and former
16:41colleagues who work on individual
16:43aspects of of these long-term
16:45investigating these long-term.
16:47Conditions,
16:48but we see increased risk of
16:50metabolic disorders.
16:51Um vascular events and then cancer.
16:54And prior to coming to NASA,
16:56one of the cancer was an area
16:58that I worked on.
16:59So I.
17:01Examined how years of shift work influenced
17:07an individual's risk of prostate cancer.
17:10There are many other people who are
17:13working on examining the associations
17:15between breast cancer and shift
17:18work and as well as other cancers.
17:21But hormone dependent cancers
17:22seem to have the strongest links,
17:24and at this point,
17:26the World Health Organization has
17:27labeled shift work as a probable
17:29carcinogen based on the evidence
17:31that's been done.
17:32In this area,
17:33so I think it's also important for
17:35shift workers to understand that
17:38there are long-term consequences
17:40that can come in conjunction with
17:42their choice to engage in shift work.
17:46So shifting gears a little bit.
17:51Now I'm going to start to get into,
17:54you know, what the mitigations are,
17:56what are the things that we can do
17:59to help people stay more alert on the job,
18:02to help mitigate some of those short-term
18:04consequences and then hopefully mitigate
18:06some of the long term consequences as well.
18:10And to do this, I'm going to
18:11talk to you about the framework
18:13of fatigue risk management.
18:14But before we can talk about
18:16fatigue risk management,
18:16we need to define fatigue.
18:18And so fatigue, you know.
18:21Similar to shift work is something that I
18:24think everyone kind of has a definition for,
18:27but most people will have
18:30a different definition.
18:31And so I personally really
18:34hate the term fatigue.
18:36When I came to NASA and my lab was
18:39called the Fatigue Countermeasures
18:41Laboratory before I arrived,
18:43I wasn't particularly excited
18:45about that and I explored
18:46trying to change the name,
18:48but it was sort of.
18:51Prevented from doing so.
18:52We're strongly encouraged not to
18:54do so by some of the other people
18:57who work at NASA. So we kept it.
18:59But now I just try to make sure that
19:01whenever I'm working with the population,
19:03I'm defining fatigue.
19:04Because in my lab,
19:06we're not talking about fatigue as a
19:08side effect of some medical condition.
19:10We're not talking about physical fatigue.
19:13We're talking really about what
19:15I've put on the screen here.
19:18This comes from the International
19:20Civil Aviation Organization.
19:22So it is very aviation focused,
19:24but I I think that the key
19:27is that we're talking about.
19:29Reduced mental or physical performance
19:31capability resulting from sleep loss,
19:33extended wakefulness,
19:34circadian phase or workload.
19:36And in my lab we we definitely
19:38don't focus as much on workload.
19:40We do incorporate it into
19:42the studies that we do,
19:43but I'm most focused on the,
19:47you know the the physiological
19:49touch points that we targets
19:51that we can potentially change.
19:53And so it's really about sleep
19:55and circadian rhythms in the end
19:57when when I'm thinking about.
19:59To you in using the word fatigue.
20:01So what is fatigue risk management?
20:04Well,
20:04fatigue risk management is a formal
20:08process that has been developed
20:12and shaped over many years,
20:13particularly in safety
20:16sensitive organizations,
20:17to provide workers in a given occupation with
20:21tools and resources to manage their fatigue,
20:25so to manage their sleep loss and to
20:27manage their circadian misalignment.
20:30And fatigue risk management is.
20:33You know,
20:34it's much more than just giving
20:36someone a tip.
20:37Sheet Tigers management is typically a.
20:43Within an organization,
20:44a sort of separate work group,
20:47so there are people who are designated
20:51as fatigue risk managers who will collect
20:55data continuously to characterize risk
20:58in the organization as they see the,
21:02you know,
21:03see risk arise as a result of maybe
21:06a particular type of work activity
21:10affecting people in a negative way.
21:13Well,
21:14maybe try to implement some countermeasure
21:17or schedule change and then we'll reassess.
21:20And this is just continuous and iterative,
21:23trying to make sure that as fatigue
21:26hotspots pop up, they're managed.
21:27And then in addition to that,
21:30fatigue risk management program really
21:33needs to provide education to workforce.
21:36So it's not just about a single
21:40strategy or a single, a single.
21:43Uh,
21:44you know,
21:45appointment where a plan is developed,
21:48typically fatigue risk management involves
21:51ongoing education for the workforce.
21:54So overall when we think about
21:56fatigue risk management,
21:57we're thinking about a dual responsibility
22:00between the worker and the the organization.
22:04It's not just that all the burden
22:06is on the worker and I understand
22:08that in a clinical setting you
22:10know you're really dealing with an
22:12individual you're not dealing with.
22:15An institution,
22:16but there may be ways that you can
22:19talk to patients about you know
22:23considering you know employers that
22:25are that have fatigue risk management
22:27programs particularly if they struggle.
22:29So for example in trucking there are,
22:33there are trucking organizations
22:35that have really robust fatigue risk
22:37management programs and
22:38there are those that don't.
22:39And so you know for patients
22:41who are vulnerable it it again
22:43may be worth a conversation.
22:44To discuss, uh, maybe you know,
22:47trying to shift to an employer that will be
22:50more supportive of the nature of the job.
22:55So how can fatigue risk management
22:58be used to mitigate the issues
23:01that we see with shift work?
23:03So again, these are institutional
23:06and individual and I'm going to talk
23:09about both to give you an overview
23:13and knowing that we can't necessarily
23:15implement change at the institutional level.
23:18There may be other ways that that
23:22individuals can take advantage of
23:25those institutional best practices.
23:27So at the institutional level,
23:30what we're really looking at are
23:32policies that promote sleep health,
23:35you know,
23:36policies that help reduce on the
23:38job sleepiness that continued
23:40education and training and also not
23:42just deployment of countermeasures
23:44but training on how to use them.
23:46So I'll talk a little bit about light,
23:48for example,
23:50you can't just deploy light boxes into.
23:54Workspace and expect that people
23:56will benefit from them.
23:58You have to actually have training
24:00so that people know what to do,
24:02how to use them and how to
24:04receive their benefit,
24:05and then infrastructure to support
24:07the countermeasure implementation.
24:09So, you know,
24:10simple example here would be nap rooms.
24:13You know,
24:14if you have an employee who like this is
24:16exhausted and leaning against a wall and
24:18catching a couple of minutes of sleep,
24:21that's not a particularly
24:23supportive environment.
24:24So to go through each of these
24:26in a little bit more detail.
24:29These are some examples of policies
24:31that the best institutions have for
24:34fatigue risk management support.
24:36So just having a fatigue risk
24:38management program is a first step.
24:41And note this is required in aviation.
24:43So I'm going to take you through an
24:46example on when we get to the end of
24:48this describing what is required in aviation.
24:50But I think aviation provides a really nice.
24:55Set of lessons learned that could
24:57be adopted in other organizations.
25:00Thoughtful schedule design.
25:01So we know,
25:03you know,
25:03we know so much about how schedules are
25:06best designed to minimize fatigue and
25:09to enhance alertness and performance
25:11and promote sleep even for shift work.
25:14And so companies that have put some
25:17effort into schedule design so that
25:19they're not just plugging in people as
25:22commodities wherever they need to fill time.
25:26But rather, um,
25:28designing schedules that
25:29work with human biology.
25:32And this is where bio
25:33mathematical models come in on.
25:35Bio mathematical models have matured
25:38to a point where many companies are
25:41now selling bio mathematical models
25:44that use the cheap process model,
25:47usually at the core,
25:49to help design schedules.
25:51And so by using bio mathematical models,
25:54you know, schedule design,
25:55you can scale.
25:57The schedule of a workforce and this is
26:01another area where I think aviation excels.
26:04Virtually every airline around
26:06the world uses some sort of
26:09bio mathematical model based
26:10on the two process model to
26:13help schedule pilots to try to minimize
26:16their fatigue and maximize their sleep,
26:19non punitive reporting of fatigue.
26:21So I think in many situations,
26:24particularly in organizations
26:25that don't have a robust.
26:27Integris management program.
26:29People are afraid to talk to their
26:32employers about their sleepiness,
26:34are afraid to ask for accommodations
26:37because there is a consequence to doing so.
26:41And so again,
26:43the best organizations actually not
26:45only don't punish people for reporting
26:49sleepiness that they don't report people
26:51for reporting inability to sleep,
26:53but they encourage reporting of that.
26:55And then finally on policies that.
26:57They all kind of measure use.
26:59I think every few weeks in the news we hear
27:02about a company that's banning napping,
27:05you know, well,
27:06I'm not sure that that's always the the
27:08healthiest policy with respect to sleep.
27:11You know, it really depends on
27:12the nature of the organization.
27:14There may be some situations where
27:16napping is entirely inappropriate,
27:18but for many organizations with 24 hour work,
27:21napping actually can be a very
27:24effective countermeasure.
27:25Education and training is another
27:28institutional touch point.
27:29So you know, I mentioned this previously,
27:32but you know,
27:34people do not get a whole lot
27:37of education about.
27:39Sleep or circadian rhythms and they
27:42get a lot of poor information online
27:45you know and so a you know the best
27:48company is the best institutions
27:51are going to provide modules on how
27:53people can manage their on the job
27:56sleepiness and you know this education
27:58and screening ideally includes you
28:01know sleep disorders screening with.
28:03Recommendations for following up
28:06with personal doctors as needed.
28:09This education should include
28:10how to use fatigue,
28:12countermeasures appropriately,
28:13how to manage difficult schedules.
28:16So again, this is a situation
28:18where in the aviation industry,
28:19we do this all the time.
28:21We have flights that are 19 hours
28:24long and we have 4 pilots who
28:27are flying on those aircraft.
28:29And so we, you know,
28:30can develop strategies for when
28:32and how people should rest.
28:34In order to make sure that the
28:36pilot crews are as loud as they
28:39can be during the entire flight.
28:41And then of course you can't
28:43just educate your,
28:45you know,
28:45your workforce at the lowest level.
28:47Management needs to be supportive as well,
28:49and so education and training should
28:52really also include management.
28:54And then infrastructure of course
28:56is something that's required for
28:58implementation of many countermeasures.
29:01And you know,
29:02if you are allow napping but
29:04have nowhere for people to nap,
29:05that's not going to be very useful.
29:08Light can be a very powerful countermeasure,
29:11but it may be very difficult for
29:13people to enhance their light
29:15exposure on their own.
29:17But changing the lighting systems
29:19within an environment can be a
29:21very effective way to promote.
29:23Partners in performance and there
29:25have been several studies that
29:26have shown that just changing the
29:28lighting in a 24 hour operation is
29:32very helpful in enhancing workers
29:35ability to stay alert on the job.
29:38And then we know that fatigue
29:41will never be eliminated.
29:42You know fatigue is something that
29:44goes hand in hand with 24 hour shifts.
29:46We're never going to be able to
29:49perfectly help people work at night
29:51as they would during the day.
29:54And so we need safety measures in place
29:57specifically for safety sensitive
29:59occupations that include, you know,
30:02clear systems for handing off work and
30:05cross checking shift changes happen.
30:08And finally on the institutional side,
30:12scheduling.
30:12So this is really the big, the big,
30:15you know, elephant in the room.
30:17This can make or break an individual's
30:20ability to cope with shift work
30:22and the lion share of scheduling
30:25decisions are happening on the
30:27institutional side of the fence.
30:29And so, you know,
30:31in optimizing schedule design, you know,
30:34institutions should again maybe be
30:36using those mathematical models.
30:38But, you know,
30:39not over scheduling people or when
30:42people do need to be scheduled
30:44for extended duty shifts,
30:45allowing protected time for sleep
30:48afterwards and recovery before
30:50bringing people back.
30:51And then in this circadian
30:53friendly length is, you know,
30:55if you're if you have people
30:57working overnight,
30:57you probably want shorter shifts than
30:59if you're working during the day,
31:01rotating shifts later rather than earlier.
31:04You know this has been something
31:07that has been.
31:08Known since the 1980s that humans
31:11do better in shifting later
31:13with rotating shifts.
31:14Yet we still see shift schedules,
31:16for example,
31:17for nurses that are shifting earlier
31:19that are starting at 3:00 AM.
31:21That doesn't make a whole lot of sense
31:23from the sleep and circadian standpoint.
31:25Minimizing the number of consecutive
31:28night shifts has been shown to be
31:31important countermeasure against fatigue,
31:33and then of course allowing time off
31:36between shifts for recovery really,
31:38no matter what type of shift
31:40a person is doing.
31:41So everything that I've talked about so far.
31:45Probably feels like things
31:46that are outside your control,
31:48particularly if you're a clinician.
31:51You know,
31:52there may be opportunities to
31:54do research or work with larger
31:57organizations to implement fatigue
31:59risk management,
32:00and if you have those connections,
32:02I would, you know, strongly encourage that.
32:06But probably more useful are the
32:08individual countermeasures that
32:10people can use to manage sleep loss
32:12and circadian misalignment and with
32:14these individual countermeasures.
32:16I really think of them as proactive
32:19countermeasures and reactive countermeasures.
32:21And there is some overlap between these just,
32:24you know, there there has to be.
32:27But I'm going to try to divide them
32:29up in these two buckets to begin.
32:32So we'll start with proactive
32:34countermeasures so, you know,
32:36feels a little funny putting
32:37us sleep hygiene,
32:38slide up to a Sleep Medicine group.
32:41We,
32:41I'm sure you know,
32:43every single person here talks about
32:45sleep hygiene probably every day.
32:47But I do want to highlight that there
32:49are some aspects of sleep hygiene that
32:51can be really challenging for shift workers.
32:53And having conversations
32:55about these specific issues,
32:56I think can go a long way in
32:59helping shift workers to manage.
33:01So optimizing the sleep environment,
33:03there have been several studies
33:05that have demonstrated that having
33:07blackout shades for daytime
33:09sleepiness is critically important
33:11in increasing the duration and
33:14quality of sleep that people obtain,
33:16you know, as with other.
33:17Best practices like turning off your phone.
33:21You know you're more likely to get
33:23more phone calls during the day.
33:25Making the environment quiet and cool.
33:28All of the things that we would
33:29normally recommend at night,
33:30but that are typically easier to
33:32achieve at night than during the day.
33:34Regular sleep wake timing is very difficult,
33:37if not impossible for shift
33:39workers to achieve.
33:40And so I think that sometimes when shift
33:42workers see sleep hygiene guide guidance,
33:44they quickly dismiss above it because they
33:48see recommendations they can't achieve.
33:50But there have been some really nice studies
33:54showing that maintaining a compromise.
33:57Day shift between your day schedule
33:59and night schedule can actually be
34:02a way for shift workers to cope,
34:05and so maybe if a person is a
34:08night worker and then they revert
34:11to day's during their days off,
34:14maybe they're keeping a very late
34:17shifted sleep wake schedule.
34:19During their days off,
34:21so that they're going to bed very late,
34:24maybe sleeping in much later than a
34:28typical lifetime would be in order
34:30to avoid that giant swing in their
34:33circadian time or not massive.
34:35Their circadian rhythm probably
34:36isn't shifting very much,
34:37but to avoid that big swing in
34:39their sleep timing relative to
34:41their circadian rhythm.
34:42So while shift worker may not be able to
34:45maintain regular sleep and wake times,
34:47there are some strategies
34:48for compromises again.
34:50It depends on the nature of the work,
34:53but there can be ways around this.
34:56Avoiding bright light before bed is
34:58another one that's really hard for
35:00particularly night shift workers
35:01because most night shift workers
35:03or many night shift workers are
35:05driving home in the light.
35:07And I personally wouldn't
35:08recommend using sunglasses.
35:09I know some people do.
35:11I think that that's a safety risk.
35:13You know you want the the bright light
35:15to help someone you know stay alert
35:18during their drive home so that they're.
35:21Getting that benefit of the countermeasure.
35:23But that's going to potentially
35:25have an acute alerting effect that
35:27will inhibit one's ability to sleep.
35:29And so perhaps,
35:30maybe we're talking about having a
35:33longer line downtime before trying to sleep,
35:36after being exposed to bright
35:37sun before sleep.
35:38Or maybe we're talking about taking
35:41public transportation home and wearing
35:43sunglasses so that you can minimize
35:45that blue light on the way home.
35:47So again,
35:48it's working with people to make sure.
35:50That the recommendations meet them
35:53where they are in their workspace and
35:56then lastly just communicating with.
35:59Family,
35:59household neighbors on one's
36:02work schedule with pilots.
36:05We often have them put in a note
36:06on their hotel room door indicating
36:08that they're sleeping so that
36:10housekeeping doesn't knock on the door.
36:12You know, just little things like that,
36:14which daytime workers probably
36:16don't have to do.
36:18They can make a big difference
36:20for night shift workers.
36:21Of course, shift work
36:23disorder is a big concern now.
36:26I am I I think you heard I'm on
36:29the extrinsic circadian sleep
36:30wake disorders task force for the
36:33American Academy of Sleep Medicine
36:36and Sleep Research society.
36:38And shift work disorder is one of
36:41the one of the disorders that we're
36:45examining to provide guidelines,
36:47clinical guidelines for
36:49recommendations in the future.
36:51And this has been a big struggle because
36:55in surveys that we've done and in looking
36:58at the literature from meta analysis,
36:59we actually find that there are
37:01not a whole lot of people diagnosed
37:03with shift work disorder.
37:05Studies sort of suggest that somewhere
37:08around 20% of shift workers may be
37:10at risk or have shift work disorder.
37:13But when we actually sort of pin
37:15down to those who are diagnosed,
37:17we're not finding very many people.
37:19And so I think screening not just.
37:22It's certainly screening for all
37:23sleep disorders is important,
37:25but for that,
37:26especially for shift work disorder,
37:28so that shift workers who are having
37:31great difficulty coping can get a
37:33health and treatment that they need
37:35to better adjust to these schedules.
37:38Um,
37:39napping again is a long standing
37:42countermeasure that I'm sure that
37:45you're already thinking about
37:47using and recommending.
37:49But I think of napping in a couple
37:51of different ways.
37:52So this is really,
37:53this is the prophylactic napping.
37:55This is recovery napping.
37:56This is napping outside of the
37:59work environment.
38:00And so when a person is shifting from a
38:03day type of shift to a night type of shift,
38:07recommending a nap at a strategic time maybe.
38:10Late afternoon before the
38:11Wake maintenance zone.
38:12You know,
38:13something that could help them
38:15better get through that night shift.
38:17And then for recovery sleep.
38:19Helping shift workers to understand
38:21when to time their sleep relative
38:24to what they're doing next can
38:26be really important.
38:27If a shift worker is again doing a
38:30night shift and then sleeping all day,
38:34but has the next day off,
38:36that actually might not make a lot of sense.
38:39Maybe it's better for them to
38:40take a shorter nap.
38:41Be awake for more of the day
38:43and then go to sleep at night.
38:46So again,
38:46it sort of depends on the circumstances here,
38:49but.
38:51There have been many studies that
38:53have demonstrated the benefit of
38:55NAPS in mitigating that on the
38:58job sleepiness that occurs and
39:01if done strategically.
39:03Napping can be a really powerful
39:06tool in this bed.
39:08Lighting is complicated,
39:10and so I.
39:13Prior,
39:13both prior to coming into NASA
39:15and now at NASA,
39:16I do a lot of work on using light
39:18as a countermeasure for the
39:21populations that we work with.
39:23Obviously bright blue and rich light,
39:25just the circadian rhythm.
39:26So if you have a maybe a
39:30nontraditional work shift,
39:31for example,
39:32we work with people who are
39:34living on Mars time on Earth,
39:36so they're shifting 39 minutes later,
39:38they're shifting their sleep
39:39schedule 39 minutes later.
39:40Every day we can give them blue light.
39:43Access to the shift their sleep
39:45so that they're getting that blue
39:47light pulse sort of just before bed
39:49on the phase delay portion of the
39:51phase response curve to shift their
39:53sleep to keep them as aligned as we
39:57possibly can to that weird Mars timing.
40:00And of course light also just
40:02makes you feel more alert,
40:03so if you're in a dark environment.
40:06You're going to feel sleepier than if
40:07you're in a very bright environment.
40:09So having shift workers just use
40:11bright light as an acute common
40:14measure can be very helpful and
40:16has a direct effect on mood.
40:18But it can be complicated if you have
40:20somebody who's shifting all over the place.
40:22For example,
40:23our astronaut population sometimes can't
40:25use light as a countermeasure because
40:27as we're building their schedules,
40:29we have to shift them so much to
40:31accommodate mission events that we
40:33could end up shifting them into a phase.
40:36Position that is not optimal for the
40:38work that they have to do in the future.
40:41And so in those cases maybe we're
40:44using other countermeasures.
40:45So the the I guess answer to
40:48light here is not that it's.
40:51Can be deployed adlab.
40:52It really should be deployed
40:54in a very controlled way based
40:55on the nature of the work.
40:59Hypnotics and chromatics. So disclaimer,
41:02I'm not a clinician and we're rarely,
41:05you know even within Tigris management
41:07where I work with flight surgeons were
41:10rarely recommending hypnotics and chronic
41:12biotics because we're trying to manage
41:14with many of the other tools that we have.
41:17But particularly for Hypnotics when
41:19we're talking about shift work,
41:22we're not, have not, we don't want,
41:25have not exceeded our first line
41:26of defense because we're not
41:28shifting this circadian rhythm and
41:29if we're really trying to shift.
41:31Circadian rhythm.
41:32If somebody says doing a couple
41:35of weeks of night work,
41:37say because they work on an oil rig,
41:39we might, we might actually
41:41recommend something like chronomatic,
41:43like melatonin to help them adjust
41:45to that state more stable schedule,
41:47rather than having flight surgeon
41:49prescribe a hypnotic because the
41:51hypnotic is going to make them sleep,
41:53it's not going to necessarily
41:55shift their circadian rhythm,
41:56although there may be some benefit
41:58to them not being exposed to light
42:00at the time they're sleeping.
42:01It's really, really complicated,
42:03but largely we're really focusing
42:05on the other aspects of fatigue
42:08risk management and with the
42:10availability of melatonin,
42:11so many people just self
42:14administer melatonin,
42:16try to be very careful and cautious
42:18in our education to the general shift
42:21working workforce about not using
42:23melatonin because they have the
42:26potential to use it inappropriately
42:28or to make themselves more
42:30misaligned with that self selected.
42:32Use.
42:34And then finally,
42:36I'm an individual countermeasures personal
42:38scheduling can be a target as well,
42:40so sometimes.
42:42People have a tendency to try to job cram.
42:47They want more days off,
42:49so they'll try to get more work
42:52into a shorter number of days,
42:54and that doesn't necessarily
42:55align with what's best for their
42:57alertness and performance and sleep.
42:59And so having a conversation about
43:02how the time off will be affected
43:05by that type of job cramming can be
43:08really valuable in helping people
43:10understand that maybe it's better to
43:12spread out shifts so that you can get.
43:14Better sleep so that you can be
43:16more alert and engaged with your
43:18family on your days off and more
43:21alert and rested in going to work.
43:23And then there are some situations
43:25where individuals can choose to say,
43:27take more early starts or late finishes.
43:32Which may be better aligned
43:34with their chronotype.
43:35That should also be encouraged,
43:37and we do that in my work all the time.
43:41So shifting now to reactive countermeasures.
43:44Caffeine, of course,
43:46is probably the most common
43:49reactive countermeasure.
43:50So these are on the job countermeasures
43:53that one can use to combat sleepiness.
43:56And I think the big problem with caffeine,
43:58like with melatonin,
43:59people can just grab it whenever they want,
44:01and many people don't understand
44:03how to use caffeine effectively.
44:06So little and often is the
44:08best recommendation,
44:09about 50 milligrams an hour,
44:10which equates to about a week.
44:11Of coffee or tea and trying
44:13to recommend that people avoid
44:15habitual use as much as possible,
44:17especially shift workers.
44:20And then avoiding caffeine
44:23within six hours of sleep.
44:26Unless required by job demands so
44:28that we minimize the impact of
44:32caffeine on subsequent sleep and
44:34then other stimulants like Modafinil
44:37certainly can be prescribed.
44:39There are some studies that
44:40support the use of Modafinil for
44:42some shift working situations,
44:44but of course that should be done
44:46in a very as needed basis with
44:49oversight of the physician because
44:50the use of these stimulants is
44:53really going to depend on the nature
44:55of the job and the type of shift.
44:57The person is doing.
44:59On the job napping as a countermeasure,
45:03you know this is sort of this
45:04is your safety valve.
45:05This is the way that a person who's
45:08at work and now suddenly feeling
45:10that excessive sleepiness can
45:12relieve some of that sleepiness.
45:15And so having nap rooms, you know,
45:18in hospitals we have call rooms,
45:20but using them during the day for Naps
45:21to release sleepiness is a good idea.
45:23In other occupations,
45:25just getting that and and napping
45:27vironment in place is important.
45:29And we in this area have in
45:33some parts of the world,
45:36pilots can actually nap in the cockpit,
45:38can of course have only one
45:39pilot at a time came out,
45:41the other has to be awake and focused.
45:44But when we have a pilot
45:45napping in the cockpit,
45:46there's huge risk of negative consequences
45:50associated with sleep inertia.
45:52So we recommend that pilots
45:53limit their nap in their cockpit
45:56seat to 40 minutes maximum,
45:58and that they're we tell them
45:59they're not allowed to take.
46:00The controls of the aircraft
46:02until 20 minutes have passed from
46:04the time that they've woken up,
46:06and during that time they have
46:07to come back into situational
46:08awareness with their copilot.
46:10So this is an example of a
46:12situation where napping can be used,
46:14but has to be used in a very prescriptive
46:17manner in order to maintain safety.
46:19And then caffeine naps for short breaks,
46:23like if a person has a lunch break and
46:25has an opportunity to have a little
46:28bit of caffeine and then a very short nap.
46:31That caffeine can mitigate
46:32the impact of sleep inertia,
46:34and that can be a very powerful
46:36countermeasure for getting
46:37through the rest of the shift.
46:39Exercise and activity breaks are another
46:41on the job countermeasure that can be used.
46:44I wanna emphasize there's,
46:45you know,
46:45evidence for this but it's limited.
46:47You know the the best countermeasure we
46:49would lose would target sleep systems.
46:50Circadian systems exercise seems
46:53to have short term benefit,
46:57so short stretch breaks during long surgeries
46:59and operating rooms seem to be beneficial.
47:02That's probably not sleep related.
47:05You know,
47:06you're you're not getting a huge benefit.
47:08There has been one study at NASA
47:11by Laura Barker and colleagues
47:13that used blue enriched light in a
47:16break room with exercise machines
47:19that mission controllers could
47:21access during night shifts.
47:24And they found that.
47:27With this.
47:29This exercise break paired
47:31with the light on the mission
47:33controllers had better alertness
47:34and performance on the job
47:36after a bit of exercise.
47:38But of course this isn't a replacement
47:40for sleep, so it's really important
47:41to educate the workforce on that.
47:43And then finally, you know,
47:45this is just a hypothetical.
47:48We really don't know anything
47:50about countermeasures that will
47:51reduce risk in the long term.
47:53And there's a recent study that suggested
47:56that limiting eating to daytime may prevent.
47:59Some of that internal misalignment
48:02that comes with glucose intolerance
48:04with nightwork.
48:06This is very early.
48:07This was a lab study.
48:08We don't know how this actually
48:10translates to the real world or
48:12this long term consequences.
48:13These are areas that I think are
48:15really important for study in the
48:16future because we have no idea if
48:18the countermeasures that we're using
48:20to mitigate the short-term impacts
48:22are healthy in the long term.
48:25So just to wrap up,
48:26I'm going to take a couple slides here
48:28to tell you about an implementation
48:30example that we've done in my lab.
48:32So in aviation,
48:34I mentioned previously,
48:35you know,
48:36obviously safety is #1 and there are
48:40lots of regulations in place to make
48:43sure that pilots are set up for success with.
48:48Their work hours,
48:49with a number of hours they have
48:51to have off in between shifts.
48:53The number of pilots who have to be
48:55in the cockpit at any given time,
48:57airlines are all in the US,
48:58are also required to have a
49:00fatigue risk management program
49:02with that ongoing education
49:04with countermeasure deployment.
49:05And you know that that's again
49:08an iterative process that's
49:10constantly evolving and shifting
49:12based on the nature of the work.
49:15And with this we can test
49:17countermeasures to see how effective
49:19they are for future deployments.
49:21So we did a study using luminet glasses,
49:24which are light emitting glasses with
49:26pilots who were flying early starts.
49:29So basically these pilots were
49:32working for five days in a row.
49:35Um flying starting around 5-6 in
49:37the morning and we gave them these
49:40luminet glasses in addition to
49:42all of the other benefits that
49:45they get from the fatigue growth
49:47management program to help attempt
49:49to shift their circadian rhythm
49:52and to enhance their alertness in
49:54going into that room they start
49:56and we compared that to a placebos.
49:59This was a randomized crossover
50:01trial within participants and we
50:03were very fortunate that this
50:04airline let us change.
50:05Balance schedules so that we can be
50:08very quasi experimental about it.
50:10And in the control condition,
50:12they didn't have any light.
50:13They just had these inner safety glasses,
50:15but we didn't tell them that they were inert.
50:17And you know,
50:18very quickly what we found was that
50:21they wore both of the glasses for
50:23the prescribed number of minutes,
50:2525 minutes in the morning before
50:27they went to work.
50:28And.
50:29We found small but positive effects,
50:34so we saw small improvements in
50:36weight so and small improvements
50:38in sleep efficiency.
50:40And we also saw a very small
50:43but significant positive
50:45improvement in sleepiness.
50:47So this is, you know again is this.
50:51You know, going to make a huge splash and is
50:53everybody going to use light glasses now?
50:56But this is just one additional
50:58countermeasure that may be useful for
51:01especially people who are struggling to
51:03deal with those early starts in aviation.
51:06So overall, um,
51:09shift work perfects everybody's body.
51:12In addition to sleep,
51:15we have short and long term
51:16outcomes and of course many
51:18mitigations for the short term,
51:20but we don't really understand
51:22what's happening in the long term.
51:24As a reminder,
51:25here's the manuscript that I mentioned where
51:28most of this information is drawn from.
51:30And then if you have further questions,
51:32feel free to reach out from that.
51:33Thanks for your attention and I'm
51:34happy to take questions now if we have.
51:39Thank you so much Doctor Evans.
51:40That was a fantastic and
51:42a very thoughtful talk.
51:45I welcome everyone to ask questions.
51:49I don't see any question in the chat room.
51:52Please feel free to unmute yourself and ask.
51:55And hi, I have a question, Aaron.
51:59So one of the problems I used to see
52:02in practice was someone who had been a
52:06nurse for decades with terrible shifts
52:10that they in that they requested.
52:12I only want to work three days a
52:14week and their sleep was terrible.
52:17During that whole interval and they
52:19assumed that once they stopped
52:22working, everything would
52:23become normal and it didn't.
52:25And they were very, very difficult to treat.
52:28Do you have any thoughts on that scenario?
52:31Yeah. Oh, my goodness.
52:33And Professor Krieger, Barry,
52:34thank you for the questions.
52:36Very nice to see you.
52:39Thank you. Yeah.
52:41So, you know, I think Doctor Vicey
52:45has some work in this area looking
52:47at how years of shift work actually
52:51leads to continued disruption once a
52:53person stops engaging in shift work.
52:56And so to me, what that says,
52:58the target really has to be early education.
53:01It has to be helping.
53:03You know,
53:03I think people do that type of scheduling,
53:06schedule cramming because
53:07they're not understanding.
53:09The bigger long term consequences
53:11of their decision making and so
53:14that would be another to add to the
53:16list of long term consequences.
53:18You know you could have persistent
53:20ongoing sleep issues just based
53:22on years of shift work.
53:24I don't think there's been a lot
53:25of work in that area but certainly
53:26there's enough now that I think it
53:28could be added to the list as a caution.
53:30But again I don't think shift
53:31workers even realize as a as a
53:33you know group if you serve it
53:34someone should probably do that.
53:36If you surveyed shift workers
53:38I bet that you would find.
53:40That they didn't even realize there
53:41were increased risks of all of
53:43these long term health outcomes.
53:44And so I think we need to do a better
53:47job educating these workforces,
53:49particularly younger patients to,
53:52you know,
53:53help them understand how their decisions
53:55now may impact them in the future.
53:58Because I I don't know of any work that's
54:01been done to mitigate the consequences after,
54:04you know,
54:05after shift work has been completed,
54:07after the years of shift
54:08work have been completed.
54:10Thank you.
54:10Yeah.
54:12Yeah. And it's it's also harder
54:14for ones who go back and forth
54:16from you know shift night,
54:18night shift to day shift.
54:19You know, it keeps changing
54:20versus having a set night shift
54:22versus day shift routine I guess.
54:26Absolutely. And you know I think,
54:28I think we have you know there are people
54:31who are just victims of circumstance.
54:33They have no control over their
54:36situation and you know that that's
54:39that's the hardest I think.
54:41But when people have some control
54:43maybe they can choose to work four
54:46days instead of three and and you
54:48know have maybe a more a schedule
54:51that allows them to maybe shift
54:52from a day to an evening to a night.
54:55You know if one can.
54:56Bid for a schedule that allows that,
54:59that's better.
54:59You know, that's going to be
55:01better for their short term health.
55:02And you know,
55:03we don't know if it'll impact
55:04their long-term health,
55:05but I would hypothesize that it
55:07probably would be better than trying
55:09to cram it all in to some crazy.
55:12I mean air traffic controllers do create,
55:14they call them Rattlers where
55:16they work a day shift,
55:17have the evening off and then
55:18come back for the night shift
55:19because they don't want it.
55:20They want to have like 5 days off in a row.
55:22But that doesn't make any sense,
55:24you know,
55:25from a from a sleep health perspective.
55:27And so a lot of the work that we
55:29do with air traffic controllers
55:30is really just education.
55:32You know,
55:32this is how this is affecting your body.
55:34And then maybe even showing them
55:36feedback on how they're performing,
55:38what their alertness looks like when
55:39they're doing that type of shift,
55:40that tends to be pretty powerful too.
55:45I have a
55:46question or answer as we were talking
55:48you know before I change is related
55:50to circadian rhythm shift worker.
55:52You know it takes a while to happen right?
55:54Example the duty hour changes.
55:56Now in terms of adopting this
55:58shift work fatigue mitigation,
56:00what do you think you know would
56:02help the most for institutions to
56:04adopt these changes nationally,
56:06for example on the job napping or
56:08nap room or the proper scheduling.
56:11You know all these things
56:12but what's your thought?
56:14Yeah. Well, I mean I definitely think
56:16it varies, occupation to occupation.
56:17So as you mentioned, I worked,
56:19you know, I worked on the resident
56:21work hour studies in Boston when I
56:23was there before coming to NASA and
56:25that was really challenging because,
56:27you know, I don't think that you can
56:29just regulate these problems away.
56:31I don't think the answer is simply saying,
56:33OK, we need to just cut work
56:35hours and that's it.
56:36In a hospital system,
56:37I think you all know very well
56:39you have to engage with the nurses
56:41and with the PA's and with all of
56:43the people who are going to be.
56:44Peripherally affected by a work hours change,
56:47you might have to do rounds twice a day.
56:49So you're fundamentally changing
56:51the nature of how a work group
56:54has operated for a very long time.
56:56And to me, you know that's that.
56:58That's where implementation science comes in.
57:01You know,
57:01bringing in people who know how you
57:04know what the best practices are
57:06for implementing to make the change
57:09as effective as it can possibly be.
57:12Change is hard no matter what you do.
57:14But.
57:14Making sure that that change is done
57:16in the best possible way I think will
57:19help mitigate some of the reactivity
57:21that comes with just blanket changes
57:23that people end up hating.
57:27Right. Thank you. Two, we
57:31have any other questions?
57:41Lauren, did you have any
57:43question? No, no. OK.
57:45Thank you. Thanks, Byron.
57:47Thank you for a fantastic talk.
57:49Good to see you. Good to see you too.
57:52Alright. Thank you so much
57:54again for this wonderful,
57:55fantastic talk as usual.
57:58And well, thank you everyone
58:00for joining us. Thank you.
58:03Thank you. Take care. Bye, bye.