High prevalence of insomnia among physiatrists in the Czech Republic: A web-based questionnaire survey

1 Introduction

Physical and rehabilitation medicine (PRM) is a medical specialty where physicians are known as ‘physiatrists’ or ‘PRM physicians’. Like other medical specialists, these physicians provide direct medical care managing various health conditions and need to receive training in different emerging methods, e.g., musculoskeletal ultrasonography [1] and robotic rehabilitation [2]. In addition, physiatrists are responsible for leading/coordinating the multiprofessional rehabilitation team, e.g., physiotherapists, occupational therapists, speech therapists, psychologists, nurses and social workers [3, 4]. Furthermore, PRM physicians interact with people of all ages with different disabling health conditions, e.g., spinal cord injury, stroke, multiple sclerosis, and polytrauma. Therefore, chronic occupational stress and emotionally challenging work, particularly when associated with inadequate reward, can result in physician burnout [5]. A career satisfaction rate of 75% was reported in the PRM specialty in 1997 [6]. Shanafelt and coauthors, seventeen years later, reported a 63.3% prevalence of burnout among physiatrists, with an unfavorably increasing tendency across time [7]. Later, in 2019 the prevalence of burnout among PRM physicians was reported as 51% [8]. Notably, burnout has also been reported to be reciprocally associated with sleep problems [9, 10]. Insomnia can be defined as an unpleasant experience of difficulty initiating sleep, maintaining sleep, and non-restorative sleep. Sleep quality is influenced by several factors, including depression, other comorbid diseases, sleep hygiene (habits around bed/bedtime to promote better sleep quality), and professional activities. Particularly, shift work was documented to be coupled with a higher risk of depression and sleep disorder development in night shift workers, e.g., physicians and nurses [11–14]. Another mechanism for developing sleep problems is work-related stress [15], which could be the main contributing factor in physiatrists. Importantly, tired physicians are at an increased risk of mistakes and poor decision-making [16]. Furthermore, a sleep disorder can lead to psychopathological impairment and other serious health problems (e.g., hypertension) [17]. The good mental shape of health care professionals is essential for their clinical work and academic performance [18]. Physiatrists’ mental health and professional satisfaction are major issues in our field that need to be investigated [19]. Although sleep disturbance has been reported in medical school students [20] and physicians across several medical specialties [21], no published studies addressed sleep patterns among physiatrists to our best knowledge. We conducted this study to evaluate sleep quality and habits and possibly associated symptoms of depression in PRM physicians.

2 Materials and methods

3 Results

A total of 102 responses were received. One questionnaire was excluded as it contained data potentially compromising the anonymization. Most of the respondents were females (76.2%), and the majority was aged between 25 and 40 years (70.3%). The sample consisted of 62 PRM specialists and 39 trainees. The median experience as a physician was eight years. Most participants (47.5%) lived with spouses and children or spouses without children (32.7%). Thirty-six (35.6%) physiatrists performed night shifts. The sociodemographic data of the participants are given in Table 1. The prevalence of significant sleep disturbance (PSQI > 5) was 64.4%, and the prevalence of symptoms of depression (BDI-II>13) was 22.8%. The mean PSQI, SHI, BDI-II scores were 6.85±3.09, 18.18±5.35, and 8.36±7.52, respectively. The scores for the PSQI, SHI, and BDI-II concerning gender, household characteristics, training status, and age are presented in the chart diagrams (Figs. 1 and 2). All PSQI, SHI, and BDI-II showed a significant mutual positive correlation at the level of significance p < 0.001. The type of professional activity (outpatient care vs. inpatient care vs. spa department) (p = 0.812) showed no relationship with sleep disturbance (Table 2). When comparing trainees with specialists regarding nightshifts, we found a significantly (p = 0.031) worse score in the SHI for those who regularly worked nightshifts only within the trainees’ group (Table 3). Among the PSQI questionnaire’s seven components, we observed a significant (p < 0.001) positive correlation of subjective sleep quality and sleep latency with SHI and BDI-II. Sleep duration and sleep efficiency were positively correlated with SHI (p < 0.001). The components assessing sleep disturbance, use of sleep medication, and daytime dysfunction were significantly positively correlated with BDI-II (p < 0.001) (Table 4). When evaluating the SHI individual questions, poor sleepers showed a significant association with emotionally burdened activities before bedtime (p < 0.001), frequent use of the bed for non-sleep associated activities, and allowing mental activities to occur in bed (both p < 0.05). Sleeping in an inappropriate bedroom (p < 0.01) and performing activities requiring high levels of attention shortly before bedtime (p < 0.05) was associated with the male gender. Living alone was associated with mental activities, such as using the internet or playing video games close to bedtime (p < 0.01) (Table 5).

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Fig. 1

A chart presents values for the Pittsburgh Sleep Quality Index (PSQI), Sleep Hygiene Index (SHI), and Beck Depression Inventory-II (BDI-II) regarding household characteristics and gender.

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Fig. 2

A chart presents values for the Pittsburgh Sleep Quality Index (PSQI), Sleep Hygiene Index (SHI), and Beck Depression Inventory-II (BDI-II) regarding age and training status.

This study showed that almost 65% of the physiatrists who volunteered in the present study had unsatisfactory sleep quality (as defined by PSQI > 5). Notably, a relationship between poor sleep quality and sleep hygiene misbehavior and symptoms of depression was found. In the general population, the reported prevalence of sleep disturbance was 36% [27]. Previous studies indicate an increased risk of sleep disturbance development among some medical specialties. Carvalho Aguiar Melo et al. reported unsatisfactory sleep quality in 59.3% of psychiatry residents [28]. The reported prevalence was even worse than 46.1%, as previously documented among anesthesiologists [29] and obstetrician-gynecologists, where 29% of physicians showed very or fairly bad quality of sleep [30]. Recently, Gustavsson et al. reported a nearly 40% prevalence of less satisfactory sleep quality among primary care physicians. Interestingly, those who worked overtime but not on night duties were at higher risk of sleep unsatisfaction than those who worked overtime and took night duties [31]. We observed a worse score in the SHI for those who regularly worked nightshifts only within the trainees’ group. We can assume that this asymmetry in sleep hygiene behavior between trainees and specialists can result from the different workloads of trainees during the night shift. Nightshifts of trainees in the PRM typically comprise duties in the PRM department and, e.g., emergency medical service. Interestingly, PRM trainees who worked night shifts did not develop sleep problems as determined by the PSQI. This effect can be due to a young age, making younger trainees more resistant to insomnia. Another study showed sleep problems in 35% of primary care physicians, with a significantly higher prevalence (40%) among women [32]. Medical specialty with an alarmingly high risk for burnout (ranging between 25% and 77.8%) [33] is emergency medicine. In this specialty, Alhifzi and colleagues reported poor sleep quality in 83.8%, determined as PSQI scores≥5 [34]. Importantly, the prevalence of hypnotic drug use reached nearly 20% of emergency physicians, based on data from 1,097 emergency physicians working in Taiwan [35]. Regarding pediatricians, a survey from the United States reported good sleep quality in 71.2% of the respondents. However, their methodology for evaluating sleep was limited to only one question regarding the duration of sleep. The authors considered it sufficient when the self-reported time was≥7 hours [36]. When speaking about non-physician members of the rehabilitation team, a study from Brazil by Lino and coworkers reported poor sleep quality in 88% of frontline working physiotherapists during the COVID-19 outbreak. In nonfrontline workers, the reported prevalence was lower at 78% [37]. On the other hand, in their survey, Whelehan and colleagues mentioned that 63.3% of physiotherapists responded that they did not feel that their practice impacted sleep [38].

In our sample of relatively young physicians, we did not find any relationship between age and sleep quality. Notably, more than 90% of participants in our sample were < 50 years old. The absence of a larger number of older physicians is a relative limitation of this study. Kováčová et al. published a research where sleep quality was assessed using an actigraphic bracelet. In this study, the authors found better sleep quality in young women. Notably, gender differences were not evident in older participants [39]. Regarding sleep hygiene, we found its misbehavior to be more prevalent in trainees who regularly took nightshifts, males, and those who lived home alone. The higher prevalence of sleep hygiene malpractice is in line with the results reported for medical students. Interestingly, according to the study with medical students, married males had worse sleep quality [40]. Another recent study found, regardless of the profession, that older women living alone had poorer sleep quality than older men [41]. We did not notice any association between smoking and sleep disturbance. That is in line with another study; the results suggest that smoking is not associated with poor sleep hygiene or sleep quality [42]. This is in contrast with a study by Wetter et al., who reported an association between smoking and difficulty initiating sleep, and symptoms suggestive of sleep fragmentation [43]. We found that 22.8% of our respondents suffered from symptoms of depression. The observed significant correlation between symptoms of depression and poor sleep quality is in agreement with other studies published in the literature [44]. Observed sleep impairment might be due to poor sleep hygiene and symptoms of depression, which showed a significant mutual relationship.

5 Conclusion

The present study found a high prevalence of poor sleep quality among physiatrists. Factors associated with an increased risk of poor sleep quality were depression and sleep hygiene misbehavior. BDI-II showed a significant mutual positive correlation at the level of significance p < 0.001. Considerable efforts should be directed toward sleep hygiene behavior [45] and mental health improving in practicing physiatrists. Sleep hygiene education can be one of the options to improve sleep quality. Last but not least, organizational strategies and individual-focused interventions, and the development of health-promoting activities should be adopted to mitigate physician burnout [46] and improve well-being. One of the promising approaches can be, e.g. animal-assisted therapy [47].

Ethical approval

Ethical approval for this study was obtained from the Ethics Committee of the General Teaching Hospital in Prague (86/21 S-IV).

Informed consent

Participants consented to participate in the study before filling out the questionnaire.

Conflict of interest

None to report.