A Sleep Doctor’s Odyssey

I am a doctor, some of the time. I think like a doctor all of the time. Otherwise, I am a husband, father, and son.

Like most doctors, I have seen medicine at its best and its darkest. I have been fortunate, at times, to have stood at the threshold between life and death, and helped tilt the balance. I have also stood there and been unable to help. Every loss is tragic, yet we continue with optimism, with fear, with hope. It is impossible to write an objective account of this work, and of everything that led me to sleep medicine. There is something irreducibly relational between doctor and patient. We can only do our best in the struggle against suffering.

What I didn't expect was that the most important lesson of my career would come from one of the most fundamental things a human being does.

I grew up living next door to an eminent oncologist. Her garden was a maze of wizened apple trees where my brother and I would regularly lose our cricket ball. She seemed to be up at the crack of dawn and home at unearthly hours. My parents referred to her in reverent tones and would move her post or bins when she was late back from work. She was always approachable, warm, yet fiercely intelligent. My awe only increased when I practiced medical school interviews with her across the kitchen table.

I was accepted into medicine at the University of Southampton. Anatomy, physiology, pathology, and pharmacology filled the first years. We practiced taking histories from patients, and actors, fumbling through clinical examinations with the particular earnestness of people who know exactly how little they know. Midway through the degree, I embarked on an elective in Swaziland, now Eswatini. The inverse care law was not an abstract concept here. It was a fact of life.

It was also here that I had my first taste of working at night and first encountered sleep in its most consequential form.

I joined the skeleton night crew in an already meagrely staffed rural hospital. The night air was cool; the stifling heat of the day had given way to an ominous calm. Somehow working at night seemed both adventurous and slightly unreal. I watched the African stars as I waited. Then a Toyota pickup drove up the rutted path and a young man was carried into our emergency room. The yellow lights flickered as moths danced beneath them. He was dressed in jeans and a shirt dusted with iron-ore red. He lay motionless as we spoke to the driver. We expected an animal collision with an elephant, perhaps, or a buffalo on a night road. We were wrong.

Sitting in the back of the pickup, he had fallen asleep, and fallen out, onto the road.

At first I couldn't see any injuries. Then a trickle of dark blood appeared from behind his head. Further inspection revealed the entire back of his skull to be caved in. I was at a loss. My third-year medical school knowledge was desperately inadequate. A three-hour flight separated him from a Johannesburg neurosurgical unit but even with surgery, his chances were slim. The best we could do was keep him comfortable. Our patient slipped away the next morning.

I didn't know it then, I was too shocked to think in metaphors, but I had already met the subject of my life's work. A man had fallen asleep and died of the consequences.

I completed medical school, graduated, and due to a quirk of the placement process, began my first job in Merthyr Tydfil in Wales, a place I had never heard of before. The year was brutal and the learning curve exponential. Staff shortages meant I was an integral part of the team from the beginning, seeing hundreds of patients, scrubbing into procedures, treating genuinely sick people. Unlike contemporaries in prestigious academic teaching hospitals, I was learning by necessity, which turned out to be an excellent education.

I then moved to Aberystwyth for further rotations in orthopaedics, palliative care, and emergency medicine. I visited the beach when I could. Night shifts were full of what I can only describe as adventure and warning in equal measure. One evening, a nurse bleeped me with a question that has stayed with me ever since. Should she wake the sleeping patient, she asked, so they could be given their sedative sleeping medication? I said no, noted it on the chart, and didn't think much more of it at the time. Looking back, it was one of the sanest clinical decisions I made that year and it pointed, obliquely, toward everything I would later come to understand about how profoundly we mismanage sleep in a medical setting.

I applied for an emergency medicine training post and was accepted into the Oxford Deanery. Here my antisocial shifts started in earnest. Whilst the clinical work in emergency medicine, ICU, and acute medicine was genuinely stimulating, I began to dread the nights. Under fluorescent lights in a windowless A&E, I lost track of whether it was day or night. There was an intense nausea in the mornings after finishing a night shift that went far beyond ordinary exhaustion. I was sleeping a broken four to five hours between shifts, while trying to prepare for postgraduate exams.

An academic clinical fellowship in ICU followed. One morning at handover, exhausted after a night on the unit, I stood in a room of exceptionally bright consultants and ambitious juniors and began presenting a new patient. "Mrs Smith," I said. "Seventy-four years old, admitted with sepsis. I have honoured her request not to be reincarnated and have signed a form instructing we do not attempt a CRP."

There was laughter. What I had meant to say was that I had completed a DNACPR form — Do Not Attempt Cardiopulmonary Resuscitation. The ICU also did not routinely measure CRP in this context. My Freudian slip of terminology was, at least, medically logical. But the ease with which the exhausted brain reaches for the wrong word, and the fact that the wrong word, here, was reincarnated, told me something I was not yet ready to fully hear.

My sleepiness had not caused harm, but I was nervous.

Soon I had stronger warnings. I walked absent-mindedly into traffic outside the hospital. I sent a letter without postage stamps. I spent several minutes trying to unlock what turned out to be the wrong flat, wondering why my key had stopped working. A close friend,  a GP, recently returned from BASE jumping in Europe, visibly thriving, watched me across a table and asked, without ceremony, whether I had lost the plot. He was right. I couldn't deliver the care I wanted to give when the job itself was breaking me down.

The moment that finally decided things came during a night shift I had worked dozens of times before. At 3am I was called to resus to assess a patient with suspected sepsis. The medical registrar on call, more junior than me, wanted to place a central line and asked me to supervise. I had placed over a hundred so I agreed. She prepped the patient under harsh resus lighting. My head swam from the glare. I stood at the end of the bed, leaning against a chair. I was trying desperately to stay awake.

The line was in safely. On the way home later, I wondered about my future.

I resigned my training number at the end of that month.

I retrained as a GP. Primary care, I quickly discovered, is medicine in its purest form: a remarkable mix of clinical medicine, policy, management, and human relationship that few other careers can match. I had not expected to end up there, but it allowed me to use and develop every skill I had.

During GP training, I attended a teaching session on sleep medicine. I was fascinated, and, frankly, unsettled. How could I know so little about the fundamental process that happens to every human being, every night? I applied to Oxford and was accepted for the MSc in Sleep Medicine. I studied whilst working full time. COVID-19 arrived mid-course, a second night shift for the entire country, and I was asked to help lead a local primary care hub assessing patients. I deferred the MSc by a year. Then I completed it.

The more I looked, the more sleep problems I found. Patients were so grateful just for someone taking an interest in their sleep. I began volunteering with The Sleep Charity, translating complex concepts into language that patients could use. I helped build a private insomnia clinic. I began advising pharmaceutical partners on the real-world delivery of new sleep therapies. More recently, I was privileged to join the sleep team at Royal Papworth Hospital: one of the country's foremost centres.

None of this felt like specialisation. It felt like a natural evolution, following a thread I had first glimpsed, without knowing what I was seeing, in a rural emergency room in Eswatini, watching a young man who would not wake up. This is not a story about a doctor who found sleep medicine. It is the story of a doctor who was broken by night shifts, by the limits of what circadian biology can tolerate, and who discovered, in the process, that the most powerful medicine we possess is the one we take for granted every single night.

I still practise primary care. I still see the same patients week after week: the anxious young father, the menopausal woman who hasn't slept properly in three years, the shift worker whose body is at war with its own clock. Each consultation is a meeting of person, science, and story. My hope, in writing here, is to share that meeting with you.

If I have learnt anything, from the dust of an African road, to the fluorescent glare of an ICU, to the quiet of a consulting room at eight in the morning, it is this: the doctor who understands sleep is the doctor who can help a person feel alive again.

And that, in the end, is why I am still a doctor. Some of the time.