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Incidence of and risk factors for nodding off

at scientific sessionsKenneth Rockwood, David B. Hogan, Christopher J. Patterson; or the Noddingat Presentations NAP) nvestigators

Abstract tive, to rushed, to Felliniesque. The incidence density curveranged from 3 nod-off episodes per lecture (NOELs) to 24

We conducted a surreptitious, prospective, ohort study to ex- NOELs per 100 attendees (median 16 NOELs per 100)piore how often physicians od off during scientific meetings nd (Fig. 1). Risk factors for NOELs are presented n Table 1.to examine isk actors or nodding off. After counting he number Interviews with colleagues who nodded off revealed thatof heads alling forward during 2 days of lectures, we calculated they were comforted to know they were not alone. Mostthe incidence density curves or nodding-off episodes er lecture had no enthusiasm to attend boring lectures but were in-(~OELs) and ~ssessed isk factors using o?istic egression naly-- clined to go if influenced by p\lyment, CME credits, guilt

SIS, n this article we report,our ~ye-o~mng ~esults nd suggest or obsessiveness. eing internists, all but 1 were relieved toways speakers an ry to avoid osing heir audience, discover that their falling asleep was not their fault but that

of the speakers.~ espite their known i~efficiency, lecture~ ("a .i,""" means of transferrinp;not~om~es of Interpretation, the speaKei'"'to-fli"epages filieaudience. wirJ -"co out going oug e mm 0 either") c~n- V':'e, observed that clini~ally important proportions of

~ tinue t:o.,Treoominate sa I11t:Clll:){nelpmg physIcIans nodded off durIng the lectures, that there ap-physicians earn their trade. At a recent 2-day lecture series, peared to be a dose-response effect and that speaker char-we noticed that many of the attendees around us were nod- acteristics were the strongest risk factors.

\ ding 9ff, 1n'ctuainp; e of our~ljthnr" (rJ P)After Our study had mportant imitations. Because e sat at. AIY awakenmghim, we decided o study he bored~m tself by the back of the room, we could not see everyone's aces.

"' measuring how often physicians nodded off during the lec- Thus, people who can sleep without head movement

tures and assessing isk factors for this behaviour. would have been missed. However, since we were count-ing physicians who were "nodding off" and not "sleeping,"

Methods we were pretty much covered there. Misclassification biaswas another possibility, especially since the rapid flashing

Si11ce e were sitting together at the back of the room, we of slides could have induced absence seizures that maycounted he number of heads alling forward as a sign of noddingoff. We chose his method because ounting is scientific. Wecarefully ecorded data on what we thought seemed ike reason-able isk factors; anything we were unsure of we made up. In asmuch as a single episode f nodding off indicates ubmaximal t-tention, we calculated ncidence density curves. To be fair to thespeakers after all, we are Canadians), we counted only 1 nod-ding-off episode er listener-colleague er lecture. For the logis-tic regression nalysis we dichotomized odding-off events s oc-curring at a frequency above he median or, at or below, themedian or less. Because his was an exploratory tudy, we also ad-ministered a short questionnaire Appendix 1) to colleagues hohad nodded off.

0r--or,

~ Results

I About 120 people attended he 2-day ecture series. We~ had to adjust our analysis because many had left by the end~ of the second day. The quality of the lectures aried rom8 entertaining and informative, to monotonous and repeti-

CMA).OEC.7,2004;171 (12) 1443

It) 2004 Canadian Medical Association or its licensors

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Table 1: Risk factors for nodding off at lectures40

Odds ratio35 . Z Factor (and 95% CI)30 Z Environmental

'" Z Dim lighting 1.6 (0.8-2.5) G..~ 25 1. Warm room emperature 1.4(0.9-1.6) l"'lA.~~ Comfortable eating 1.0(0.7-1.3) /'Q 20 Audio~isual ( ;t-S. 15 Poor slides 1.8 (1.3-2.0) . S -

~ Failure o speak nto microphone 1.7 (1.3-2.1)10 Circadian

Earlymorning 1.3(0.9-1.8)5 Post prandial 1.7 (0.9-2.3)

Speaker-related0 Monotonous one 6.8 (5.4-8.0)---0510152025303540 Tweed acket 2.1(1.7-3.0)---

Duration of lecture, min Losing place n lecture 2.0 (1.5-2.6)

Note: CI = confidence interval.

Fig. 1: Special ncidence density curve, showing number of nod-ding-off events per lecture (NOEls) per 100 attendees overlength of time of presentation. among attendees on when the speaker's prefatory comments

would end and the actual topic of the lecture addressed.have been mistaken for nodding-off events. Another limi- We were surprised to see the relation between tweedtation was one of undercounting, especially during lectures and NOELs. Further analysis shows that it is tweed, notby the more boring speakers. Such speakers can induce plaid, that is implicated. Tweed is often worn by fops, butinattention (and its common correlate, fantasy) to the ex- many otherwise admirable men wear tweed from time to

r. tent that it becomes mpossible to concentrate on the task time without apparent adverse effects. Chronic tweed

of counting nodding heads. However, as far as we can tell, wearing, however, might indicate a boring phenotype, or itat least 2 of us were attentive at any given time, so we might be causal: weed may harbour little insect-like crea-doubt that undercounting was a factor. Perhaps his is fan- tures whose dander could cause asthma and chronic hypox-tasy, though. Overcounting may have occurred if some of emia, with subsequent cerebral dysfunction. Without ap-the NOELs were actually vigorous noddings in agreement propriate clinicopathological correlation it is impossible to(NIAs). However, experienced observers such as ourselves say. Thus, we have resolved, in the interests of science, ocan readily distinguish between NOELs and NIAs by a va- sacrifice a few boring speakers and study their brains, pend-riety of associated factors, including timing, amplitude, ing ethical approval.frequency, and presence of snoring, drooling and gasping. The questionnaire administered to the nodders-off wasNarcolepsy, however, must remain in the differential diag- revealing. Most were reassured o know that it wasn't theirnosis of NOELs. fault. One participant, however, insisted on accepting the

Our study was not precisely double-blinded, since we blame, and indeed on making sure that all physicians whocould not find a valid way of unobtrusively counting people nodded off were to be blamed entirely. We have encour-with our eyes closed. The frequent nodding off of one of us aged his person to switch to a career better suited to physi-(C.].P.) is a form of blindness, and, as s often the case, our cian-blaming, such as law, evidence-based medicine orcolleagues had no idea of what we were up to. Therefore, bioethics. (The last option appears o be the most efficientwe claim a one-and-a-half-blinded design. (This study de- for career change, often requiring no more than a mini-sign has received scandalously ittle formal attention from sabbatical and a willingness to preface even the most banalmethodologists, something that one of us [C.].P .], being 10- comments with ''as Plato has aught us.")cated at McMaster University, hopes to put.right, if he can Nodding off at presentations s common and may pose astay awake.) risk to the health of patients. Studies are required to assess

We were interested to observe that some intrinsically the effectiveness of interventions (e.g., lessons in publicboring talks (those with obscure topics, few data, absent speaking, wardrobe makeovers, drama classes) n prevent-analyses) ad unexpectedly ow NOEL rates. We attributed ing nodding off during lectures.this to the bizarreness of the presentation. Factors such aswandering off to inspect the screen, dropping the micro-phone or just raving - although disconcerting to the audi- Kenneth Rc:kwo.od is from Dalhousie University. Ha1!fax. NS. David H?gan is

. . .. from the Umverslty of Calgary. Calgary, Alia., and Christopher PattErson IS fromI ence - helped to keep the physIcIans awake, as dId sIde bets McMaster niversity, amilron, nto

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Appendix 1: Questionnaire used to interview physicians who nodded off

'-, Did you feel encouraged o know that you were not alone? circle one)~~f~ 1 2 3 4 5

" Very encouraged, Neither ere nor More

able to live a there despondentnormal life again than ever o bewithout shame part of such

rabble'.

Would you be likely to attend such a lecture again? (circle one)

1 2 3 4 5Can't wait - Will go along Would rather

always need a nap if paid have teethdrilled

Whose aultdo you hink t was hat you nodded ff? circle one)1 2 3 4 5

The speaker's ault Mea maximatirely culpa

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~ The long and the short of it

Michelle Greiver

.he day after I returned from summer vacation this year,

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I felt as f I needed some medication to help me cope, with the accumulated pile of correspondence, lab re-"

ports and phone calls to return. Perhaps someoneshould devise a "morning-after-vacation" pill. My of-

fice administrator says that going through all this material is likeconducting an archaeological dig, in which I remove progressivestrata of charts to get to the bottom of things. And of course therewas the usual volume of patients with urgent problems that could behandled only by me (it's nice to be thought indispensible) and thathad to wait (the urgency notwithstanding) for my return.

To boot, the little steel bar that provides tension to hold the ear-pieces of my stethoscope n place broke hat day, so that the instru-ment kept falling off my ears. ordered a new one, and the manufac-turer has sent me one that is 27 inches ong, a stethoscope n Viagra. Ican hold the bell at arm's length, perhaps (qr patients I don't really

N care about. The company says hat's the only length they have: hey're supersizing everything these days. The long and the short of it is, I feel~ ike I've got an elephant's runk swinging around my neck. MyoId" forme fruste was never as rustrating as his.8 Dear Santa, really have ried to be good. Next year could I2 please ave a ong vacation and a short stethoscope? !!

r-,: .Q8 Michelle Greiver s a family physician n Toronto. Onto ~

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CMAj. DEC. 7, 2004; 171 (12) 1445

ICJ 004 Canadian Medical Association or its licensors.

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