Fighting Fatigue in Residency Training and For Life

I got this message from the Co-Director of our Residency Training Program, Dr. Allison Williams, MD, about the need for all faculty members and resident physicians to complete MANDATORY training on ways to recognized and manage signs and symptoms of fatigue. Hey it’s a requirement from the Accreditation Council for Graduate Medical Education (ACGME). I had to review critically important information about this and I learned a few new things that I’d like to pass on to you. We need to learn about and cope with fatigue in order to be in the best position to improve quality of patient care, resident physician well-being–and of course, because the ACGME requires us to learn it and demonstrate knowledge about this issue.  The following was an outstanding educational presentation from Dr. Williams.

The ACGME created Duty Hours restrictions mainly to address concerns about fatigue leading to medical errors that could cause harm to our patients. In fact, it sounds shocking but 44,000-98,000 patients die annually from preventable errors. Obviously, we want to raise awareness about the issue, but more than that empower trainees to learn skills that will allow them to manage fatigue so they can provide high quality medical care to patients. While there may not be direct evidence to show that, there is every reason to believe that arming ourselves with knowledge and working to change the culture of current physician training programs can’t hurt us or the people we care for.

So what’s the evidence that fatigue influences patient care in a way that causes serious errors? It’s limited:

  • Root Cause Analysis of adverse events-only about 4.5% are attributable to fatigue
  • Malpractice claims-5% of trainee cases and 1% of non-trainee cases cite fatigue as a factor in adverse events
  • Odds ratio of 1.61 that there’s increased risk of percutaneous needle stick injuries at night

But hang on, there are several extant resident surveys showing that medical errors can be linked to the number of calls per month and longer working hours. Residents believe that fatigue is one of the major causes of medical errors. One reason for not seeing more direct harm to patients is the mitigating factor of staff supervision heading trouble off at the pass.

Furthermore, there is strong evidence that fatigue can affect patient care skills, including:

  • Slower response time on monitoring tasks for fatigued anesthesia residents
  • Reduced speed and/or quality of skills in a simulated intubation task for emergency physicians
  • Slower time and more errors in a simulated laparoscopic task for surgeons
  • Reduced alertness, falling asleep, and behavior changes in tasks using a patient simulator

And let’s remember that resident physician well-being can be harmed by chronic fatigue and long duty hours:

  • Increased risk for motor vehicle accidents and near misses
  • Depression, with about 30% of residents reporting depressive symptoms related to sleep deprivation
  • Pregnant resident physicians have double the rates of premature labor and preeclampsia of other working women

Therefore the ACGME Mandates for Alertness Management/Fatigue Mitigation requires programs to:

  • Educate all faculty members and fellows to recognized the signs of fatigue and sleep deprivation;
  • Educate all faculty members and fellows in alertness management and fatigue mitigation processes;
  • Adopt fatigue mitigation processes to manage the potential negative effects of fatigue on patient care and learning, such as naps or back-up call schedules

So what types of fatigue are there? They include acute sleep deprivation or hours without sleep, circadian rhythm effects, and chronic sleep deprivation.

Acute fatigue grows after 17-19 hours without sleep and this gets worse the more time you go without sleep. Our sleep clock is in the hypothalamus in the supra-chiasmatic nucleus. We are programmed for two periods of decreased alertness and those occur between 3 a.m and 7 a.m. and between 1 p.m. and 4 p.m. (can you say “siesta”? Muy bien, muy bien). The effects of sleep deprivation actually mimics the effect of a having a blood alcohol level of 0.08 mg/dl.

Chronic fatigue is getting less than 6 hours of sleep a night for 2 weeks, which is equal to going 24 hours without sleep along with a sense of subjective sleepiness. Did you know that 20% of resident physicians report getting less than 5 hours of sleep a night, and 66% report getting by on less than 6 hours of sleep a night? Moreover, those who are chronically fatigued are less aware of the effects of this condition and actually rate themselves as performing at a non-impaired level, probably because they lose that subjective sense of sleepiness you get when you’re acutely sleep-deprived.

We need to know the signs and symptoms of fatigue and they include irritability, moodiness, and disinhibition. There can be frontal lobe dysfunction such as apathy, impoverished speech, and flattened affect, as well as impaired memory and inflexible thinking and planning skills. Intrusive sleep can occur as well with microsleep episodes of 5-10 seconds leading to lapses in attention. It can also be easier to nod off when just sitting around and REM sleep phenomena can occur, including hypnagogic hallucinations.

The effects of fatigue include increased tolerance for risk, passivity, problems thinking. and psychomotor slowing.

So what are some of the strategies for managing fatigue? System changes like work hour restrictions, personal habit changes like improving sleep, and–you guessed it, sucking down the joe. Caffeine in non-psychosis producing amounts can be helpful. Mitigating the effects of fatigue can be finding alternative transportation and changing the culture of medical training and practice.

Duty hours restrictions as of 2011 include:

  • 80 hours a week
  • Maximum per shift: 24 + 4 (16 for interns)
  • 1 day in 7 off all clinical responsibilities
  • Call no more often than 1 in 3

And for every 1 hour off duty, the resident should increase sleep by about 20 minutes. You should use time off to get some sleep. Now there are competing views on duty hour restrictions, and you might want to take a look at what Dr. Kevin Pho says about it at link http://www.kevinmd.com/blog/2011/08/work-hour-restrictions-improve-patient-safety.html. Dr. Pho makes a good point about the problem with handoffs and I’ve posted about this as well, so have a look at short links, http://wp.me/p1glcu-1ms (Back When I Never Got to Sleep) and http://wp.me/p1glcu-1t1 (Getting the Handoff Right).

Remember about basic sleep hygiene, something we’re always telling patients:

Another strategy is to take naps to get extra rest. I flunked napping in Kindergarten, so this probably wouldn’t help me. But it’s worth a shot. Caffeine, usually in the form of coffee can help, as long as you don’t overdo it, which can lead to tolerance and withdrawal. A dose of 200-600 mg of caffeine can produce a significant performance boost. Here’s  a table of relative caffeine doses in various energy boosting drinks:

There are other pharmacologic agents, including melatonin as a hypnotic.

Finally, one of the most important changes we can make as professionals is to change the culture in which we learn and practice. The culture teaches us to tough it out and be superdoctors. Hey, it’s not cool or tough to smoke; it’s not tough or cool to try to take care of patients when you’re fatigued. And while there’s healthy debate about whether duty hours restrictions can make hospitals safer because of the many reasons why safety is a major challenge to maintain, it’s tough to argue with trying to improve the quality of life and health of physicians themselves.

Hey, somebody needs a nap.

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Comments

  1. Great review and tutorial! A couple more things to add to the list for consideration for anyone working >40hrs/12+ consecutive hrs:

    If the prefrontal cortex is cooled (ice packs/colling caps) insomnia can be eliminated (Sleep 2001 conference abstracts supplement – 0534 FRONTAL CEREBRAL THERMAL TRANSFER AS A TREATMENT FOR INSOMNIA: A DOSE-RANGING STUDY Nofzinger E1,2, Buysse DJ1 1Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh,
    PA, USA, 2Cereve Inc, Allison Park, PA, USA). So go to sleep with an ice pack on your head.

    Since night shift folks have to fight that 3 am dip, it helps to make midnight mini rounds with the nurse(s) to check physician orders for routine things such as pain meds, anti nausea/indigestion prns, VS/activity orders/parameters, skin care, diet orders, etc – all of the things that nurses may need to deal with during that time period, but which don’t warrant an eyes on assessment by the covering doc. Way back when as a new grad and night charge nurse (30 yrs ago – sheesh), I did this with the PGY1s on a medical unit, and I paged them a total of three times in 6 mo: an arrest, an acute GI bleed, and a hypoxic episode – I still remember each event because it was so rare. They got to sleep, patients didn’t have to wait on comfort measures and so slept and rested better, and I didn’t have to chase down sleepy/cranky docs. Win, win, win. We sat together with charts open, reviewed orders, planned for the night and were done for 23 patients in about 30 minutes. Conceivably, this could be done during signouts as long as an RN is present. As a bonus, we often found and corrected near miss errors.

    Happy holidays and thanks for all of the nifty items you provide here!

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    • Hey, I’m doing triage call tonight for our Medical-Psychiatry Unit and saw your comments. I really like the midnight mini rounds idea. It sure seems to me that both psychiatry and medicine residents are a whole lot busier than when I was in training.

      Happy holidays to you too and I appreciate your thoughts!

      Best wishes,

      Jim Amos, MD

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