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I AM no fan of being sleep-deprived. I hate that hazy, muddled feeling of forcing my brain to function exhausted while it screams at me to stop.
Stop now. Sleep.
Doctors are no strangers to fatigue. Admittedly I have never had to work the outrageously long calls that my predecessors had to, but like any professional group that has to provide round-the-clock services with limited resources, we still fight an inevitable battle to ward off fatigue.
Ultimately, the problem with fatigue is its capacity to insidiously impair us. And if that happens while we are caring for patients or behind the wheel after a long shift then we risk converting that impairment into serious – sometimes fatal – harm.
Put simply, we know that fatigue kills, so how are we doing managing our risk? Do we have a mature and functional approach to recognising and mitigating our potential for impairment? Or are we still kidding ourselves that we can suck it up and soldier on?
- Related: MJA InSight — David Hillman: Value of sleep
- Related: MJA InSight — Jane McCredie: Working rites
- Related: MJA InSight — Rob Mitchell & Will Milford: Working hours balancing act
The answers are not clear-cut. Effects of fatigue will vary depending on the duration and quality of preceding sleep, the familiarity of the task being performed, and whether there is anything else contributing to potential impairment, like illness.
There have been some significant improvements in the safety of rostered working hours for trainees and full-time hospital doctors. The adoption of safe working hours is the reason why I never had to work 36 hours straight when I was training. I was certainly grateful for that fact, but beyond recognising that working continuously for periods that the community-at-large would think were insane, have we changed much else?
Of course, not all of us are full-time staff, which makes negotiating on-call and routine rosters all the more difficult. Many hospital doctors work solo and balance work across multiple hospitals in public and private practice. Maintaining safe hours beyond training while in solo practice can be a real challenge.
Some attempts have even been made to formally quantify and manage fatigue risk using validated screening tools, but they’ve by no means been universally adopted or accepted. These tools are designed to account for various factors affecting fatigue and generate a risk scoring to assist in rosters and duty hours.
These systems are often drawn from the aviation industry. Pilots are a group renowned for their safety culture and their early adoption of fatigue risk management systems. I’m fortunate to be able to work alongside aviators in aeromedical retrieval. Their focus on mitigating and avoiding fatigue-related errors leaves us looking pretty amateur.
Our culture is not like theirs. If we’re honest, we still think being tired is a bit soft. In certain parts of medicine there remains the part martyr and part tough guy mentality that says “fatigue doesn’t affect me”. Throw in some commercial imperative and limited options for after-hours cover and the preconditions for practising while fatigued are set.
Interestingly, there has even been some concern raised in the medical literature that reduced work hours increases clinical handovers and dilutes clinical experience, both of which may not be good for patient safety. There isn’t actually any evidence that reduced hours is not good for patient safety. However, there hasn’t been a huge decline in medical errors as a result of reduced working hours either.
These concerns aside, can it really be anything but good to get enough sleep?
The pilots I work with will not fly if their fatigue scoring places them in a high-risk group. They’ll still get the job done by arranging another crew, and this may lead to brief delays but they are disciplined about minimising risk.
And they know that the only cure for fatigue is sleep.
When I’m bouncing around in the back of the plane in bad weather, I’m grateful that the pilot isn’t fatigued.
Can we be sure that we’re not?
Dr Simon Hendel is a Melbourne-based anaesthetist and aeromedical retrieval consultant.
During our lifetimes we have managed to curtail the ridiculous hours worked by obstetricians in training in the past. However private obstetricians have failed completely to develop a rational working culture and the insurers are still looking the other way. For how long?
I wonder if the country could afford to have all its doctors, nurses, and paramedics being paid a pilot’s salary and working pilot hours.
This is a valid point. Similarly, our firefighters work 70 days a year. 140 12 hour shifts. 70 x day and 70 x night. This includes all of their training. Many pilots and firies however are not paid as well as doctors, contrary to popular belief.
The pilots (and firies actually) also have great governing bodies. STringent regulations etc. They require frequent compulsory medical examinations and blood testing for drugs, STI’s etc. Who is going to do that for the doctors?
But can the country afford the meidicolegal bills caused by errors caused by fatigued medical staff?
I for one don’t miss 36 (sometimes 72) hour shifts!
Aeroplanes are mechanical devices designed by humans, where it is possible to detect defects by strict logic, so protocolised check lists work well. Clinical medicine is all not that! Valuable information is lost at each handover – we all remember information that should have been passed on, no matter how minor. The more handovers there are a 24 hour period, the higher the risk of lost data. While I do not advocate 24, 36 or 48 hour shifts, there has to be a balance between physician fatigue vs advantages of continuity of care. My problem is defining that line.
I wonder if the country could afford to have all its doctors, nurses, and paramedics being paid a pilot’s salary and working pilot hours.
Some excellent points in this article, which will a significant issue for the colleges training specialists in the future. Striking a balance between safer work conditions but still ensuring adequate contact time with patients to develop the necessary skills and knowledge to be able to practice as a specialist will be an issue. It may result in some training programmes becoming longer to compensate for reduced work hours. Proponents of continuous on call rosters covering several days continuously will point to the benefits of continuity of care for patients and the learning opportunities it provides trainees, but what remains questionable is how much a doctor in training is able to learn and retain when in a fatigued state. These doctors are also in the process of learning and consolidating core procedural skills that they will build into their practice in the future. The potential for accidents and mistakes due to fatigue is not acceptable in other industries such as commercial transport where safety restrictions apply to their fully qualified pilots and drivers, let alone those still in training. The tolerance of the general public towards treatment injury and accidents is considerably less than it has been in the past. Patients and their families come into clinics armed with information from the Internet. Hospitals and staff must be seen to take all necessary precautions to minimize risk for patient harm, it would seem appropriate ensuring staff are in a fit state to be providing care to patients would be part of this process.