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  • Managing Fatigue

    Managing fatigue

    Working while fatigued

    Fatigue is a risk to the health of both you and your patients. Staff shortages and the demands and expectations of hospital culture have led to most doctors having had the experience of working fatigued at some stage of their career. However, from a wellbeing and medico-legal perspective, the stakes are high and the implications of decision-making failures due to fatigue are great.

    The primary focus is often on junior doctors in the public health system working on-call or long shifts. But doctors working excessively long hours in private practice, such as those participating in operating lists exceeding 12 hours, are also exposed to fatigue-related risks and medico-legal claims if complications occur. Fatigue and its implications are a profession-wide concern.

    The impact of sleep deprivation

    A strong body of evidence has now demonstrated that circadian rhythm disruption and sleep deprivation impairs performance and, in the long term, can lead to depression, anxiety, diabetes and heart disease[1, 2, 3].

    Human error rapidly increases in hospital and clinical environments when tired doctors are under pressure to continue working. Increased surgical complications, needle stick injuries, and errors not being intercepted have all been linked with fatigue and sleep wake cycle disruptions in empirical studies[1].

    Psychomotor and other functions vital to the practice of medicine including cognitive impairment, memory lapses, reduced motor control and micro sleeps have all been shown to increase among fatigued doctors with obvious implications for patient safety [1].

    One randomised prospective study tested the removal of extended working hours and 24 hour (or longer) on-call shift from junior doctors’ rosters. The results showed a significant reduction in attention failures in wakeful time, reduced sleepiness and better sleep duration. By contrast, junior doctors in the control group, whose work hours were unchanged, made 22% more serious errors [4].

    Avoiding the sick role

    Doctors are less likely than the rest of the population to have their own GP and are more likely to self-diagnose and self-medicate, driven by the lingering misperception that to admit illness is to admit failure[8].

    “It’s the idea of the wounded healer – doctors don’t talk about being sick they feel embarrassed, they feel they have crossed the line and become one of ‘them’, a patient,” Dr Kay says.

    Awareness of the impact

    Results from a 2009 survey by Salaried Doctors Queensland indicated that 88% of doctors surveyed had experienced dangerous levels of fatigue while working. Of further concern is that 80% also felt they had made mistakes in prescribing medications while fatigued, and 59% felt they had made errors performing procedures[5].

    Awareness of the impact of fatigue

    Andi Csontos, National WHS Partner at Deloitte, conducted focus groups with doctors in training as part of her research into sleep deprivation for the Australian Medical Association. She found many of them normalised their fatigue, even though most of them were operating at well below acceptable performance levels by the third or fourth day of their 14-day shift roster[6].

    “Their level of awareness was quite low and what they were willing to tolerate was quite high. They would say a 60-hour week is normal, but when we showed them the impact on their ability to perform they were genuinely quite surprised and concerned,” she says.

    Medico-legal ramifications

    Legal claims may follow adverse events caused by fatigue, so all reasonable steps should be taken to reduce the likelihood of fatigue, which can diminish a doctor’s judgment and skill. Doctors may be subject to complaints and disciplinary proceedings where harm occurs to a patient as a result of fatigue. This has occurred – conditions were imposed on a junior doctor’s registration for deficient treatment of a paediatric patient who died. At the time of treatment the doctor was in the 20th hour of a 24-hour shift.

    Employer and employee responsibilities

    Occupational health and safety legislation throughout Australia requires that employers minimise risk to both employees and the public by having safe work practices. Even where there are no specific limits stated for work periods, an employer that knowingly allows an employee to work excessive hours is likely to be in breach of legislation. An employee who works while fatigued, without taking steps to highlight their condition with their manager or reduce the risk to others, may also be in breach. Such breaches can result in penalties such as fines.

    Seeking solutions

    Workforce shortages and changing work patterns (e.g. part-time doctors) have a significant impact on the demands placed on doctors. Research published in 2014 indicates that 40% of GPs would like to reduce their hours further, which in real terms have already fallen from 45.6 hours per week in 1999 to 42.2 in 2014[7]. For this reason future workforce planning and policy development will need to ensure doctors’ working hours are not worsened by these changing workforce trends.

    Experts have also argued that given the surge in domestic medical graduates, increasing from 1,335 in 2006 to an anticipated 3,200 in 2014, administrators and policy makers face an opportunity to reform hospital rostering and working hours. It is up to policy makers to take the lead and make evidence-based changes that would most likely improve the wellbeing of doctors and patient safety[1].

    International precedents could also be looked at in Australia. Working time limits in European Union countries have gradually reduced the maximum time doctors’ work per week to 48 hours, with 11 hours break between work periods and at least one full day’s break in seven[8]. Such an approach could help reduce the burden for local doctors and promote work-life balance and doctor health overall.

    Cautionary Tale

    Tips

     

    Managing fatigue and optimising your sleep

    • Managing fatigue involves self-care and attention to lifestyle factors including regular exercise.
    • Have a good sleep environment, free of technology
    • Limit your consumption of alcohol
    • Whilst at work keep well-hydrated, and take 10-minute power naps during a long shift
    • Consider seeing your GP for advice before fatigue becomes a problem

    If you have serious concerns about fatigue at work consider taking the following steps:

    • Contact Avant’s Medico-legal Advisory Service for support and advice. This will help you understand where you stand on your particular situation.
    • See your own GP should you feel that working conditions may be affecting your health.
    • Contact your local Doctors Health Advisory Service for support and advice.
     
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    Tools and Resources

    Avant Medico-Legal Advisory Service

    Key Support Services

    The AMA Fatigue risk assessment. Are you at risk of fatigue? The AMA has produced an online risk assessment tool to determine if your roster is fatigue inducing. Doctors who are assessed as being at risk are encouraged to raise this with the hospital management. Take the test at: http://safehours.ama.com.au/

    References
    1. Kevat DA, Caeron PA, Davies AR, Landrigan CP, et al. Safer hours for doctors and improved safety for patients. Med J Aust 2014; 200(7): 396-398.
    2. Dawson D, Reid K. Fatigue, alcohol and performance impairment. Nature 1997.
    3. Dinges DF, Kribba NB. Performing while sleepy: effects of experimentally induced sleepiness. In: Monk TH, editor. Sleep, sleepiness and performance. Chichester: Wiley, 1991.
    4. Landrigan CP, Rothchild JM, Cronin JW, et al. Effects of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med 2004: 351: 1838 – 1848.
    5. Salaried Doctors Queensland survey 2009 <http://deadtireddoctors.org/Stories.aspx>
    6. Csontos, A. Fatigue management takes off. NSW Doctor 2010; 2: 18.
    7. Norman R, Hall JP. The desire and capability of Australian general practitioners to change their working hours. Med J Aust 2014; 200(7): 399-402.
    8. Overview of overseas experience in regulating hours of work of doctors in training. Canberra: Australian Medical Association, 1998.