Sleepy residents: Embrace fatigue-proofing strategies for safer care

Residents need to identify what mistakes they commonly make when fatigued and communicate with healthcare team members when they’re feeling tired, attendees heard at the annual clinical and scientific conference of the Society of Obstetricians and Gynecologists of Canada, held in Ottawa in early June. Fatigue is unavoidable in residency. It’s just one of the ways physicians set aside their humanity in an effort to serve others, said Dr. Taryn Taylor, assistant professor in the department of obstetrics and gynecology and a scientist in the Centre for Education research and innovation at Western University in London, Ontario. If it can’t be avoided, the answer is to develop fatigue-proofing strategies, meant to reduce the risk of a fatigue-related mistake. These were introduced by Drew Dawson and colleagues from the University of South Australia in Adelaide, Australia in Sleep Medicine Reviews in 2012. Getting the opportunity to sleep The first fatigue-proofing strategy is having the opportunity to sleep. Some jurisdictions, such as the U.K., the U.S. and the European Union have limits on the number of hours a medical resident can work. Back in 2013, the Royal College of Physicians and Surgeons of Canada and other medical associations studied the question of residency hours and decided not to limit hours, but instead recommended that all residency programs required a fatigue risk management plan. Restricted duty hours don’t necessarily get rid of fatigue. Dr. Taylor and colleagues conducted interviews with medical residents from Europe in 2016. Despite a limit on residency hours, the residents still reported being fatigued, suggesting straightforward solutions are unlikely to solve fatigue. Their findings were reported in Academic Medicine in 2017. The opportunity to sleep then depends on napping while on-call and a schedule that will allow some restorative sleep. To help with napping, the Resident Doctors of Canada helped create standards for resident call rooms, including a comfortable bed and black-out curtains. Even if a resident gets some sleep while on call, they may have sleep inertia when they wake. This is when it takes the brain time to wake up, even if the body is functioning. Dr. Taylor noted residents should be mindful of this effect, “especially when calling staff.” A garbled phone message could lead to medical errors. Read: Ontario family doctors facing burnout, shortage to worsen, OMA says Being able to actually sleep Falling asleep while on-call or after a shift can be difficult due to circadian rhythms or non-work demands. Dr. Taylor recommended that to help fall asleep, limit exposure to light after a night shift. For example, wear sunglasses on the way home from a night shift. Adding light before a shift can help as well. She said every resident should get a light therapy lamp when they enter the program. Acknowledging and communicating signs of fatigue Physicians need to recognize what behaviour they exhibit when they’re tired, and what kind of mistake they are likely to make. Fatigue manifests itself differently in everyone. When Dr. Taylor interviewed physicians about fatigue, some reported that they were more likely to be unfriendly; others said they have eye fatigue and others said they were more likely to get distracted. Some noted that their handovers may be less thorough. Using a stimulant may stave off sleepiness. Caffeine can help at the right time of a night shift or time on call, Dr. Taylor said. She interviewed some physicians who use modafinil to help with fatigue. All members of the healthcare team should watch for signs of fatigue. Dr. Taylor quoted a study done by NASA in the 1980s where flight crews who'd worked for three days actually made fewer errors than rested crews. The researchers thought perhaps the fatigued team did better because they’d collaborated for three days, allowing for more functional communication. A team that works together often can notice tired behaviour and “they feel they can call you out,” Dr. Taylor said. Healthcare teams are often dynamic, but a team that works together more consistently may be able to better recognize fatigue in others and adjust accordingly. Medical learners often don’t inform others that they’re tired, Dr. Taylor found in her interviews with medical students. “Although the medical students rely on the system to protect them from mistakes while fatigued; if we don’t know they’re fatigued, the system can’t form a safety net around them,” Dr. Taylor said. There is a concern that there’ll be pushback if medical learners raise the issue of fatigue. While speaking up is often framed as the medical learner being brave, “how do we train the team leader to actually listen?” Dr. Taylor asked. Detecting and discussing fatigue-related errors or events Most physicians know when they’re tired. “We’re good at assessing sleepiness, what we’re not good at is assessing how it impacts performance,” Dr. Taylor said. There’s an idea that physicians are indefatigable, that they are a special breed of person who can overcome fatigue and perform well. There’s also a belief that 'my tired colleague is not as good as tired me,' Dr. Taylor said. There’s also a belief that fatigue can be overcome with practice, but here’s no evidence that persistent sleep deprivation makes you better at it. While some studies show fatigue is related to medical errors, such as more needle sticks, other research suggests no rise in mistakes when fatigue is involved. For example, a study from Western University in London, Ont., showed surgeons who had worked the night before had no more accidents or mistakes than those who had not worked the night before. The study was published in JAMA in 2013. A fatigue-related event isn’t always a medical error, but could be something that impacts the patient experience. For example, Dr. Taylor said a nurse she interviewed told her about a fatigued doctor who burst into a room where a patient was about to deliver a stillborn baby, disturbing the calm and solemn ambiance by treating it like an emergency. The role of fatigue in patient safety should not be minimized. Fatigue is often left out of the discussion of the cause of mistakes or near misses in incident reviews, Dr. Taylor said. “We need to talk about fatigue in [morbidity and mortality] rounds,” she said. Read: Metformin shown to reduce incidence of long-COVID Residency programs Various obstetrics and gynecology residency programs are experimenting with how they do on-call and night shifts, or night floats, in an effort to provide more balance to residents. Different centres have different schedules. In London, Ontario, junior residents do the night floats and senior residents tackle the 24-hour on-call. At Queen’s University, residents do night floats from Monday to Thursday and then a split shift for a month, and then get a day schedule for a month. The fatigue risk management plan has to be unique to the institution, because the number of patients each program serves in a year differs, said Dr. Rachel Wang, a fifth-year obstetrics and gynecology resident at the University of Alberta. While fatigue has been examined in other industries, there’s very little research in the context of medicine, Dr. Taylor said. One problem with studies evaluating strategies or interventions is the lack of rested controls. “It’s really hard to find a rested resident,” Dr. Taylor noted. The problem is that there’s no handbook that will work for every physician, she said. While there should be system-wide strategies to mitigate fatigue, in the end, it’s up to the resident to self-identify their own limitations when dealing with little sleep, tell others, and make adjustments to minimize harm. Read: Do low-risk pregnancies need a third trimester ultrasound?

Sleepy residents: Embrace fatigue-proofing strategies for safer care

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