The Oh-So-Sleepy Doctor

When you’re meeting a kid you’re about to anaesthetise, the first couple of minutes are a pretty important determinant of how the rest of your interaction will go.  Plenty of those kids are fairly stressed. I suspect more than a few are waiting to meet this guy.

Actually those scrubs would have some advantages

Actually those scrubs would have some advantages

So if you find something that works you tend to stick with it. Which is why I often introduce myself as “the sleepy doctor (because, you know, saying anaesthetist 10 times a day just gets tiring).” Sounds like the lamest of Dad jokes (it is) but trust me, it kills in the under 10 set. Any parents nearby get to fling back an equally inane remark about hoping it’s not me who’ll be doing the sleeping and we’re away.

It came to mind when I was reading another airing of the doctors and fatigue issue in the BMJ the other day (helpfully passed on by the excellent Dr Mel Thomson who mustn’t be busy enough with maggots).  As it’s behind a paywall, the pdf is right here if you want it (Doc Fatigue).

It raises a few well-worn arguments and casts about a few lazy analogies and stereotypes, all while suggesting people don’t take fatigue seriously enough in medicine. It’s fair to say that opening an article with a fiery plane crash and closing with allusions to lessons “bought in blood” provides bookends to a not entirely balanced comment piece.

Fatigue and Sharp Objects

Fatigue is well known to impair your fine motor skills and reasoning abilities, along with a bunch of other quite relevant mental faculties hopefully employed by medicos. Anyone who has pulled an all-nighter for an assignment or tried to reconstruct the superlogical planning you came up with at 4 a.m. when you’re still up at 10 a.m. could attest to that.

So you’d think it’s self evident that anything contributing to fatigue should be stamped out when you’re trusting people to handle pointy things or deal with stuff most people value. Like their life, for example.

Acting on the potential risks of fatigue is not necessarily simple though. Have you seen the evidence that teenagers require different sleeping patterns? Or that they perform better at school if you start a bit later? Or that teens are involved in fewer traffic accidents if school starts later? No one seems to be marching the streets though. Perhaps they’re waiting for more evidence. Perhaps everyone is still wrestling with the changes across society that would be necessary to facilitate a shift in school start times. Either way, it’s another example that wrestling with a response to fatigue is no easy thing.

Note the time efficient use of the commute for sleep AND yoga. [via the]

Note the time efficient use of the commute for sleep AND yoga. [via the]

Sleep is Just a Baby

The study of sleep and fatigue is still in its infancy. It’s not that long ago that sleep was thought to be a time when not much happened. This might explain why there is precious little evidence demonstrating directly that patients do suffer ill effects from doctors being fatigued. There is enough out there that various bodies have been trying to modify factors like work hours to produce change, as much as the writer of the above article might like to say it is “on the fringes”.

In Australia, the Australian Medical Association launched the Safe Working Hours campaign in earnest in 2002. Change has been produced, although audits show some of the hours worked are still excessive. The European Working Time Directive aims to produce similar change.  In my experience, most clinicians support this stuff, unlike the article’s Surgeosaurus (the dinosaur famed for its grumpy belittling of junior staff and fondness for white coats I assume). That doesn’t mean there aren’t reasonable concerns to raise with the way changes are implemented.

The Many Sides to Safety

We know that the number of adverse events in hospitals that could have been prevented are horrifying , but not really the specific role of fatigue within that mix. So it would be good to start with more rigorous research in that area. To lampoon anyone raising concerns about the focus on hours alone misses the point entirely.

I’d be happy to dismiss the concern that reducing exposure to the real world of hospital medicine leads to less experienced doctors. It’s not that difficult to see that time spent in the hospital working at the intellectual level of gutter sludge on the 35th hour of a shift is probably not productive clinical experience anyway. The extra duration of training required to offset these changes would be pursued by those working in subspecialties regardless.

The real issue is with adequate resourcing of safe working hours. If you’re going to change a roster so that doctors aren’t working prolonged shifts, you have options. One is to increase your staffing considerably so that a similar experience mix is still in the hospital. This also provides junior staff with vital senior support.

The other option is to bump up your staffing a little (mostly with junior doctors), make shifts shorter (but with more requirement to hand over care between shifts, a known issue in patient safety) and  introduce long weeks of night shifts that last up to 12 hours (a little like trying to impose a sudden reversal in sleeping patterns analogous to jet lag). Which practice would you think is more common in a cash restricted environment?

So it is worth looking closely at whether the way we’ve introduced reduced working hours for doctors has actually achieved its goals. The questions should be whether fatigue has actually been reduced, doctors are still trained well and patients are actually safer.

Captain Safety

Pointing to all things aeronautical is another lazy line to run. There are some archaic attitudes out there in medicine. There is absolutely a need to accept that fatigue matters. It’s also true that aviators can teach us a thing or two.

The writer dodges an essential issue though. The aviation industry hasn’t just addressed the attitude, they’ve addressed the whole system and accepted the cost of solutions.

Hospitals are not resourced to provide long hours of 1:1 tuition for every practitioner. They are not resourced to allow teams to debrief every job. They are not funded to incorporate team-based training and simulation training in the weekly routine. Staff movement and turnover is much higher. Handover of patients and tasks occurs in large teams, not small ones. And the hospital is only a small part of how the whole issue of safety is valued by the administrations running them and overseeing them.

Safety Clickbait

By all means, raise fatigue as an issue. But if all you’re going to do is dirty up  your hands and finger paint caricatures to discuss it, then what’s the point? It turns out that improving safety isn’t as simple as sharing anecdotes and telling doctors to go and have a nap.

The writer could have chosen to talk about the need to look at the whole system, fund safety initiatives properly and monitor results. Or would that have been too much like rational discourse, rather than the clickbait I so clearly fell for?





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