In recent years, the spotlight has focused on the problem of fatigue amongst doctors.1 A number of fatal road traffic collisions involving sleep-deprived junior doctors prompted further assessment of the magnitude of the problem.2,3 Greater appreciation of the consequences of circadian rhythm disruption and inadequate rest on physical and cognitive performance have raised questions about the safety of doctors, patients, and the general public.4,5 Whilst being fatigued is not a new challenge faced by medical staff, changes in service demands and workforce pressures have resulted in greater recognition of the issue and the implementation of steps to prevent it and minimise its impact.6,7 This article will serve as an introduction to the problem within our specialty; however, a more detailed discussion of the topic will take place at Euroanaesthesia Vienna in June 2019.
Most doctors working in anaesthesia and intensive care will undertake some kind of shift work with out-of-hours commitment. The nature and intensity of this commitment will vary between facilities, depending on the services offered and workforce available. The European Working Time Directive, where applied, serves in some part to ensure a degree of moderation of working hours; however this is not universally applicable and only addresses part of the issue.8Discussions regarding the multitude of causes of fatigue are beyond the scope of this article; however sleep deprivation, cognitive overload, and inadequate rest opportunities are largely responsible.9,10Fatigue can be acute, chronic, and often both.9The repercussions of night working, at their most extreme, can be fatal.2,3 For most, fatigue results in more minor consequences; however this is likely to be more because of luck than judgement.11
Night shift work results in sleep debt.12,13 Rapidly cycling between shift-types may cause insomnia and disordered sleep – the so-called Shift Work Sleep Disorder.14 Caffeine, exposure to daylight, abnormal melatonin release, and daytime disruptions are some of the things that can impair sleep onset after a night shift and disturb subsequent sleep cycles.15,16 Long shifts in themselves will result in tiredness and sub-optimal cognitive performance.17 As tiredness worsens, decision fatigue may result in impaired logical reasoning as time goes on.18 Fatigued individuals are more likely to have misplaced confidence, take risks, and make errors.19 Sleep is a crucial component of memory consolidation and learning that is particularly significant for trainee doctors but relevant to all.20 Over time, the cumulative effects of chronic fatigue and sleep deprivation are known to have serious effects on all areas of health and well-being.21 The medical workforce is ageing and the implications of alterations in circadian rhythm and sleep patterns in older doctors, along with the consequences of these, also need to be considered.22
Adequate rest breaks taken during shifts enhance performance and improve the safety of patients and doctors alike.21Napping whilst on night shifts is to be encouraged. This will involve the provision of appropriate, easily accessible rest facilities.7 Strategies such as bleep sharing/filtering should be used wherever possible in order to facilitate rest breaks. Awareness of the problems of driving when critically tired is crucial and everyone should be familiar with the law relating to this.23
Out-of-hours work is inevitable for anaesthetists and intensivists. The effects of fatigue on doctors, patients, and the public can no longer be ignored. We have a duty as a profession to ensure the safety of our patients whilst promoting the sustained, healthy careers of doctors providing service, education, and research. The heroic denial of fatigue is no longer acceptable; doctors are not superhuman beings. We must work to eradicate the professional shame associated with acknowledging that biology affects us in the same way as everyone else. Drawing parallels with aviation can be frustrating, yet no comparison highlights the risks of those undertaking high-stake tasks when fatigued any better than the example of a sleep-deprived pilot flying a jet full of school children across the Atlantic. No one can function safely and effectively when critically tired, and we must do all that we can to ensure that no one is expected to do so.
Doctors, managers, patients, and the general public all have a responsibility to recognise the need for appropriate rest within the workforce. This should be possible by fostering a candid approach to the acknowledgement of tiredness and empowering each other to take proper breaks. Free, accessible rest facilities of adequate standard should be routinely available. The risk and impact of fatigue should be considered during job planning and rota design to ensure that doctors get the opportunity to recuperate adequately between shifts. Thought needs to be given to the fact that a ‘one size fits all’ approach is unlikely to be appropriate and that the needs of younger doctors may be different than those later on in their careers. Progress in this area is long overdue. The acknowledgement of fatigue and its consequences must act as an impetus to encourage collective change from this point onwards.
- James SM, Honn KA, Gaddameedhi S, Van Dongen HPA. Curr Sleep Med Rep2017;3(2):104-12.
- Durmer J, Dinges D. Semin Neurol 2005;25(1):117–25.
- McClelland L, Holland J, Lomas JP, et al.Anaesthesia2017;72(9):1069–77.
- Akerstedt T, Wright K.Sleep Med Clin2009;4(2):257–71.
- Linder J et al. JAMA Intern Med2014;174(12):2029-31.
- Gander P, Merry A, Millar M, Weller J. Anaesth Intensive Care2000;28:178-83.
- Costa G. Handb Clin Neurol2015;131:437-46.
- Kaufman D, Milstein M. 2013. Sleep Disorders, inKaufman’s Clinical Neurology for Psychiatrists. 7th ed.Elsevier, London.
- Link H, Sack R. Virtual Mentor2009;11(11):876-81.
- Danziger S, Levav J, Avnaim-Pesso L. Proc Natl Acad Sci U S A2011:108(17):6889-92.
- Killgore W. 2015. Sleep Deprivation and Behavioural Risk-Taking. In Modulation of Sleep by Obesity, Diabetes, Age and Diet, 279-87. Elsevier.
- Sarode et al.Res Medica2013;21(1).
- British Medical Association. https://www.bma.org.uk/-/media/files/pdfs/collective%20voice/policy%20research/education%20and%20training/fatigue-sleep-deprivation-briefing-jan2017.pdf?la=en, 10-11.
- Folkard S. Shift work, safety and ageing. Chronobiol Int2008;25(2):183-98.
Acknowledgements: Dr Emma Plunkett, Dr Roopa McCrossan