Authors: Amy M. Pichoff, M.D. et al
ASA Monitor 12 2018, Vol.82, 16-19.
Is fatigue inevitable? It seems rare these days to ask a physician how they are doing and receive a reply other than “tired.” Demands on our time seem never-ending. Attempting to accomplish everything on the proverbial “to do” list and balancing an anesthesiologist’s work schedule, which is often highly variable, unpredictable and usually out of one’s control, precipitates chronic fatigue.
We are not alone. Ten percent of adults are affected by insomnia. The American Psychiatric Association’s DSM-5 defines this as “difficulty with sleep initiation, difficulty maintaining sleep, or early-morning waking with an inability to return to sleep that causes clinically significant distress or impairment in activities and occurs at least three nights per week for three months or more” in individuals with adequate opportunity for sleep and symptoms not explained by other medical or mental conditions.1 However, a much larger group of individuals has sleep disorders that do not meet insomnia criteria. In fact, 56 percent of Americans reported sleep problems over the previous year.2
There are myriad reasons for disordered sleep and fatigue in our society, including voluntary behaviors and factors outside one’s control. Intentionally staying up later than desirable (watching television, social media, household chores), personal obligations (child or elder care), work schedule (long hours, varying shifts, overnight calls), stress and lifestyle changes (divorce, birth of a child), medical conditions (insomnia, sleep apnea, pain, anxiety) and medications may all contribute.3,4
Role of Sleep
Sleep is vital to health and plays a critical role in brain functioning. Several theories exist to explain sleep’s function. These include: 1) the energy conservation theory, in which a decreased metabolic rate promoted survival from an evolutionary perspective when food was scarce; 2) the restorative theory, in which the body rejuvenates and repairs from oxidative stress and energy store depletion that occurs during wakefulness; and 3) the information processing theory, in which sleep aids learning and memory storage.3 Sleep needs vary among individuals, but a minimum recommendation of seven hours per night on a regular basis has been established for adults, but ideally the average adult should sleep 8.5 hours per night.5
Effects of Sleep Deprivation
Sleep deprivation occurs when an individual has inadequate sleep or poor sleep quality. Sleep disturbances have been identified as a global public health concern, as sleep deprivation increases risk for various health conditions (cardiovascular disease, diabetes and some types of cancer), all-cause mortality (including suicide), depression and marital trouble, and reduces cognitive functioning and impairs motivation.2,3 In a study of pediatric anesthesiologists, a 17-hour overnight shift was associated with a significant increase in total mood disturbances, including tension, anger, fatigue, confusion, irritability and feeling jittery when compared to the rested control group.4 The most common reason for early physician retirement is the desire to avoid sleepless nights related to on-call duties.3
While personal consequences are concerning, as physicians we can’t overlook the alarming impact fatigue has on delivery of patient care. Fatigue significantly increases the risk of medical errors and adverse events.6 Continuous work exceeding 12 hours has been equated to a blood alcohol level of 0.1 percent (above the legal blood alcohol limit in the U.S.), and overnight calls of 17 hours were associated with significant impairments in psychomotor vigilance tests (an assessment of sustained performance).4,7 A study assessing non-technical skills in anesthesiology residents found significant impairment after a single night shift compared to rested colleagues. Non-technical skills included task management, team work, situational awareness and decision-making. Teamwork, which included the exchange of information, was the category most deleteriously impacted by sleep deprivation. This has implications in patient care as transitions in care (handoffs) have been identified as a contributing factor in adverse patient events. In addition, in simulated crisis scenarios, performance of non-technical skills correlated with technical skills.8
Fifty percent of anesthesia care providers report they have made an error that they attributed to fatigue, and residents subjected to more than five 24-hour calls per month were three times as likely to commit a fatal patient error.4,5 Much of the data on physician sleep deprivation has focused on residents, and while the ACGME has instituted work hour restrictions for trainees, no such restrictions are in place for attending physicians.
Recognizing Sleep Deprivation (Signs and Symptoms)
Warning signs of sleep deprivation include increased fatigue, excessive daytime somnolence and slower reaction times. The drive for sleep may be so strong that it may be out of one’s control. This causes one to fall asleep for a few seconds (microsleep) during periods of inactivity and has resulted in serious and fatal accidents.9
How do you know when you’re fatigued? One study queried attending ICU physicians about fatigue recognition. Participants consistently described a sensation of “mentally slowing down,” demonstrated by taking longer to make decisions, forgetting things they normally knew and failing to recall new information that had been presented to them. Emotions such as frustration, impatience and being short-tempered were also signals of fatigue. Those interviewed reported feeling tired, desiring sleep and falling asleep as physical indicators of fatigue.6 In healthy research subjects restricted to four, six and eight hours of sleep per night, performance consistently deteriorated while subjective feelings of sleepiness increased only modestly and plateaued, demonstrating that individuals underestimate fatigue.5
Sleep hygiene practices have been promoted for individuals with insomnia. Traditional recommendations include main-taining a quiet, cool, dark bedroom, restricting the bedroom for sleep only and leaving the bedroom when unable to sleep.1 In addition, the avoidance of light-emitting electronics prior to sleep is recommended as they increase alertness, disrupt the circadian clock, suppress melatonin, delay and decrease REM sleep and diminish alertness the next morning.3
More research is needed to identify specific populations who would benefit from each recommended practice. In addition, the impact of dosing, timing, frequency and an individual’s habituation to the interventions must be clarified before robust recommendations can be made. Until then, it seems reasonable to select and consistently implement one or two interventions in order to determine the impact these modifications have on your own sleep.
Solutions for sleep deprivation and fatigue are often difficult for anesthesiologists to follow because of complicated work schedules and overnight call obligations. Avoiding fatigue through improved sleep quality and adequate sleep quantity is the long-term solution. However, there will be times where we find ourselves fatigued despite our best efforts. There are interventions that have been demonstrated to mitigate fatigue in the short term (Table 2).5
Of note, combining these countermeasures has a synergistic effect on alertness and performance. Specifically, combining bright light with strategic napping or bright light with caffeine have proven to be beneficial.5
Additional strategies utilized to mitigate fatigue in ICU physicians have included minimizing the number of tasks to be performed while fatigued, using techniques to improve retention of information (taking notes, repeating back details), using a structured approach to care (mental checklists), asking for help from colleagues (curbside consults), minimizing distractions, planning ahead (schedule around times when fatigue is anticipated), double-checking performance (write out plan or talk about plan with others) and adjusting expectations (mental preparation for fatigue, realize it is finite).6
Developing a night float or hospitalist system for call as initiated by some physicians may alleviate issues associated with sleep deprivation. This system has enabled obstetricians to focus on their patients during waking hours while obtaining adequate sleep at night when laborists help manage their patients.3 A similar system in which dedicated anesthesiologists cover overnight shifts may be desirable in our specialty.
While some of these interventions might be easily implemented, others would require a more significant overhaul of our culture in medicine related to perceptions of physician commitment, dedication to patient care and resilience. Other high-reliability organizations, such as the transportation industry, have strict regulations in place for fatigue risk management among commercial pilots, truck drivers, train engineers and marine operators.3,5 Research outlining the significant negative impact fatigue has on human performance is abundant. Despite a culture in medicine that teaches otherwise, physicians are equally prone to these effects. It is imperative that real, sustainable, cost-effective solutions be identified to optimize our ability to take the best possible care of patients. As we seek better and safer patient care, asking physicians to work longer and harder is no longer a viable proposition.
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2. Irish LA, Kline CE, Gunn HE, Buysse DJ, Hall MH . The role of sleep hygiene in promoting public health: a review of empirical evidence. Sleep Med Rev. 2015;22:23-36.
3. Abrams RM . Sleep deprivation. Obstet Gynecol Clin North Am. 2015;42(3):493-506.
Saadat H, Bissonnette B, Tumin D, et al. Time to talk about work-hour impact on anesthesiologists: the effects of sleep deprivation on Profile of Mood States and cognitive tasks. Paediatr Anaesth. 2016;26(1):66-71.
4. Wong LR, Flynn-Evans E, Ruskin KJ . Fatigue risk management: the impact of anesthesiology residents’ work schedules on job performance and a review of potential countermeasures. Anesth Analg. 2018;126(4):1340-1348.
5. Henrich N, Ayas NT, Stelfox HT, Peets AD . Cognitive and other strategies to mitigate the effects of fatigue. Lessons from staff physicians working in intensive care units. Ann Am Thorac Soc. 2016;13(9):1600-1606.
6. Saadat H, Bissonnette B, Tumin D, et al. Effects of partial sleep deprivation on reaction time in anesthesiologists. Paediatr Anaesth. 2017;27(4):358-362.
7. Neuschwander A, Job A, Younes A, et al. Impact of sleep deprivation on anaesthesia residents’ non-technical skills: a pilot simulation-based prospective randomized trial. Br J Anaesth. 2017;119(1):125-131.
8. Cirelli C, Benca R, Eichler AF, eds. Insufficient sleep: definition, epidemiology, and adverse outcomes. UpToDate website. https://www.uptodate.com/contents/insufficient-sleep-definition-epidemiology-and-adverse-outcomes. Last updated September 25, 2018. Last accessed October 9, 2018.