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Personal Management Skills in Fellowship Training. Fatigue, Stress, and their Reduction During Training. July 2012. Fatigue, Stress, and their Management During Training. Case synopsis Background NEJM study review Management suggestions Organized discussion. Background.

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fatigue stress and their management during training
Fatigue, Stress, and their Management During Training
  • Case synopsis
  • Background
  • NEJM study review
  • Management suggestions
  • Organized discussion
background
Background
  • ACGME limits resident to 320 hrs/4 weeks
  • Does reducing work hours:
    • Increase duration of sleep?
    • Reduce “Attentional failures”?
methods
Methods
  • 20 interns, two 3-week ICU rotations
    • “Traditional”: Q3 call, ~ 30 hr shift, clinic/wk, 1 day/wk off
    • “Intervention”: shifts, max 16 hrs, 1 day/wk off

1.76 hr

Nap

methods con t
Methods (con’t)
  • Sleep/work hour logs recorded
  • “Attentional failures” (AFs) measured by continuous electrooculography (EOG)
    • Slow, rolling eye movement
    • Correlate with psychomotor task performance
results1
Results
  • 6.6±0.8 vs. 7.4±0.9 hrs/day sleep
    • Difference of 0.8 hr/day (48 min)
    • Loss of 19.2 min sleep per week for each additional hour worked
slide9

**13/20 subjects decreased AFs

Not shown: 1.5 x the number of attentional failures at night vs. day

discussion
Discussion
  • Small changes in absolute sleep time (48 min/day) = major difference AF number
  • 1 hr work = 20 min less sleep
  • More attentional deficits later in day
  • Translates into serious medical errors
discussion questions
Discussion Questions
  • How do you recognize your own fatigue and stress in the workplace – what behaviors, errors?
  • What remedial actions do you take to reduce fatigue when you have fellowship responsibilities?
  • Do you notice fatigue in your attending physicians, and how do you deal with it?
  • What impact has fatigue and stress from the GI fellowship program made on your lives?
  • Can we do more to reduce these factors in the training program?
the impact of sleepiness and fatigue on physician performance

THE IMPACT OF SLEEPINESS AND FATIGUE ON PHYSICIAN PERFORMANCE

Rebecca P. McAlister, MD

Washington University School of Medicine

july 1 2003
July 1, 2003
  • ACGME Resident Duty Hour Requirements
    • No more than 80 hrs/wk averaged over 4 wk
    • No more than every third night in house call
    • At least 24 hr away every 7 days
    • No more than 30 hrs of continuous work
    • At least 10 hours off between work shifts
slide16
Faculty and residents must be educated to recognize the signs of fatigue, and adopt and apply policies to prevent and counteract its potential negative effects.
    • ACGME Common Requirements 2004, revised 2011
industry monthly limits
INDUSTRY MONTHLY LIMITS
  • ACGME 320-352 HRS
  • COMM AVIATION 100 HRS
  • TRUCKING 260 HRS
  • SMALL MARITIME 360 HRS
  • RAIL 432 HRS
  • UK 224 HRS
sleepiness and fatigue
SLEEPINESS AND FATIGUE
  • SLEEPINESS
    • Acute sleep loss
    • Chronic sleep restriction
    • Circadian displaced waking (shift work)
  • FATIGUE
    • Physical/cognitive demands without recovery
    • Psychological exhaustion (“burnout”)
sleepiness
SLEEPINESS
  • SUBJECTIVE MEASUREMENTS
    • Epworth Sleepiness Scale
  • OBJECTIVE MEASUREMENTS
    • Multiple Sleep Latency Test (MSLT)
    • EEG Microsleeps
epworth sleepiness scale 0 3
EPWORTH SLEEPINESS SCALE0 - 3
  • How likely are you to doze in these places
    • Sitting and reading
    • Watching TV
    • Sitting inactive in public place
    • Passenger in car >1 hr
    • Lying down in afternoon
    • Sitting and talking
    • Sitting quietly after lunch (w/o ETOH)
    • In a car, while stopped in traffic
epworth sleepiness scale
EPWORTH SLEEPINESS SCALE
  • HIGHEST SCORE POSSIBLE 24
  • UPPER NORMAL <11
  • MILD SLEEPINESS 11-13
  • MODERATE SLEEPINESS 14-17
  • SEVERE SLEEPINESS >17
sleep homeostatic drive sleep load
SLEEP HOMEOSTATIC DRIVE (SLEEP LOAD)
  • Builds up during wakefulness
  • Reaches maximum in late evening
  • Determined by the duration and quality of previous sleep and time awake since last sleep
  • Significant interaction with the circadian rhythm
sleep requirements
SLEEP REQUIREMENTS
  • Typically 8 hours per day (6-10)
  • Average American approx 7 hrs per day
  • Average resident 6 hours per day
interaction of circadian rhythm and homeostatic drive
INTERACTION OF CIRCADIAN RHYTHM AND HOMEOSTATIC DRIVE
  • <5 HRS SLEEP CAUSES INCREASED HOMEOSTATIC DRIVE
  • RESIDENTS ROUGHLY EQUIVALENT TO NARCOLEPSY AND SLEEP APNEA
consequences of sleep deprivation
CONSEQUENCES OF SLEEP DEPRIVATION
  • Less than 5 hrs, homeostatic drive rises sharply
  • After 4 hrs, can function reasonably well for 2-3 days
  • After one night of no sleep, cognitive performance declines 25%
  • After second missed night, cognitive performance declines to 40%
sleepy people exhibit
SLEEPY PEOPLE EXHIBIT..

Fatigue Lack of initiative

Lack of energy Indifference

Apathy Irritability

Inattention Ptosis/eye irritation

Difficulty concentrating Slow reaction time

Poor communication Poor decision making

sleepiness erodes performance
SLEEPINESS ERODES PERFORMANCE
  • Pediatric sleepiness scale ratings are inversely related to middle school grades
  • Performance error peaks reflect circadian troughs
  • Fatigue related accidents peak at 6AM and 2 PM
  • Rested night shift workers have lower performance than day shift
studies on residents
STUDIES ON RESIDENTS
  • Rarely or never controlled for stimulant use, chronic sleep deprivation, circadian rhythm during testing, level of training
  • Small study size and significant drop out
  • Self selection of work hours / tolerance
  • Applicability of test to actual practice
  • Effect of practice
slide36
No evidence that 80wk will reduce MD fatigue or its consequences
  • 24 hr continuous duty limit well beyond the 16-18 hr increased risk rate for wakefulness
  • Sleep loss / fatigue can be recognized and managed but not eliminated
altertness management
ALTERTNESS MANAGEMENT
  • SIGNS AND SYMPTOMS OF SLEEP LOSS AND FATIGUE
  • INTERVENTION STRATEGIES
signs and symptoms
SIGNS AND SYMPTOMS

Falling asleep while sedentary

Irritability

Repeatedly checks work

Difficulty focusing / concentrating

Apathy or indifference

symptoms of drowsy driving
Symptoms of Drowsy Driving
  • Long blinks
  • Head nodding
  • Difficulty focusing on road
  • Missing exits / forgetting drive
  • Drifting from lane
  • Closing eyes at light
  • Slowed reaction time
drowsy driving
DROWSY DRIVING
  • 100,000 drowsy driving crashes / yr
  • 37% driving population have “nodded off”
  • Population at highest risk
    • Male 2X
    • Ages 16 – 29yo
    • Shift worker, esp rotating shifts and post call
    • Untreated sleep disorders
          • NHTSA
drowsy driving1
DROWSY DRIVING
  • CIRCADIAN RHYTYM
    • Use it, don’t fight it
  • NAPS/CABS
  • DEATH MORE LIKELY THAN WITH ETOH