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  1. Personal Management Skills in Fellowship Training Fatigue, Stress, and their Reduction During Training July 2011

  2. Fatigue, Stress, and their Management During Training • Case synopsis • Background • NEJM study review • Management suggestions • Organized discussion

  3. Background • ACGME limits resident to 320 hrs/4 weeks • Does reducing work hours: • Increase duration of sleep? • Reduce “Attentional failures”?

  4. 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

  5. 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

  6. 85 hr/wk 69 hr/wk Results

  7. 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

  8. **13/20 subjects decreased AFs Not shown: 1.5 x the number of attentional failures at night vs. day

  9. Oct 28, 2004

  10. 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

  11. 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?

  12. THE IMPACT OF SLEEPINESS AND FATIGUE ON PHYSICIAN PERFORMANCE Rebecca P. McAlister, MD Washington University School of Medicine

  13. 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

  14. 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

  15. NEJM e3 (1-6), 2010

  16. EDUCATIONAL OBJECTIVES • The basics of sleep physiology and sleep deprivation will be reviewed. The impact of sleepiness & fatigue on physician performance will be examined and suggestions made for alertness management.

  17. INDUSTRY MONTHLY LIMITS • ACGME 320-352 HRS • COMM AVIATION 100 HRS • TRUCKING 260 HRS • SMALL MARITIME 360 HRS • RAIL 432 HRS • UK 224 HRS

  18. SLEEPINESS AND FATIGUE • SLEEPINESS • Acute sleep loss • Chronic sleep restriction • Circadian displaced waking (shift work) • FATIGUE • Physical/cognitive demands without recovery • Psychological exhaustion (“burnout”)

  19. SLEEPINESS • SUBJECTIVE MEASUREMENTS • Epworth Sleepiness Scale • OBJECTIVE MEASUREMENTS • Multiple Sleep Latency Test (MSLT) • EEG Microsleeps

  20. 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

  21. EPWORTH SLEEPINESS SCALE • HIGHEST SCORE POSSIBLE 24 • UPPER NORMAL <11 • MILD SLEEPINESS 11-13 • MODERATE SLEEPINESS 14-17 • SEVERE SLEEPINESS >17

  22. 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

  23. SLEEP REQUIREMENTS • Typically 8 hours per day (6-10) • Average American approx 7 hrs per day • Average resident 6 hours per day

  24. INTERACTION OF CIRCADIAN RHYTHM AND HOMEOSTATIC DRIVE • <5 HRS SLEEP CAUSES INCREASED HOMEOSTATIC DRIVE • RESIDENTS ROUGHLY EQUIVALENT TO NARCOLEPSY AND SLEEP APNEA

  25. SK Howard, et al, Acad Med 2002

  26. 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%

  27. 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

  28. 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

  29. The Far Side, G Larson

  30. Grantcharov TP, et al, BMJ 2001

  31. 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

  32. STUDIES ON RESIDENTS • Perceived vs. objective sleepiness • Diminished mood, increased depression • Increased anger, frustration, dysphoria • Decreased satisfaction with training • Subnormal serum testosterone levels • Singer F, Zumoff B, Steroids 1992

  33. 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

  34. ALTERTNESS MANAGEMENT • SIGNS AND SYMPTOMS OF SLEEP LOSS AND FATIGUE • INTERVENTION STRATEGIES

  35. SIGNS AND SYMPTOMS Falling asleep while sedentary Irritability Repeatedly checks work Difficulty focusing / concentrating Apathy or indifference

  36. 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

  37. NAPPING • PROPHYLACTIC • Brief naps prior to 24 hr loss • THERAPEUTIC • Q 2-3 hrs X 15 min • MAINTENANCE • 2-8 hour nap prior to 24 hr loss

  38. NAPPING • Sleep inertia • Avoid deep sleep arousals • Limit nap to 40 min • Circadian nadir 2am – 9am • Most resistant to counter measures

  39. RECOVERY FROM SLEEP LOSS • TWO DAYS TO REPLACE CHRONIC LOSS • MSLT NO CHANGE PRE AND POST CALL UNTIL 4 DAYS OF NORMALIZED SLEEP

  40. SHIFT STRATEGIES • 1 WK ADAPTATION (W/O RETURN TO DAY/NIGHT ON DAYS OFF) • MINIMIZE INTERRUPTIONS TO SLEEP • PROPHYLACTIC NAPS • SPLIT SLEEPS • EFFECT OF BRIGHT LIGHT

  41. 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

  42. www.nhtsa.dot.gov/people/injury/drowsy_driving

  43. DROWSY DRIVING • CIRCADIAN RHYTYM • Use it, don’t fight it • NAPS/CABS • DEATH MORE LIKELY THAN WITH ETOH