Waking up to the effects of fatigue in doctors

On the evening of 12 February 2009, a Colgan Air aircraft carrying 45 passengers, two pilots, and two flight attendants stalled on approach to an airport in New York. The pilots failed to notice their low speed and did not respond to the stall warnings in time. The plane crashed, killing all on board. The pilots had travelled far to get to the departure airport and, in breach of company policy, had slept in the crew room the night before. The National Transportation Safety Board, in its accident report, concluded that pilot fatigue was a contributing factor to the crash.

Pilot fatigue is a recognised problem in the aviation industry, and there have been several symposiums on aviation fatigue. As a passenger, I am relieved that the industry is making efforts to identify the extent of the problem and to find solutions to reduce it. In medicine, the problem remains on the fringes. Some doctors will happily describe their struggle to stay awake on their drive home after a long shift, but little is said about the hours before, caring for patients in a similar state of somnolence.

Mention the European Working Time Directive (EWTD) to a group of surgeons and a good many of them will pull faces of disgust. “When I was a houseman,” one dinosaur will bellow, “we used to work most days and most nights, and we turned out all right.” Others will nod in agreement. Then the old fellow will lament the advent of today’s trainees: lazy, demanding, and quite unable to perform anything but the most basic of procedures.

And so, while some hospitals may be EWTD compliant, others tacitly encourage or turn a blind eye to violations of the EWTD. There are doctors out there who are working far more hours than the law permits and rotas that, under careful scrutiny, would leave trusts open to legal action. The true state of affairs on the working hours of doctors cannot be gleaned from a mere look at the documents. Until a case is brought, or some eagle eyed journalist delves deeper into the issue, things are unlikely to change. The juniors are either too scared to speak out or have come to share the views of their seniors.

My focus here is not the EWTD, whose merits or demerits can be debated at length, but the problem of fatigue in doctors. In 2009 Matthew Worrall of the Royal College of Surgeons wrote: “There is much evidence that excessive fatigue leads to impaired reasoning and motor skills. But it seems there is a real lack of evidence for how that condition in an individual can translate into harm for patients in the hospital environment.”1

That last sentence brings to mind the illuminating 2003 study on the effectiveness of parachutes, published in this journal, which concluded as follows: “As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials.”2

Fatigue adversely affects vigilance, alertness, motor coordination, information processing, and decision making. These are qualities that, for most specialties, are essential.

There is no simple solution to the problem of fatigue, but the search for an answer cannot start in earnest until there is greater recognition of the effects of fatigue on patient care and physician wellbeing and an abandonment of the traditional, macho attitude of “to hell with sleep, just do it!” We are poor judges of our own tiredness.

In a 2007 study of junior doctors in New Zealand, based on 1412 anonymous questionnaires, 30% of respondents had an Epworth sleepiness score greater than 10 (that is, “excessively sleepy”), and 42% could recall a fatigue related clinical error in the past six months.3 A 2012 report for the General Medical Council on the impact of the EWTD concluded that, despite the beneficial impact of the directive, “trainees still work tiring, and potentially dangerous, working patterns.”4

The truth is that fatigue remains a problem in medicine. Change is needed at both the individual and organisational level. Reduced working hours may call for improvements to handovers at the end of shifts, for example. Individuals or managers may need to speak out against unsafe practices, be it about dangerous rotas, unreasonable requests to cover for absent colleagues, inadequate rest periods, manipulation of monitoring exercises, or even a belief that the next operation is one too many. In the face of anticipated opposition from senior colleagues or management, speaking out may require considerable moral courage.

Fatigue is not a sign of weakness or something that can be suppressed by a cup of coffee in the mess or a splash of water on the face. More research and education into the effects of fatigue on the performance and wellbeing of doctors are needed. Existing studies on the impact of reduced work hours on medical errors vary in their findings and their methodological quality. Research into fatigue, and the ways to manage it, is an area where medicine lags behind the aviation industry.

If the thought of a fatigued pilot at the controls of your plane is frightening, so too should be the thought of a fatigued doctor in a hospital or consultation room. Sully Sullenberger, who ditched his aircraft on the Hudson River in January 2009 after both his engines failed, noted that many of the lessons learnt by the aviation industry had been bought in blood.5 Ignoring the age old problem of fatigue among doctors will come at a similar price.