Why physicians ignore fatigue

Several years ago, I spoke at Baylor College of Medicine in Houston, where Michael DeBakey, the legendary heart surgeon, was master of the universe for nearly half a century.

I heard lots of DeBakey stories during my visit, but one in particular really stuck with me. “A few years back,” someone told me in a voice of hushed reverence usually reserved for descriptions of flawless beach days and single malt scotch, “he performed 16 open heart operations in a single day.” This was clearly intended to impress, but all I could think was, “Boy, I wouldn’t want to be patient #16.”

Lacking any information to help us understand when fatigue trumps even legendary prowess, such monumental tales of endurance can take on Man of Steel proportions. But a recent study in the Journal of the American College of Radiology may be the start of efforts to trim Superman’s cape.

Researchers from the Universities of Arizona and Iowa observed radiologists as they reviewed a handpicked set of 60 bone x-rays, half with fractures and half without. As their eight-hour workdays wore on, the radiologists’ accuracy fell by an average of 4%, with equal drops in sensitivity (missing a true fracture) and specificity (incorrectly calling a fracture when there was none). The degradation in performance was statistically significant.

While this might not seem like a huge hit in accuracy, it does mean that if you trip on a curbstone and end up in the ER with a broken ankle, you’d be better off timing your accident for the morning: nearly one in 20 more radiographs will be called incorrectly at 4 pm than at 9 am. And the study probably underestimated the impact of fatigue and eyestrain for several reasons. Much of radiologists’ time these days is spent in reading CTs and MRIs, each with scores of images to review and lots of scrolling, a much more complex and fatiguing task than reading plain films. The investigators observed only an 8-hour workday – some radiologists actually work far longer days than that, notwithstanding the field’s reputation as a “lifestyle specialty.” Finally, all 40 participating radiologists knew they were being observed, providing ample opportunity for the Hawthorne effect to play out.

More importantly, if this is how performance degrades among radiologists, just think about cardiac surgeons. Eight hours of work? The surgeon is just warming up. Sitting in an Aeron chair sipping a low-fat latte? Nope, erect but stooping uncomfortably, up to his or her elbows in blood and guts. In a quiet, darkened room, just me, my PACS system, and my iPod? Not exactly – the surgeon is meticulously performing an extraordinary array of procedural tasks while choreographic a large supporting cast, in an environment that ranges from tense to Normandy-like. Missing a subtle fracture: minimal clinical consequences, sometimes even none. The surgeon has a beating heart in his or her hands.

Taken together, it seems hard to believe that surgeons (or any physicians, really) can defy the cognitive laws of gravity – the ones that say that humans get tired, and when they do they don’t perform very well.

Until recently, nurses were the only group of caregivers studied regarding the link between fatigue and performance. Penn researchers found clear evidence of patient harm when nursing shifts lasted more than 12 hours. Over the past decade, we’ve seen great interest in one specific group of physicians: residents. Why have we focused on residents and nurses while ignoring the impact of long hours and fatigue on practicing physicians’ performance? I think there are a few reasons. Both nurses and residents are salaried, which means that duty hours are discussed as part of the cornucopia of issues that typically arise in employee/employer negotiations. In contrast, most practicing docs are self-employed, and, absent any standards or regulations, are expected to choose their own hours to optimize work-life balance, income, and (one hopes) performance.

But there are deeper forces at work that help explain why issues surrounding fatigue have been ignored when it comes to practicing physicians. Conditioned by long hours during residency, an “eat what you kill” payment system, and being put on a pedestal by everyone from our patients to our parents, most of us simply assume that we can, and should, work for as long as we can keep our eyes open and bodies erect. We’re simply not very good at recognizing our own fatigue or admitting that it might be compromising our ability to function.

That’s why this radiology study – which hints that this invincibility myth is just that, a myth – is important. I hope that we’ll see more studies addressing this topic, covering questions like: how long can a physician work before he or she begins putting patients at risk? How does this differ by specialty and setting? Are there strategies (such as so-called strategic napping) that can help physicians work long hours without compromising care? Can we make our own judgments about our fitness for practice or do we need someone else to do this to/for us?

If research demonstrates that we are working longer than we should yet we resist self-regulation (always a good bet), will we ultimately have our duty hours regulated, just like pilots and truck drivers… and now residents? I think so. Most of today’s practicing physicians wouldn’t like that.

But the next generation of physicians may be a different breed. Doctors trained in the era of duty hour restrictions – particularly those who go on to be employed by hospitals or health systems – might ultimately welcome such limits, particularly if they’re enacted with some thoughtfulness and flexibility.

More importantly, so might their patients.

Bob Wachter is chair, American Board of Internal Medicine and professor of medicine, University of California, San Francisco. He coined the term “hospitalist” and is one of the nation’s leading experts in health care quality and patient safety. He is author of Understanding Patient Safety, Second Edition, and blogs at Wachter’s World, where this post originally appeared.

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  • http://doctorrw.blogspot.com/ Robert W. Donnell

    Great post, Bob. We old farts need our rest too.

  • Jane Ragan

    Hello Dr. Wachter,
    I’m wondering how you might suggest those of us in community hospital hospitalist practice might manage not working extended hours or disruptively frequent extended night blocks. Quite frankly there just don’t seem to be enough doctors available to manage this sort of thing. Perhaps they are beating the doors down to work in urban areas, but many beautiful rural ones seem to be like ours: very close to becoming physician shortage areas. Few PCPs remain on staff to offer moonlighting possibilities, and many are FPs and not comfortable covering a 10 bed ICU. This topic needs some healthy discussion.

  • http://www.medicallessons.net Elaine Schattner, M.D.

    Interesting. Yesterday I wrote on older physicians’ long hours and fatigue @MedicalLessons – http://bit.ly/fE0KJU

  • http://fastsurgeon.blogspot.com JF Sucher, MD FACS

    I believe that you stated this, but it may not be evident to the casual reader. That is, there is a significant difference between performing an operation versus sitting in a dark room reading images. It’s just not comparable. It’s also a lot easier to focus and stay engaged if your the one doing the operation versus just watching it (just like the difference between playing golf and just watching it).

    To date, we have no objective evidence that patients have more complications if they undergo an elective operation as last on the schedule versus first. I have complete confidence that there is no difference.

    I am a strong patient safety advocate with a partnership focused on improving patient outcomes. However, I am becoming more concerned about the atmosphere of increasing regulations that feel more focused on box checking under the guise of “patient safety”. Telling individual professionals when they can work and when they can’t will have wide reaching effects across the already stressed health care system.

    Specifically, in general surgery, there is an increasing shortage of general surgeons with a crisis brewing across the nation as it relates to coverage for emergency services. Putting some arbitrary cap on surgeon work hours will most certainly bring this active volcano to full on eruption. Who will tell Mr. Smith that his perforated duodenal ulcer will just have to wait until tomorrow because the surgeon is over his work hour limitation? Hopefully Mr. Smith won’t die of peritonitis while waiting.

  • Charles Turpin

    Fatigue harms performance. Period. To perfom a high risk procedure while tired, if an alternativew exists, is insane. There is a serious shortage of superior performing baseball pitchers; even so, when such a pitcher tires he is relieved – because the coach says so. No one would call this regulation – and no one would give the pitcher the final say.

    • Vox Rusticus

      Forget about the baseball analogy. It is irrelevant and fails to make a point. Length of working shift has been shown to affect performance in anesthesiologists. Where is the evidence on workday length or case length that supports your conclusion for surgeons? Saying “fatigue harms performance” is not an argument at all. What exactly is “fatigue?”

  • http://www.medicanix.net autoclaves

    If research demonstrates that we are working longer than we should yet we resist self-regulation (always a good bet), will we ultimately have our duty hours regulated, just like pilots and truck drivers

  • Bladedeoc

    Yeah, because DeBakey walking in to do the distal anastamosis of the LIMA after the fellows have prepped, draped, opened the chest, harvested, put the patient on bypass and did the proximals was incredibly fatiguing. They ran three rooms, all staffed by fellows. Whatever the merits of the fatigue breeds mistakes arguments, using DeBakeys production stats is a poor example.

  • DRJEBJ

    I agree with Bladedoc. I had the pleasure of assisting
    Dr. Debakey once as a third year medical student during a repair of Tetralogy of Fallot in 1989. He was only in the room approximately 25 minutes for the most critical part of the procedure. His work was a marvel to behold but all of the preparatory work and closure was done by the cardiothoracic fellows, (many of whom were experienced CV surgeons from other countries.)

  • jsmith

    What Jane said. Docs don’t grow on trees. Out here in rural America it is often a choice between a tired doc or no doc at all. I suspect it is often the same in suburban or urban America as well.

  • http://shrinkrapping.blogspot.com/ Greg Smith MD

    Very interesting post. I am a psychiatrist working three different jobs, out of both love for what I do and a need for enough income to support my family. One of these jobs is a telepsychiatry position that often requires that I work sixteen hour shifts, usually from eight in the morning to midnight. I find that I am most productive and sharp early in the shift, which would be expected I suppose, and that I must try harder to keep myself focused and sharp as the evening wears on. This is clinically significant in this study with an n of one, in that a lot of psychiatric patient show up in crisis in emergency rooms from about four in the afternoon until well into the night. I am not allowed to nap or sleep on the job, so for now a “strategic nap” is not possible. Coffee helps, but that’s another story for another day, isn’t it?
    My family and friends have had several discussion over the last year or two on the changing “rules of engagement” for today’s interns and residents as compared with how we “old farts” trained (I am fifty three years old). Of course, as you said, we were all trained to work hard, work long hours, and not complain. It was part of the training and the job that was welcomed as we became doctors. I’m aware of the studies that look at degrading performance over time, but I’m also well aware personally of how grueling, long, tedious, difficult hours and situations build character, competence and ability under stress. I think it’s important to look at both sides of the issue and come up with the best solution that works in the service of the physicians of tomorrow as well as patient safety.
    Thanks for a very good post.

    Greg Smith MD

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