Managing the Risks of Fatigue in General Practice - For GPs and GP Registrars
What's all the fuss about?
The medical profession has a strong commitment to high quality patient care. This commitment often translates to working patterns that may leave you exposed to higher than acceptable risks of fatigue.
Fatigue is associated with a number of different factors such as sustained mental or physical effort, inadequate rest breaks and environmental stresses such as heat, noise and vibration. The underlying physiological causes of fatigue and potentially poorer task performance are sleep loss and disruptions to circadian rhythms.
Sleep is a vital physiological need like hunger and thirst and if sleep is disrupted or we are deprived of normal sleep - sleepiness results. Most people need 8 hours sleep, although this varies from person to person.
Failure to get normal sleep results in sleep debt that accumulates and can only be paid back by undisturbed, restorative sleep. While the debate over fatigue often focuses on the number of hours worked, it is also about how much sleep you get.
The impact of fatigue is serious and is often equated with alcohol consumption. Performance impairment following 18 hours of sustained wakefulness is similar to having a blood alcohol reading of greater then 0.05%.
A number of studies have linked fatigue with higher risks of medical error. Studies have also shown that fatigue can put you at greater risk of accidents such as motor vehicle crashes.
Insufficient sleep can have a deleterious impact on individual health. Research has linked fatigue to gastrointestinal problems, cardiovascular disease and stress.
Effectively managing the risks of fatigue is good for your patients and good for your own health and wellbeing.
Assessing your fatigue risk
GPs are highly skilled professionals who have undergone a rigorous and demanding training program. Like all doctors you are accustomed to pushing mental and physical boundaries in your efforts to give patients the best possible care. Unfortunately, when it comes to fatigue, research shows this can lead to a culture of denial and unrealistic expectations of performance.
Look for risk factors in your work schedule
Being a GP your workload is often unstructured and clinical contact time is intense. You are also likely to be self-employed - so you face the pressure of looking after patients as well as maintaining a viable business. The first step to effectively managing fatigue is to undertake an honest and frank assessment of your working hours.
For GPs working in small practices, or in locations where access to health care is difficult, this may not be easy. You may see your work situation as being inescapable and have become accustomed to thinking that you must soldier on regardless. The reality is that you probably face a high fatigue risk.
Look for factors that place you at a significant or higher risk of fatigue. Exposure to multiple risk factors will have cumulative effects. Remember to include clinical and non-clinical work in your assessment as well as work that is often completed in your "private" time such as medico legal and insurance work.
The following checklist has been adapted from the AMA's National Code of Practice for Hospital Doctors. It is based on a 7-day period and sets out the types of risk factors that you should consider.
The checklist is generic so that it can be used by practice principals, contracted GPs, GPs in full time
or part time employment as well as GP registrars. The checklist also recognises the role of after hours GP services.
Fatigue risk checklist - 7 day period
Less than 50 hours worked
50 to 70 hours worked
More than 70 hours worked
No more than 10 consecutive hours in any one period
Up to 14 consecutive hours in any one period
14 or more consecutive hours worked at least twice
Three or more short breaks taken during daily working hours
One or two short breaks during daily working hours
No short breaks during daily working hours
Little or no unscheduled extra work
More than 10 hours extra unscheduled work
More than 20 hours unscheduled extra work
Scheduled on call for less than 3 days in seven days
Scheduled on call for 3 days or more in a 7 day period
Scheduled on call continuously for more than 7 day period
No night work
At least 2 nights of work or extended hours into the night
At least 3 nights of work or extended hours into the night
Minimum 10 hour breaks between work periods and 2 days free of work
Minimum 10 hour breaks between work periods and one day free of work
Less than minimum 10 hour break on at least two work periods and no full day free of work
No changes to work schedule without notice
Changes to work schedule through additional hours and call outs worked
Work schedule changed so much because of additional hours and call outs so as to become unpredictable
Maximum opportunity for sleep to be taken at night, including two full nights of sleep
About two-thirds of sleep able to be taken at night including one full night of sleep
Less than half of sleep able to be taken at night and no opportunity for one full night of sleep
The above checklist is not intended to be exhaustive, but rather a tool to help you assess your risk. Other factors that need to be considered include:
- Lifecycle (eg age or family commitments)
- Intensity and nature of work
- Work environment (eg lighting and ventilation)
- Incidence of sleep disorders
Minimising your fatigue risk
Redesigning work schedules to eliminate risk is the best way to make your work patterns safer. However, this is not always realistic or possible. Where you cannot eliminate a risk it is possible to take steps to mitigate the risk. For example, you can compensate for an extended period of continuous work by having a longer break before starting work again.
Tips for designing your work schedule
In designing your work schedule, you should try to:
- Minimise the occasions where you are required to work more than 10 hours in a shift
- Ensure that you can get a minimum of 8 hours sleep between the end of one shift and starting work again
- Ensure that any period of extended hours is compensated for with a longer break before starting work again
- Ensure you have regular time (a minimum of 24 hours) free of work in a 7 day period in which unrestricted sleep is possible
- Ensure that you have a longer break between and following nightshifts
- Maximise the opportunities to take short breaks while at work
While much of the discussion about fatigue focuses on the pattern of hours worked, you can reduce the impact of fatigue by working smarter. Consider the following ideas.
- Complex tasks should be scheduled during the day and routine/administrative tasks should be minimised as far as possible
- Undertake complex tasks early in the shift where practicable
- Ensure you have sufficient staffing support during peak work periods
- Defer non-urgent work to allow appropriate rest and recuperation
Where clinically appropriate, delegate tasks to other members of the practice team and other health professionals. The use of practice nurses, for example, can help increase the efficiency of the practice and let you focus on higher-level work.
Look after your own health
Take some leave
Taking sick leave, annual leave or time off for professional development is very important. Illness leaves you more vulnerable to fatigue while a holiday or break for professional development can help recharge the batteries.
You can discuss cover for your absence with other doctors in your practice. It is important to ensure that alternative care arrangements are put in place for your patients (eg locum cover) or your patients can access information on where to obtain treatment in urgent cases.
Make sure you have your own GP
Staying healthy and having someone who can give you objective advice on your health is also vitally important. Having a regular GP can help you to look after your general health and identify and address the symptoms of fatigue.
Exercise and lifestyle
There is little doubt that exercise, proper diet and watching your alcohol intake can help you to cope better with the impact of fatigue - as well has have many other positive health benefits.
This fact sheet is not intended to be exhaustive. It provides useful information on various risk factors and practical steps to minimise your fatigue risk.
If you would like a more in depth assessment of your fatigue risk, you can use the AMA's fatigue risk calculator at http://safehours.ama.com.au. You can also contact the AMA offices in your state or the local Doctors' Health Advisory Service.