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14 Mar 2019

BY DR JOHN ZORBAS, IMMEDIATE PAST CHAIR, AMA COUNCIL OF DOCTORS IN TRAINING

The day starts like any other day. You wake up, get ready and head off to work at the Intensive Care Unit at Mount Saint Elsewhere Hospital. You head to morning handover, well rested and ready for the day. The same cannot be said for your other registrar.

Despite a well written rolling roster that provides time for recovery, a recent sick call and a few nasty consecutive shifts means their fatigue is starting to catch up with them. So, a plan is made to relieve this doctor by lunchtime, otherwise they’ll hit their fatigue limits and will have to be sent home.

But that’s OK, because there are enough other well-rested staff around them to fill the gap. The day will continue and the workload will be managed.

Except it’s not Mount Saint Elsewhere and this isn’t a happy article. It’s 2019, it’s Australia, and currently we live in a country where not only do we not manage fatigue in medicine, but we brazenly refuse to acknowledge that fatigue even presents a risk to ourselves and our patients.

I’ve roughly split the group in two now. Half of you are thinking “well of course, there’s nothing new here, we know fatigue is a problem!”.

The other half are thinking “doctors aren’t pilots John, and this isn’t aviation”. To the second group, I hope to make the case for why you’re wrong. And to the first group smugly judging the second group, I’d like to point out that our inertia on this issue makes us as complicit as the second group.

Firstly, on fatigue and doctors. We’re an odd bunch, us doctors. Like alcohol, fatigue will reduce your situational awareness. Like alcohol, fatigue will impair your ability to make and recall memories. Like alcohol, fatigue will reduce your performance insight and allow risk to creep up on you undetected. Like alcohol, fatigue will erode emotional control and lead to decisions and outbursts that you’ll regret the next day (if there is a next day).

Hell, fatigue is so much like alcohol that we’ve even got research demonstrating that 17 hours of being awake is the psychomotor equivalent of a BAL of 0.05 per cent, an unthinkable way to present to work. But I don’t want to talk about the quantum of harm. Every time we have that conversation, some smug little troglodyte says “well, where’s the trial showing the effect on doctors?”.

Instead of pointing out that doctors are indeed human too and bound by the laws of biology, let’s engage in the following Socratic dialogue:

  1. Increasing fatigue will lead to an increasing chance of medical error (i.e. there is an upper limit on being awake and functional);
  2. Medicine in Australia has poor or non-existent controls around fatigue; and
  3. Medicine in Australia allows for uncontrolled fatigue and therefore causes harm to both patients and doctors as a consequence.

We can argue the quantum of harm another day. Right now, I want to focus on changing a profession that uses the essential oil of resilience rather than vaccine of sleep. Let’s say you’re a believer. Let’s say you acknowledge that fatigue management is a problem in medicine. Great; same page so far. So who needs to fix this? “Them!”, we scream in unison. But who is them? Is it our hospitals and practices? Is it the colleges and societies? Is it the medical board? It’s us, because we are all of the above.

Every time a doctor talks about fatigue, we share our collective “thoughts and prayers” on social media, we bemoan the fact that the system isn’t better and we get back to business as usual. I’d argue that it starts with us. When doctors are falling asleep on the flight deck, the correct next step is not to refer the next patient. It’s to recognise the true emergency here: that this doctor is too fatigued to provide safe and effective care to themselves or their patients, and they need time to recover.

The correct next step is to approach this as a profession, not as juniors and seniors, and demand or write rosters that prevent this from occurring. And

furthermore, we need to collectively recognise that fatigue is not a sign of physical or mental weakness. Sleep is a necessary bodily function, and it should cause no more alarm or drama than a meal eventually resulting in a bowel motion.

So far, medicine has been allowed to evolve and develop in a silo where sleep does not exist. We don’t actively consider our prior sleep/wake behaviour. We don’t prospectively predict and guard against cumulative fatigue. Rosters aren’t written according to best fatigue management practices, including on-call time. There are no regular audits of our rosters to ensure compliance. Our culture actively ostracises those who discuss or declare fatigue.

There are no requirements to train doctors, or those who employ doctors, in fatigue management or fatigue recognition. There are no rules forcing doctors to acknowledge work at multiple employers and the effect that this will have on fatigue. In a lot of ways the naysayers are right. We’re not like aviation. We’re not that smart. Midnight oil is a fossil fuel and we’re running out of it. It’s time to wake up, smell the coffee and think about your fatigue management before you touch your next patient.


Published: 14 Mar 2019