Wednesday, February 1, 2012

Research on fatigue and work hours annoys me

A paper from the University of Pittsburgh just published in the journal Academic Emergency Medicine claims that emergency medicine docs have problems with short-term memory and sleep after working what seem to be modest shift durations of only 6 to 8 hours.

The study involved 13 ED MDs who were tested before and after both day and night shifts. As is typical of studies in this genre, the tests had nothing to do with what an MD actually does while working but rather were quizzes with names such as the Paced Auditory Serial Addition Test (PASAT), the University of Southern California Repeatable Episodic Memory Test (REMT), the Trail Making Test (TMT), and the Stroop Color-Word Test. Just reading about how these tests are done made me sleep. Never mind having to be subjected to them.

Quality of sleep was assessed by something called the Pittsburgh Sleep Quality Index (PSQI).

Facts that the authors probably did not anticipate would draw a reader’s interest include the following:

The ED docs worked an average of fewer than 10 shifts per month.
7/13 were overweight or obese.
4/13 had at least 4 alcoholic drinks per week.

Like most papers, the abstract does not really reflect all the goodies inside. Table 2 is an elegant massaging of the statistics with 32 different sets of 95% confidence intervals for the memory tests.

The paper notes “Sleep quality was worse in EPs (emergency physicians) compared to the normal population, with 31% of subjects reporting poor sleep quality.” Just in case you forgot, 31% of 13 is 4 people. In the discussion, the authors blamed poor quality sleep on fatigue, which was also quantified. They then made the startling revelation that “sleep disruption continues routinely beyond training years and may be a widespread issue among health care providers.” No kidding?

I have another theory. My experience (based on an “n” of one) is that I often have trouble sleeping when I’m working. I worry about the patients, the decisions I’ve made, whether I checked that lab result, will that clip fall off and lead to bleeding and so on. I think many doctors and nurses have similar thoughts.

But I saved the best for last. Performance on the memory tests was worse for all the ED docs AFTER WORKING BOTH DAY AND NIGHT SHIFTS.

The authors suggested “symptom improvements” might ameliorate these problems. My suggestion, which I blogged about in detail in October of 2010, is to do what the US Navy has successfully done for centuries. That is, have all doctors stand watches of no more than 4 hours at a time. It’s a little inconvenient, but it would reduce fatigue and stress markedly. [Click here to read how it would work.]

I want to thank Andy Neill who blogs at Emergency Medicine Ireland for bringing this paper to my attention.


Tom said...

If everyone weren't so concerned about taking credit for their own published articles, maybe they could pool resources and manage to actually do a decent study with a good methodology and a sample of, oh, more than a couple dozen. Too bad that won't happen. 100% of this commenter bemoans this.

Anonymous said...

Not sure what Navy you are referring to, but the Nuclear Navy would laugh at 4 hours! If anything, the hours a nuclear sailor puts in on watch without breaks,makes residency for Drs. laughable.

The Nuclear navy has found pushing someone to their limit from the beginning of their training actually develops their ability to tolerate much longer shifts with a higher level of attention.

Wife of a ex-nuclear Navy enlisted guy whose extensive hours left me more alone with the kids then a wife of a brain surgeon.

Skeptical Scalpel said...

Thanks for the comments. I agree with Tom

Anonymous, I was referring to the surface navy, which does have 4-hour watches on the bridges of most ships. I agree with your statement about training. You might enjoy my blog post about Harvard suggesting that doctors be trained like Navy SEALs.

Anonymous said...

A bit off topic but, about the symptom management, I do find myself purposely keeping "on edge" sometimes. This is something we do automatically in case of call, you've done this haven't you? A way of keeping a certain increased LOC/sharpness available if needed. This is over time, enormously fatiguing. I have learned to stop doing that somewhat.

Also, I have found that I will be wide awake at 0200 if I drink in the late afternoon or early evening even just one beer on a hot summer day. When I was younger I did not have this problem. Just a possibility to look into for those who are not sleeping.


Skeptical Scalpel said...

SCRN, Thanks for commenting.

I too often sleep fitfully when I'm on call. It's not only worrying about what's already happened. As you describe, it's the anticipation of the phone ringing.

Alcohol is a well-known stimulant. I never touch it (except for hand washing) when I'm on call.

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