Friday, June 8, 2012

Resident fatigue & medical errors

The media frenzy about the latest entry in the resident fatigue research sweepstakes was predictable. There were many websites carrying the story with the usual misleading headlines, hand-wringing and “Oh, the humanity” quotes. There are too many such articles to cite them all. Here are a few.

Fox News Tired surgical residents may up error risk, study suggests
LA Times Study finds residents often fatigued
Daily Briefing Despite new rules, residents' fatigue continues to cause errors
MedPage Today Too little sleep makes Jack a dull surgeon
Orlando Personal Injury Legal Blog [one of many such blogs] Fatigued Hospital Residents Make More Mistakes

If one takes the time to read the paper, one will find the following:
  • It studied only 27 orthopedic residents.
  • It did not study medical errors but rather sleep and wakefulness.
  • The amount of time that a resident moved his arm was measured by a device. The movements were then converted into “predictions” of fatigue which were then extrapolated into levels of risk of error.
Regarding the results, here are some important issues:
  • Although residents working night shifts got less sleep than those working in the daytime, the difference was only 0.6 of an hour [36 minutes] and was not statistically significant, p = 0.08.
  • When awake, all residents were fatigued about half of the time.
  • More than 25% of the time, all 27 residents allegedly worked in a mental state equivalent to a blood alcohol level of 0.08% because of fatigue.
  • Due to their pervasive fatigue, night-float residents were predicted to have a 24% increased risk of medical error, and even day shift residents had a 19% increased risk of medical error (P=.045).
This leads to some questions:
  • Why are day shift residents so tired?
  • Why do day shift residents get only 5.7 hours of sleep per night?
  • If day shift residents are tired and night shift residents are even more tired, what is the solution?
  • Could it be that a facetious suggestion I made in a blog that residents should work like sailors aboard ship in rotations of 4 hours on duty and 8 hours off duty is not so unrealistic?
  • Will this paper be cited by plaintiffs’ lawyers?
What do you think?


Michael Tomasson said...

I am not a surgeon, but I would much rather have a tired surgeon with good hands who was passionate about excellence. A hack who is well-rested is still just a hack, and IMHO making surgical training 9-5 day camp is going to turn out more hacks. Research that focuses on fatigue only without looking broadly at reasons for outcome differences is not good science. The recent obsession with sleep and rest has, again, IMHO gone overboard and (in internal medicine anyway) is creating an army of well-rested passionless drones with a very high tolerance for mediocrity.

Skeptical Scalpel said...

Very well said. Thanks.

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