a guide for training directors and faculty
David G. Bienenfeld, M.D.

 The recent focus by our certifying agencies on resident work hours is only one manifestation of a growing awareness in many sectors of the harmful effects of workplace fatigue on employee performance.  In residency training, impaired performance means missed opportunities for learning and, at worst, hazards to patients.

Fatigued residents typically have difficulty with:
·                    Appreciating a complex situation while avoiding distraction
·                    Keeping track of the current situation and updating strategies
·                    Thinking laterally and being innovative
·                    Assessing risk and/or anticipating consequences
·                    Maintaining interest in outcome
·                    Controlling mood and avoiding inappropriate behavior

More specifically, signs of fatigue include:
·                    Involuntary nodding off
·                    Waves of sleepiness
·                    Problems focusing
·                    Lethargy
·                    Irritability
·                    Mood lability
·                    Poor coordination
·                    Difficulty with short-term recall
·                    Tardiness or absences at work

High risk times for fatigue-related symptoms are:
·                    Midnight to 6:00 AM
·                    Early hours of day shifts
·                    First night shift or call night after a break
·                    Change of service
·                    First 2 to 3 hours of a shift or end of shift
·                    Early in residency or when new to night call

Fatigue can be modeled as the result of forces producing fatigue and forces reversing its effects, i.e. recovery. 

Moves to limit fatigue-related problems include:

·                    The 80-hour limitation to which our programs are held will certainly help reduce the total
                     number of hours worked
·                    In general, the residency workload should allow for as little variation in work schedules as is
                     feasible. 
·                    Rapid or frequent shifts from day to night work are known to increase risk of fatigue
·                    Individual residents may need individualized schedules to accommodate idiosyncratic energy
                     cycles.
·                    Many physical illnesses can present as fatigue and should be ruled out when daytime fatigue
                     seems out of proportion to the resident’s workload. The resident should be encouraged to
                     consult his/her primary care physician.  Sleep studies may be warranted.
·                    Depression and other psychiatric syndromes may first be manifest as fatigue.  Proper
                     diagnosis and treatment should be recommended.