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At Avant we recognise that your practice entity has separate risks and exposures.
Fatigue is a risk to the health of both you and
your patients. Staff shortages and the demands and expectations of hospital
culture have led to most doctors having had the experience of working fatigued
at some stage of their career. However, from a wellbeing and medico-legal
perspective, the stakes are high and the implications of decision-making
failures due to fatigue are great.
The primary focus is often on junior
doctors in the public health system working on-call or long shifts. But
doctors working excessively long hours in private practice, such as those
participating in operating lists exceeding 12 hours, are also exposed to
fatigue-related risks and medico-legal claims if complications occur. Fatigue
and its implications are a profession-wide concern.
A strong body of
evidence has now demonstrated that circadian rhythm disruption and sleep
deprivation impairs performance and, in the long term, can lead to depression,
anxiety, diabetes and heart disease[1, 2, 3].
Human error rapidly
increases in hospital and clinical environments when tired doctors are under
pressure to continue working. Increased surgical complications, needle stick
injuries, and errors not being intercepted have all been linked with fatigue
and sleep wake cycle disruptions in empirical studies.
Psychomotor and other functions vital to the practice of medicine including
cognitive impairment, memory lapses, reduced motor control and micro sleeps
have all been shown to increase among fatigued doctors with obvious
implications for patient safety .
One randomised prospective
study tested the removal of extended working hours and 24 hour (or longer)
on-call shift from junior doctors’ rosters. The results showed a significant
reduction in attention failures in wakeful time, reduced sleepiness and better
sleep duration. By contrast, junior doctors in the control group, whose work
hours were unchanged, made 22% more serious errors .
Doctors are less likely than
the rest of the population to have their own GP and are more likely to
self-diagnose and self-medicate, driven by the lingering misperception that to
admit illness is to admit failure.
“It’s the idea of the wounded
healer – doctors don’t talk about being sick they feel embarrassed, they feel
they have crossed the line and become one of ‘them’, a patient,” Dr Kay says.
from a 2009 survey by Salaried Doctors Queensland indicated that 88% of doctors
surveyed had experienced dangerous levels of fatigue while working. Of further
concern is that 80% also felt they had made mistakes in prescribing medications
while fatigued, and 59% felt they had made errors performing procedures.
Andi Csontos, National WHS Partner at
Deloitte, conducted focus groups with doctors in training as part of her
research into sleep deprivation for the Australian Medical Association. She
found many of them normalised their fatigue, even though most of them were
operating at well below acceptable performance levels by the third or fourth day
of their 14-day shift roster.
“Their level of awareness was
quite low and what they were willing to tolerate was quite high. They would
say a 60-hour week is normal, but when we showed them the impact on their
ability to perform they were genuinely quite surprised and concerned,” she
Workforce shortages and changing work patterns (e.g.
part-time doctors) have a significant impact on the demands placed on doctors.
Research published in 2014 indicates that 40% of GPs would like to reduce
their hours further, which in real terms have already fallen from 45.6 hours
per week in 1999 to 42.2 in 2014. For this reason future workforce
planning and policy development will need to ensure doctors’ working hours are
not worsened by these changing workforce trends.
Experts have also
argued that given the surge in domestic medical graduates, increasing from
1,335 in 2006 to an anticipated 3,200 in 2014, administrators and policy makers
face an opportunity to reform hospital rostering and working hours. It is up
to policy makers to take the lead and make evidence-based changes that would
most likely improve the wellbeing of doctors and patient safety.
International precedents could also be looked at in Australia. Working time
limits in European Union countries have gradually reduced the maximum time
doctors’ work per week to 48 hours, with 11 hours break between work periods
and at least one full day’s break in seven. Such an approach could
help reduce the burden for local doctors and promote work-life balance and
doctor health overall.
If you have serious concerns about fatigue at work consider taking the following steps:
Avant Medico-Legal Advisory Service
Key Support Services
The AMA Fatigue risk assessment. Are you at risk of fatigue? The AMA has produced an online risk assessment tool to determine if your roster is fatigue inducing. Doctors who are assessed as being at risk are encouraged to raise this with the hospital management. Take the test at: http://safehours.ama.com.au/