Physician Fatigue

Abstract

I n 1984, when Baylor began its liver transplantation program, ischemia times were kept to a minimum because organ preservation techniques were not as good as they are today. As a result, many organ transplants were performed in the middle of the night. It was clear to all in the operating room that between the hours of 1:30 AM and 4:00 AM it was hard to maintain the same level of vigor that was present the rest of the time. As dawn came, the team would become revitalized. Many research projects were also under way with this trans-plantation program, and it became apparent that many data points were missed during the early morning hours. However, our group was still able to produce many peer-reviewed publications and gain some recognition. At one international meeting, I was asked to give a presentation on "how to do 2 AM research." This presentation led to a review of the effects of fatigue, one of the major causes of dysfunctional behavior by physicians in the operating room environment and the cause of many medical errors. Recently the Institute of Medicine extrapolated the incidence of adverse events in hospitalized patients from 2 large studies and concluded that at least 44,000-and maybe as many as 98,000-Americans die each year as a result of medical errors (1). Despite an extensive volume of research data in the area of sleep deprivation and performance, information relating directly to physicians is inconsistent. However, when these data are combined with those obtained from aviation and industry in general, valid conclusions can be made. The human being is a complicated physiological machine that is prone to err. The incidence of human error is increased by fatigue, sleep deprivation, and stress (2). As performance decreases , errors of omission occur with increasing frequency. This may be demonstrated by minor errors, or "slips." These "slips" may be exhibited as recording errors or recent memory loss, and they rarely lead to a major event. However, as performance further deteriorates errors of commission occur: these are "mistakes" where the planning process itself is flawed. These mistakes may lead to technical or judgmental errors, such as selecting a wrong or inappropriate technique that results in an adverse outcome (for example, administering succinyl choline to a paraplegic). These mistakes, of course, may have devastating results. FATIGUE Fatigue is the inability or unwillingness to continue effective performance and is caused by excessive workload, stress, sleep loss, and circadian disruption (3). Fatigue and sleep deprivation are different entities. Fatigue is more responsible for performance changes than are circadian rhythm disruptions, and the degree of fatigue can be affected by environmental conditions (4). Cog-nitive function deteriorates more than physical performance, and fatigued individuals demonstrate impaired learning and thought processes, memory defaults, and interpersonal dysfunction. SLEEP LOSS Sleep deprivation may be seen if <5 hours of sleep occur in a 24-hour period. It can cause measurable deficits in cognitive function; however, motivation can compensate for decreased performance by increasing an individual's effort and arousal (3). The overall effects of sleep deprivation are decreased efficiency, instability, recent memory deficit, difficulty in thinking, deper-sonalization, and inappropriate humor. Continuous working adversely affects cognitive function and mood to the detriment of the person.