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Challenges in Resident Training

Fatigue as Impairment or Educational Necessity? Insights Into Surgical Culture

Coverdill, James E.; Bittner, James G. IV; Park, Mary Anne; Pipkin, Walter L.; Mellinger, John D.

Editor(s): Aagard, Eva MD; Reed, Darcy MD

Author Information
doi: 10.1097/ACM.0b013e31822a6b40
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Abstract

Fatigue has moved close to the center of the educational stage. The Accreditation Council for Graduate Medical Education (ACGME) now requires that residents and faculty members be educated to recognize signs of fatigue and engage in fatigue mitigation.1 Shifts for interns cannot exceed 16 hours, an upper threshold recommended for all residents by the Institute of Medicine on the basis of research that suggests performance wanes after that much wakefulness.2 These changes highlight unambiguous convictions: Fatigue is an impairment that jeopardizes both physicians and patients; fatigue can and should be minimized if not avoided entirely; education about fatigue means learning to recognize and avoid it.2–4 The ACGME policies aim to upend long-standing patterns of fatigue-related belief and behavior.

Our goal is to elucidate contemporary fatigue culture, a set of beliefs and behaviors associated with fatigue and working while tired. Cultural understanding facilitates change, as it is rarely effective to simply declare a culture “wrong,” especially one that is long-standing and widely held.5 In this study, we focus on residents and faculty members in general surgery, a group with long-hour traditions.6 Surgeons have opposed work hours reforms because of the perceived value of prolonged continuity of care for both learners and patients and the risk of discontinuities induced by patient handovers.7 Two recent studies, however, suggest that resistance may stem from broader cultural traditions. One noted an “underlying culture… which may involve less willingness to accept the natural limitations of human performance.”8(p465) A recent survey of program directors in general surgery shows that fatigue was the lowest-rated factor among 11 barriers to quality care and had little bearing on perceived surgical performance.9 Our study aims to provide a more complete understanding of fatigue culture among surgical faculty and residents.

Method

Data come from a fieldwork project and a multicenter study. For the fieldwork, the lead author obtained approval and consent to observe all residents and faculty in an academic general surgery program. Observations began in 2007, exceeded 1,000 hours, covered all arenas of work and education, and were recorded as daily field notes. Those observations guided the formulation of questionnaire and interview items for a 2009 study of categorical residents and faculty members in a diverse mix of six university-based and nine other general surgery programs. The study was reviewed and approved by institutional review boards (IRBs) at each of the 15 data-collection sites and at the lead author's university (University of Georgia, Athens, Georgia). The data-collection sites requested that they not be identified. On-site coordinators secured local IRB approval and launched two prongs of data collection. The first was an anonymous questionnaire, focused mostly on professionalism, reported on elsewhere.10,11 The questionnaire produced an 82% response rate (N = 592), with 47% (N = 276) also offering to participate in a follow-up interview.

Interviews constitute the second prong of the multicenter study and the primary evidence drawn on here; although the fieldwork and interviews suggest similar patterns, the interviews better establish the outlines of a general fatigue culture. The lead author conducted interviews with 52 residents and 58 faculty members chosen randomly from the roster of volunteers in each program (using a list of names and a random number table). Interviews were split across program types (50 from university programs and 60 from nonuniversity programs) and averaged 30 minutes. Most were conducted by telephone, and all were recorded (with permission).

Two interview questions, suggested by the fieldwork, were used to explore fatigue culture. The first question asked whether participants believed that duty periods in excess of 16 hours diminished cognitive or physical aspects of surgical performance; the second question asked how they might explain to the public how it is possible for surgeons to be skilled and safe after working 24 or more hours. Together, the two questions and follow-up probes sparked extensive discussions of experiences with, and beliefs about, fatigue. Analysis of the roughly 300 pages of interview transcripts and more than 1,000 pages of field notes involved thematic coding after five readings and use of MAXQDA text-analysis software (Verbi Software, Marburg, Germany). None of this evidence has been used in previous publications.10,11

The fieldwork project IRB, and several multicenter study IRBs, insisted that participants be assured of strict confidentiality. That promise meant that the qualitative analysis was conducted by the lead author, an external investigator, and focused on dominant themes that did not require consensus-generating coding discussions. A member check with 10 surgical residents and 10 faculty members, all of whom affirmed the description of fatigue culture offered here, helped establish the validity of the results.

Results

Four dominant themes surfaced in the fieldwork and interviews. One concerns the emergence and character of fatigue, whereas the others suggest that fatigue represents a form of necessary education. In addition to these themes, residents (identified by assigned number and postgraduate year, or “PGY”) and faculty members (identified by assigned number and the notation, “FAC”) also discussed how performance deficits due to fatigue could be offset by the advantages of continuity of care, an argument advanced elsewhere that is not covered here because of space limitations.7

Theme 1: Fatigue matters but does not impair

A dominant view is that fatigue emerges after working about 24 hours, but is shaped by context and activity levels. Residents described how “it really has a lot more to do with the surrounding circumstances” and that “it's not so much how long you work on a given day, but what came before on previous days and even the shift itself” (ID#1:PGY2). Some long shifts have lulls that permit rejuvenating naps or camaraderie while others do not; some come after a string of grinding shifts that induce weariness at the beginning of the shift; some involve relatively easy-to-manage activities and cases while others do not.

All residents and the vast majority of faculty hold that fatigue matters. One resident described how at the end of a long call, “your attention span is a little decreased, your alertness is decreased, and your technical skills are hindered just a little bit, not because you can't do it, but because you just want to get it over with” (ID#2:PGY2). Patience, empathy, cheerfulness, efficiency, and speed were repeatedly mentioned—and observed in the fieldwork—as waning in the face of fatigue. Faculty members also mentioned fine-motor skills as victims of fatigue:

When you're doing surgery, if you're really tired, you're going to be more likely to break the suture when you're tying the knot. And is that significant? I don't know. Does it take you a little bit longer? Do you have to maybe dissect that tissue plane a little bit more slowly? Yes. But I don't see where people are making holes in bowel that they otherwise wouldn't have if they were well rested. (ID#1:FAC)

Both residents and faculty members thus believe that fatigue surfaces at or after 24 hours of duty or a string of challenging duty periods and has deleterious effects on emotions, cognitive capacity, and fine-motor skills.

Few, however, believe that fatigue threatens patient safety. A widespread conviction is that surgeons surmount fatigue to meet patient care needs: “If a patient needs something done, that would hold my attention regardless of the fatigue” (ID#3:PGY4). Residents typically argued that the fatigue-induced changes they experienced “can't really be seen as detrimental to the patient” (ID#4:PGY3). Faculty members often expressed categorical views, such as “I've been in this business for 20 years and have never seen a problem because of resident fatigue” (ID#2:FAC). Problems, they argue, arise for other reasons: “What causes errors is a lack of experience and training” (ID#3:FAC). Fatigue is thus thought to matter, but not to impair.

Theme 2: Learning to manage fatigue

During the fieldwork and interviews, residents claimed that long shifts get “easier after your first couple of months, surely after the first year” (ID#5:PGY5) and that “you get used to it—over time, your body gets accustomed to working with less sleep” (ID#6:PGY4). Many described learning, not just physical conditioning, as key:

As a surgeon, you learn to work when you are tired and you do what you have to do. You rest when you can. I think that's part of our learning process too—we need to learn to work well even when we are beat. (ID#7:PGY4)

Faculty members framed fatigue management as physical and mental conditioning, often likening it to the training of elite athletes and soldiers who push the bounds of biology.

The military trains their people under extreme conditions so they can tolerate it when they go to Afghanistan. For the Tour de France, riders train under extreme conditions. They know how hard they can push, when they need to rest, and how to rest efficiently. I think it is a skill that you learn through experience. I think that physicians, and surgeons in particular, have learned how to apply the mental and physical concentration when it counts to get the job done. (ID#4:FAC)

Additionally, surgeons believe that fatigue can be offset by deeply established skills. A resident put it this way: “Once you've obtained surgical skills at a certain level, you can still perform with fatigue. but you need to be trained at that level where your skills come, kind of, automatically” (ID#8:PGY4). A faculty member voiced a similar belief:

I think there's no question that an excessive period of time, particularly for people with minimal knowledge, is probably not as safe. As you gain more knowledge, you react more by a patterned or automatic reaction than trying to compute it cognitively. So I think a senior resident probably has a better capability of pulling a 24-hour shift than a junior resident who's overwhelmed and lost, but less so than an attending. (ID#5:FAC)

Key to the skill-offsets-fatigue belief is automaticity, whereby capability develops to the point that skillful performance requires little effortful control. Overall, surgical culture holds that one can learn to work while fatigued through conditioning made possible by repeated exposure to fatigue and skill development.

Theme 3: Learning one's limits

Surgical culture emphasizes experiential learning, with many in the fieldwork claiming that “you don't learn surgery—or how to be a surgeon—from a book.” Experiences with fatigue are seen as the only way to “learn one's limits.” One resident described how “it's on us to realize when we've reached our limit—if I'm so tired that I could adversely affect a patient, I try and realize that and acknowledge that to my peers and my staff” (ID#6:PGY4). Faculty members highlighted the learning value of experiencing fatigue:

When you're working past 24 hours there is definitely a blunting of thought process that needs to be adapted to. You need to learn and understand your limitations. In training you really need to have those kinds of longer duty hours in order to be able to understand what you can and can't do. (ID#6:FAC)

These beliefs imply that the self-assessment of fatigue can be reasonably accurate and can be learned through experience. Knowing “one's limits” was described by faculty members during the fieldwork as a critical component of surgical judgment.

Theme 4: “Real life” requires managing fatigue

Residents and faculty members invoked the expression “real life” to explain that the practice of general surgery requires the ability to work while fatigued. Residents anticipated taking long call in their practices; without substantial experience with long shifts, “I'd feel underprepared—you need to know what that's like” (ID#9:PGY3). Another noted that “forcing residents to work all night is good because when you graduate and you're an attending surgeon, it's not a 9 to 5 job” (ID#10:PGY4). Faculty members recounted practice requirements—or pointed to them during the fieldwork—to justify exposing residents to fatigue as an educational necessity.

There are times when you go for 30 hours. You're on call, it's a bad weekend, and you're operating. If you're not trained to go through that, when you actually get to the real life environment, you won't function well and you're going to be a danger to your patients. So that amounts to a lack of proper training. (ID#7:FAC)

This theme surfaced repeatedly during the fieldwork. For example, one attending, providing advice to a chief resident transitioning into private practice, touted the “three As”: availability, affability, and ability. Being available nights and weekends, he emphasized, was required for the successful practice of general surgery. He explained how staffing constraints (other surgeons may not be available), limited reimbursements (revenue may be insufficient to add staff), and tradition (expectations of patients and referring physicians) mean that general surgery can demand long hours and working while tired. For many, “proper training” implies that residents experience fatigue, learn to perform capably and confidently while fatigued, and know their limits.

Discussion

The study has important findings for surgical residency training. Previous research identified an “optimism bias,” where others are beset with risks and limitations that surgeons are not, and a tendency to downplay the effect of fatigue on performance.8,9 Our research confirms those views and identifies an overlooked strand of surgical culture—namely, that encounters with fatigue are an educational necessity for residents. In training, residents learn to assess their level of fatigue, their limits, and how to function effectively when fatigued. And because most believe that the practice of general surgery requires the ability to work while fatigued, encounters with fatigue during residency become essential to a proper education. The study has clear limitations, including fieldwork in a single program, a relatively small number of multicenter interviews, a single interviewer and data analyst, and information on but one discipline. To our knowledge, however, it is the first to explore empirically an important conceptual framework in the study of duty hours reform (described as “successful sleep-deprived practice is a skill”),12(p22) and thus it enriches what is known about fatigue culture among surgeons.

Fatigue culture among surgeons conflicts with ACGME policies that maintain that fatigue jeopardizes patient care and should be minimized if not avoided entirely.1 Fatigue-focused educational programs based on those convictions will almost certainly be ineffective in general surgery because faculty members on the whole do not embrace or model those views. During the fieldwork, there were many long, obligation-driven workdays (and nights) among attending surgeons, which were noted by residents. A survey of practicing general surgeons corroborates those patterns, with an average of 2.6 nights on call per week and 20% working more than 80 hours a week.13 As noted recently, “[w]e are teaching doctors to minimize medical mistakes and personal stress by working fewer and less sporadic hours without providing them the necessary resources or coordination of services to meet these goals once they have completed their training.”14(p1843) At present, fatigue culture aligns with practice in suggesting that surgeons can and must learn to work fatigued.

A transition to a “safety culture”15 that minimizes fatigue will likely require two large and costly steps. The first is a sustained dialogue between sleep scientists and surgeons, perhaps by way of panel discussions or featured presentations at professional conferences (e.g., Dinges 2010).16 Increasingly, sleep scientists argue that it is impossible to accurately self-assess levels of fatigue, gauge risk while fatigued, or, in general, learn to manage fatigue.17 This dialogue must be “enabled”15 by esteemed leaders and organizations—perhaps the American College of Surgeons—who would nurture and support the shift to a safety culture. A second step goes beyond culture to address practice. A safety culture requires that beliefs be paired with “meaningful practices” that “enact a safety culture”15(p65) by ensuring that surgeons need not operate or provide patient care while fatigued. Although surgeons will need to play a key role in enacting practices supportive of a safety culture, dramatic behavioral and cultural change will also be required of patients, surgery departments, other hospital departments and staff, institutions, and the health care system as a whole.17 These steps would neutralize the “real world” argument, a key buttress of fatigue culture, by reformulating culture along with professional and organizational practices.

Acknowledgments:

The authors wish to thank the residents and faculty members in the 15 general surgery programs who gave generously of their time to help with our project. The argument and analysis benefitted from thoughtful comments received during a presentation to the Surgical Education and Performance Group at Southern Illinois University (Springfield, Illinois). Drs. Louise E. Arnold, David A. Rogers, and Hilary Sanfey provided insightful comments on an earlier draft, and the authors thank them.

Funding/Support:

The Department of Surgery at Georgia Health Sciences University (Augusta, Georgia) provided funding for this research.

Ethical approval:

The study was reviewed and approved by institutional review boards at each of the 15 data-collection sites and at the lead author's university (University of Georgia, Athens, Georgia). The data-collection sites requested that they not be identified.

Other disclosures:

None.

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