To the Editor
The recent article by de Oliveira et al.1 provides some insight into the prevalence of burnout and depression among anesthesiology residents in the United States. We would like to share our experience with this problem in Ireland. We conducted a survey of all anesthesiology residents in Ireland to determine the impact and sources of stress in their working lives. Our findings mirror many of those highlighted by de Oliveira et al.1
We received 39 responses in our national survey of residents (termed specialist registrars) in anesthesia, equating to a 55% response rate. This is comparable with the response rate in the survey of U.S. residents. Eighty-seven percent of the trainees reported work in excess of 48 hours per week. Interestingly, 51% of those who replied to the survey felt that they worked excessively long hours. Most respondents (79%) felt that pressure at work had affected their health and that work-related stress caused them to perform less well “sometimes” (50%) or “often” (10%), and 42% often come to work when they are not well enough to work. Eighty-six percent of respondents replied “sometimes” or “never” when asked if they could talk to someone at work if they felt they were under excessive pressure.
Concern regarding training doctors’ working hours and the consequent impact on patient care and physician health has recently received much media attention in Ireland.2 There is disquiet in the medical profession in Ireland at the fact that residents there continue to work outside the limits defined as acceptable by the European Working Time Directive.3 This legislation limits the hours a doctor should work to 48 hours per week. Anesthesiology residents in Ireland routinely work shifts in excess of 24 hours, and in some other specialties, shifts can extend to 36 hours. In the move for reform, emphasis is being placed on enforcing a maximum shift period of 24 hours rather than reducing to a 48-hour working week per se. This issue has escalated in importance in the last year, and the trade union representing residents in Ireland will soon ask members to vote on whether to proceed to strike action in protest against what are felt to be unsustainable work patterns.
It has been well demonstrated that prolonged periods of continual wakefulness result in impaired concentration and motor skills.4 Twenty-four hours without sleep impairs the ability to perform certain cognitive tasks to the same degree as that from a blood alcohol level of 100 mg/dL.5 Fatigue in residents is associated with reduced vigilance and in 1 study was associated with impaired ability to detect significant changes in clinical variables when monitoring patients in simulated scenarios.6 Given these proven negative effects of fatigue on cognition, it seems intuitive that trying to introduce measures to prevent chronic sleep deprivation in residents would be in the interest of patient safety.
Studies have looked at establishing a link between doctor fatigue and negative patient outcomes. This work relies predominantly on self-reporting of errors and retrospective data with respondents consistently reporting an association between medical errors and doctor fatigue.7 The best available evidence demonstrates that the incidence of serious medical errors committed by critical care interns increased by 36% when working >24 hours vs a maximum shift length of 16 hours.8
It is possible however that shortening resident shifts and more frequent personnel changes introduces a lack of continuity of care, and in turn increases the likelihood of medical mistakes. There is evidence to suggest that cross-coverage (care by a trainee doctor who was not on the patients’ primary care team) is associated with an increased adverse event rate. However, there has been increased awareness of this potential problem in recent years, and research has been performed on interventions to prevent errors due to inadequate handover during resident shift changes. It has also been shown that a structured handover process is an effective tool in preventing handover errors and improving patient safety.9
In summary, we would question whether there is still justification for working shifts in excess of 24 hours, particularly in high acuity specialties such as anesthesia. We welcome the attention that your recently published article casts on the matter.
Abigail M. Walsh, MB, BMedSci, MRCP, FCARCSI
Department of Anesthesia and Intensive Care Medicine
Mercy University Hospital
Denise McCarthy, MB, FCARCSI
Kamran Ghori, MBBS, FCARCSI, MD
Department of Anesthesia
Bons Secours Hospital
1. de Oliveira GS Jr, Chang R, Fitzgerald PC, Almeida MD, Castro-Alves LS, Ahmad S, McCarthy RJ. The prevalence of burnout and depression and their association with adherence to safety and practice standards: a survey of United States anesthesiology trainees. Anesth Analg. 2013;117:182–93
2. . Doctors to Ballot for industrial action over hours. The Irish Times. 2013
3. . Directive 2003/88/EC of the European Parliament and of the Council of 4 November 2003 concerning certain aspects of the organisation of working time. Official Journal of the European Union. 2003:9–19 L 299
4. Howard SK, Gaba DM, Smith BE, Weinger MB, Herndon C, Keshavacharya S, Rosekind MR. Simulation study of rested versus sleep-deprived anesthesiologists. Anesthesiology. 2003;98:1345–55
5. Williamson AM, Feyer AM. Moderate sleep deprivation produces impairments in cognitive and motor performance equivalent to legally prescribed levels of alcohol intoxication. Occup Environ Med. 2000;57:649–55
6. Denisco RA, Drummond JN, Gravenstein JS. The effect of fatigue on the performance of a simulated anesthetic monitoring task. J Clin Monit. 1987;3:22–4
7. Morris GP, Morris RW. Anaesthesia and fatigue: an analysis of the first 10 years of the Australian Incident Monitoring Study 1987-1997. Anaesth Intensive Care. 2000;28:300–4
8. Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, Lilly CM, Stone PH, Lockley SW, Bates DW, Czeisler CA. Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med. 2004;351:1838–48
9. Agarwal HS, Saville BR, Slayton JM, Donahue BS, Daves S, Christian KG, Bichell DP, Harris ZL. Standardized postoperative handover process improves outcomes in the intensive care unit: a model for operational sustainability and improved team performance*. Crit Care Med. 2012;40:2109–15