Fatigue risk management revisited

Dear Colleagues,

As FPs, we know the effects of sleep deprivation and what it is like to function on little sleep. Your College was part of a consortium to address issues related to resident duty hours, with a view to optimizing patient care and resident educational experiences. This was triggered, in part, by some provincial regulations prohibiting resident duty beyond 16 hours. Key findings included the following.¹

• Traditional duty periods present health risks to residents, and duty periods of 24 hours or more should be avoided.

• Fatigue impairs cognitive and behavioural performance.

• A tired doctor is not necessarily an unsafe doctor.

• No conclusive evidence shows restrictions on consecutive resident duty hours are necessary for patient safety.

• Efforts to improve patient safety and resident fatigue must be comprehensive and not focus solely on duty hours.

• No clear evidence shows restrictions on duty hours positively or negatively affect resident academic performance.

• There is evidence supporting suboptimal patient care and educational outcomes in surgery, resulting from the restriction of resident duty hours.

• Duty hour regulations necessitate reorganization of health human resources and care delivery systems.

One recommendation emerging from this report was to develop and implement a comprehensive approach to minimizing fatigue and fatigue-related risks during residency across Canada. The CFPC is a member of a group aiming to do this, under the auspices of the Royal College.

I am pleased this work includes FPs, given the importance of this issue to how we care for patients. An environmental scan has been completed looking at the medical literature and information from other industries such as aviation and mining. A fatigue toolbox with tools to facilitate self-evaluation of sleepiness and tips to prevent and address fatigue will soon be available.

There is considerable heterogeneity in how FPs provide after-hours care. In the 2013 National Physician Survey, 64% of FP respondents provided on-call care.² Their work settings are varied: private offices (60%), community clinics (17%), walk-in clinics (15%), emergency departments (18%), nursing homes and long-term care facilities (19%), and teaching hospitals (19%).² The variety of practice settings affects workload and the nature of the on call provided.

Many FPs provide on-call or after-hours care as part of a group. Some of the newer models of care include obligations to provide after-hours care.^3,4 That said, opportunities for improvement in patient access to after-hours care remain.⁵ In 2015, 52% of people aged 16 or older in Ontario reported having after-hours access to primary care.⁶

Other factors, such as rural or remote location, affect access. For example, more people in rural Ontario (67%) had difficulty accessing after-hours care, compared with those in urban areas (49%).⁶ This also affects the responsibilities of providers working in resource-constrained environments, which in turn can accentuate fatigue.

As a self-regulated profession—with a not-always predictable or structured workload and where clinical contact with patients and volume can be intense—it is important for FPs to assess their work hours and determine their fatigue risk. Consider multiple risk factors, as they will have a cumulative effect. Consider clinical and nonclinical (eg, medicolegal, insurance, form completion) duties as well as administrative responsibilities. The Australian Medical Association has done considerable work in this area, including the development of a fatigue risk checklist.⁷

We must pay attention to our schedules (eg, minimize the need to work more than 10 hours continuously; ensure a minimum of 24 hours free from work in a 7-day period, during which uninterrupted sleep is possible) and look for ways to work smarter (eg, do more-complex tasks earlier in the day; minimize administrative tasks; delegate to team members; ensure in advance sufficient staff during peak periods). As we tell our patients, it is important to look after one’s own health, and this includes having our own FP.

The Fatigue Risk Management Task Force will launch a survey later this month to determine if the proposed fatigue risk management strategy and the fatigue risk management toolbox resonate with postgraduate medical education offices and clinical training environments, and can be used by clinical training sites to develop their own policies. The family practice community will be included in the invitation.

Fatigue risk management is, ultimately, providing good care by taking good care of ourselves, and about organization of work at the individual, practice, and system levels.

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