Study finds surgical residents often fatigued

CHICAGO – A study involving 27 orthopedic surgery residents suggests that surgical residents are often fatigued during their awake time, according to a report in the May issue of Archives of Surgery, a JAMA Network publication.

Medical error is a problem worldwide, and a growing body of literature indicates that fatigue may play a significant role in medical error, according to background information in the study.

Frank McCormick, M.D., from the Harvard Combined Orthopaedic Residency Program and Massachusetts General Hospital, and colleagues, evaluated surgical residents' sleep and awake periods that were continuously recorded via actigraphy, a wristwatch-type instrument worn to record and store data for sleep and awake intervals that can be used to assess individual mental fatigue.

Of 33 volunteer orthopedic surgical residents, 27 (82 percent) completed the study. The mean (average) amount of daily sleep for the residents was 5.3 hours, with individual mean amounts ranging from 2.8 hours to 7.2 hours.

The authors found that, overall, residents were functioning at less than 80 percent mental effectiveness due to fatigue during a mean of 48 percent of their time awake. Residents were also functioning at less than 70 percent mental effectiveness due to fatigue during a mean of 27 percent of their time awake.

Night-float rotations resulted in higher levels of fatigue than day-shift rotations, with night-float residents sleeping an average of 5.1 hours daily and day-shift residents sleeping an average of 5.7 hours daily.

In conclusion, "resident fatigue was prevalent, pervasive, and variable," the authors conclude.

(Arch Surg. 2012;147[5]:430-435. Available pre-embargo to the media at http://media.jamanetwork.com.)

Editor's Note: This study was supported by a grant from the Orthopedic Research and Education Foundation, by a departmental grant from an academic enrichment fund, and by hospital grant support from the Center for Quality and Patient Safety. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

In an invited critique, Thomas F. Tracy Jr., M.S., M.D., of Hasbro Children's Hospital and Brown University, Providence, R.I., writes, "There is a lot to like in this study by McCormick and colleagues … Their actual determination of fatigue during certain periods is not startling, but its pervasiveness is a finding we simply cannot avoid and may have paid lip service to in the past. It is unlikely that the data in this study will be refuted."

"Tested cognitive errors that occur in judgment or performance during fatigue infer medical error or the potential for it. Unfortunately, we have few examples of direct specific correlations from large-scale cause or high-fidelity systems failure analysis that clearly define the fatigue-harm axis across surgical services," Tracy continues.

"From this and other studies, it seems we have made things worse by our attempt to fill mandates of prescribed work hours on the basis of activities external to health care delivery systems. If we are really serious about this, it may be time to debate work hours and methods in training centers to mitigate patient error with the inclusion of these measurements to adequately design shift configuration," Tracy concludes.

(Arch Surg. 2012;147[5]:435-436. Available pre-embargo to the media at http://media.jamanetwork.com.)

Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

To contact Frank McCormick, M.D., call Kory Zhao at 617-726-0274 or email kdodd1@partners.org. To contact critique author Thomas F. Tracy Jr., M.S., M.D., call Jill Reuter at 401-444-6863 or email jreuter@lifespan.org.