Clinical Experience and Education/Fatigue Management and Mitigation - Challenges and Opportunities

Most CLEs have met their responsibilities to follow duty hour guidelines and implemented the basic strategies required for ACGME accreditation. Nevertheless, residents, fellows, faculty members, and nurses still report instances of resident and fellow fatigue. Fatigued providers can place patients at risk for medical errors and also jeopardize their own health (e.g., car accidents, burn out). Fatigue management is about both patient safety and provider well-being.

Across most CLEs, assessment of resident fatigue appears to be largely limited to monitoring the number of hours worked. Yet there are many other factors that can cause fatigue, including task or mental overload due to high-volume or high-acuity patient activity, circadian rhythm disruption, chronic sleep deficit, and non-work related activities. Moreover, “fatigue” can also be a precursor to burnout or a marker for depression.9 CLEs should be encouraged to train residents, fellows, faculty members, and other clinical staff to consider such factors—and not only work hours—in determining a provider's “fitness for duty.”

This paradox of CLEs meeting the requirements while still having reports of fatigue suggests that the most common strategies for fatigue management may be insufficient. CLEs need to implement more advanced strategies, such as scheduling to maximize rest and re-set circadian rhythms, strategic naps, batching calls, and systems to relieve tired providers. For meaningful change to occur, CLEs need to progress from individual tactics toward system-wide strategies that are routinely monitored to ensure their efficacy.

These strategies should also include faculty members. A number of factors related to financial productivity, patient complexity, and regulatory requirements have increased faculty workload over the past decade. The ACGME, through accreditation requirements and attention to duty hours, has encouraged better fatigue management for residents and fellows. However, there are no widespread comparable guidelines for faculty members, resulting in faculty fatigue, increased patient safety vulnerability, and physician burnout. Patient care would benefit from CLEs taking a more systematic approach to fatigue management that includes all health care professionals.

By instituting and enforcing duty hour requirements, the ACGME has responded to public concerns and established standards to mitigate risks to patient safety. However, within the GME community there appears to be some reluctance to use the flexibility built into the ACGME requirements—that is, the exceptions in the Common Program Requirements. The CLER site visit data suggests that more work is needed to communicate circumstances in which making an exception is not only acceptable but necessary in order to assure safe, high quality patient care.

Based on faculty concerns raised during the group interviews, the current ACGME duty hour requirements appear to have amplified the importance of achieving good hand-offs at every change of care. As noted above, many faculty members and program directors perceived increased risk to patients due to more frequent hand-offs. While this concern is worth noting, it also should be stressed that when hand-offs are performed in an accurate and reliable manner, more frequent hand-offs should not, in and of themselves, increase patient risk. However, when hand-off processes are not accurate or reliable, increasing the frequency of hand-offs could increase vulnerabilities in patient care.