Fatigue in Residency Education: Understanding the Influence of Work Hours Regulations in Europe

Altered neutrophil extracellular traps formation among medical residents with sleep deprivation

Resident physicians on long-term night shifts often face sleep deprivation, affecting the immune response, notably neutrophils, vital to innate defense mechanisms. Sleep-deprived residents exhibit altered neutrophil counts and reduced phagocytosis and NADPH oxidase activity, critical to combating infections. Our study focused on neutrophil extracellular traps (NETs), a defense process against pathogens not previously linked to sleep loss. Results revealed that sleep-deprived residents exhibited a 19.8 % reduction in NET formation compared to hospital workers with regular sleep patterns (P < 0.01). Additionally, key NETs proteins, Neutrophil Elastase and Myeloperoxidase, were less active in sleep-deprived individuals (1.53mU; P < 0.01 and 0.95U; P < 0.001 decrease, accordingly). Interestingly, the ability to form NETs resumed to normal levels three months post-residency among pediatric residents. The causal relationship between reduced NETs due to sleep deprivation and the increased susceptibility to infections, as well as its implications for infection severity, is a critical area for further investigation.

A qualitative study on the adoption of the new duty hour regulations among medical residents and faculty in Korea

Duty hour regulations (DHRs) were enforced in 2017 in Korea to prevent the detrimental effects of excessively prolonged working hours among medical residents. We investigated the adoption of and implications of the new DHRs among medical residents and faculty members. Semi-structured interviews were conducted with 15 medical residents and 9 faculty members across general surgery, internal medicine, obstetrics-gynecology, and pediatrics departments at Chonnam National University Hospital. Based on the constructivist grounded theory, we developed themes from the data by concurrent coding and analysis with theoretical sampling until data saturation. In addition, respondent validation was used to ensure accuracy, and all authors remained reflexive throughout the study to improve validity. The methods of DHRs adoption among residents and faculty members included the following 4 themes: DHRs improved work schedule, residents have more time to learn on their own, clinical departments have come to distribute work, organization members have strived to improve patient safety. Residents have undertaken initial steps towards creating a balance between personal life and work. Teamwork and shift within the same team are the transitions that minimize discontinuity of patient care considering patient safety. Teaching hospitals, including faculty members, should ensure that residents' work and education are balanced with appropriate clinical experience and competency-based training.

The fatigue paradox: Team perceptions of physician fatigue

OBJECTIVES

Ongoing calls to implement fatigue risk management in residency education assume a shared understanding of physician fatigue as a workplace hazard, yet we lack empirical evidence that all health care team members maintain this assumption. Thus, this study seeks to explore how health care team members understand the role of physician fatigue in an effort to inform the implementation of fatigue risk management in residency training and medical practice.

METHODS

This study uses constructivist grounded theory to explore perceptions of workplace fatigue and its impact on clinical practice. We conducted individual semi-structured interviews with physicians, nurses and senior residents across four hospitals in 8 different specialties for a total of 40 participants. Constant comparative analysis guided data analysis and led to the final grounded theory.

RESULTS

While participants outlined multiple problematic manifestations of physician fatigue on clinical performance, they were reluctant to acknowledge any negative impact of fatigue on patient care. We refer to these contradictions as the fatigue paradox. Four key themes sustain the fatigue paradox: the indefatigable physician, blind spots, faith in safety nets and the minimisation of fatigue-related events.

CONCLUSIONS

This study suggests that health care team members do not universally feel that physician fatigue is problematic for patient care, despite providing multiple examples to the contrary. This paradoxical understanding of fatigue likely exists because the system relies on fatigued physicians, particularly trainees, and provides few mechanisms to critically examine fatigue. Successful implementation of fatigue risk management in residency training may prove elusive if clinical supervisors are skeptical of the potentially negative impact of workplace fatigue.

Sleep education improves knowledge but not sleep quality among medical students

STUDY OBJECTIVES

Poor sleep quality, often resulting from poor sleep hygiene, is common among medical students. Educational interventions aimed at improving sleep knowledge are beneficial for sleep quality in healthy populations. However, sleep education is often given minimal attention in medical school curriculums. The aim of the study was to explore whether a short educational intervention could improve sleep knowledge, and consequently sleep quality, among medical students.

METHODS

We recruited preclinical- and clinical-stage medical students during the 2017-2018 academic year. Students completed a demographic survey, the Pittsburgh Sleep Quality Index (PSQI), the Epworth Sleepiness Scale (ESS), and the Assessment of Sleep Knowledge in Medical Education (ASKME) questionnaire. Students then attended a lecture on the physiology and importance of sleep. To assess the efficacy of the intervention, questionnaires were repeated 4 months thereafter.

RESULTS

A total of 87 students (31 preclinical) with a mean age of 25.86 years (standard deviation [SD], 3.33), 51 of whom were women, participated in the study. At baseline, students had poor sleep quality with a PSQI mean score of 5.9 (SD, 2.37), without significant sleepiness, and a mean ESS score of 8.86 (SD, 4.32). The mean ASKME scores were consistent with poor sleep knowledge at 11.87 (SD, 4.32). After the intervention, the mean ASKME results improved to 14.15 (SD, 4.5; P < .001), whereas sleep quality did not. The effect was similar in preclinical and clinical medical students.

CONCLUSIONS

Sleep knowledge was inadequate among medical students, who also experienced poor sleep quality. A short educational intervention improved sleep knowledge but was insufficient at improving sleep quality. Further studies are needed to determine which interventions may provide benefit in both sleep knowledge and sleep quality.

Acute and chronic sleep deprivation in residents: Cognition and stress biomarkers

OBJECTIVES

Insufficient sleep affects circadian hormonal profiles and inflammatory markers and may modulate attention, executive functioning and decision-making. Medical professionals and specifically resident physicians, who are involved in long-term nightshift schedules during their post-graduate training, are prone to acute and chronic sleep deprivation and disruption, putting them at risk for making medical errors. The aim of the study was to evaluate the impact of chronic and acute-on-chronic sleep deprivation and disruption among residents on selected physiological and cognitive measures.

METHODS

Thirty-three medical and surgical residents were evaluated twice - at baseline and after a 26-hour shift. Eighteen young attending physicians who did not engage in nightshift schedules served as controls and were evaluated once. Measures included morning cortisol and high-sensitivity C-reactive protein (hs-CRP), computerised tests of attention and behaviour, the Behaviour Rating Inventory of Executive Function, a risk-taking questionnaire and the Pittsburgh Sleep Quality Index.

RESULTS

Residents, but not attendings, reported chronic sleep disruption and deprivation. Residents at baseline exhibited reduced morning cortisol levels and elevated hs-CRP levels, compared to attendings. Residents at baseline had impaired global executive function compared to attendings. A nightshift with acute sleep deprivation further reduced residents' executive function. Residents at baseline and after a nightshift demonstrated increased impulsivity and slower processing time than attendings. Residents and attendings did not differ in risk-taking tendencies which were assessed in a separate cohort.

CONCLUSIONS

In a real-life setting, resident physicians exhibit increased low-grade systemic inflammation (hs-CRP) and impaired HPA-axis function. Their chronic sleep curtailment is associated with greater impulsivity, slower cognitive processing, and impaired executive function. Future research is warranted to understand how improving working schedule by increasing sleep duration may minimise the short-term and potential long-term risks to physicians in training.

Prevalence of fatigue among postgraduate trainees in the United States and Japan

BACKGROUND

The difference in prevalence of fatigue among postgraduate trainees between the United States and Japan is unknown.

METHODS

A cross-sectional survey using Iowa Fatigue Scale was administered on postgraduate trainees in two internal medicine residency programs in New York and five postgraduate residency programs in Japan.

RESULTS

Of the 393 trainees, 135 (34%) completed the survey. Seventy-seven (57%) were US trainees. Both fatigue (42% vs 81%) and severe fatigue (4% vs 19%) were more prevalent in Japan (P < .01). US trainees felt more productive during work hours but less fatigued.

CONCLUSIONS

Fatigue was more prevalent among postgraduate trainees in Japan.

Resident Physicians are at Increased Risk for Dangerous Driving after Extended-duration Work Shifts: A Systematic Review

BACKGROUND

Resident physicians often work longer than 24 consecutive hours with little or no sleep. A systematic review of the literature was conducted to investigate the risk of resident physician motor vehicle collisions (MVC), and dangerous driving, after extended-duration work shifts (EDWS).

MATERIAL AND METHODS

A keyword search was performed for original research articles evaluating any aspect of driving safety following EDWS for the resident physician population. Two authors independently reviewed articles for inclusion. Subsequent independent data abstraction and quality appraisal were carried out. Five articles met the study inclusion criteria.

RESULTS

The quality of the evidence was low to very low. Results were not pooled due to study heterogeneity. Residents reported between 2.3 to 3.8 hours of sleep during EDWS. Three survey-based studies identified an increased risk of MVCs and falling asleep at the wheel after EDWS. One study associated weekly cumulative sleep hours lost with the risk of falling asleep while driving. Both driving simulation and survey studies linked EDWS with MVCs. Notably, a driving simulation study found an increase in crash frequency in male residents post-EDWS. Additionally, a survey reported that the risk of an MVC post-EDWS increased by 16.2% per shift worked in a month.

CONCLUSION

The period following EDWS is associated with an increased risk of potentially life-threatening driving safety risks for resident physicians. These observations warrant careful consideration. They suggest that there is a need for greater awareness and action in order to avoid the occupational and public health risks of driving after EDWS.