Watch for signs of resident fatigue

Residency Program Insider, May 24, 2005

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Dear residency program colleague:

The Accreditation Council for Graduate Medical Education's common program requirements state that "faculty and residents must be educated to recognize the signs of fatigue, and adopt and apply policies to prevent and counteract its potential negative effects."

How can you help your residents avoid the adverse effects of fatigue? First, you need to be able to recognize it. Watch for the following common signs of fatigue:

1. Verbal complaints
Verbal complaints are probably the most common signs of fatigue. Comments about fatigue and exhaustion are blatant, but other, more subtle, verbal comments are just as indicative of fatigue. For example, residents may

Such verbal expressions of fatigue are red flags for program directors. Since residents usually are reluctant to admit being fatigued, anyone who speaks up and says they need rest should be taken seriously. Keep in mind that residents who complain most often and most loudly about being tired may not be suffering from the effects of fatigue as much as your colleagues who suffer in silence. When a resident admits to him- or herself that he or she is fatigued, they have likely reached the point where they can pose a real danger.

How often do your residents complain of fatigue? Are there particular residents who complain more than others? Are these people "spreading" feelings of exhaustion and discontent by constant negative words and actions? Are they truly experiencing life-altering fatigue, or are they what can only be described as "difficult" residents? Even if the latter is the case, appropriate fatigue-reducing interventions may help to offset some of this negativity. Unfortunately, residents who verbally express feelings of fatigue may be unfairly labeled as "difficult" or "trouble makers" when in reality they need help dealing with their fatigue and its causes.

2. Inconsistent performance
Watch for inconsistencies in the resident's performance. Any deviation from the resident's usual performance level should be considered a warning sign for fatigue. Examples include inattentiveness in a normally attentive resident, or one who has difficulty with a task that he or she has done a hundred times before. For example, if you have to give a resident a lab value three times before he listens and writes it down, and then he reads it back to you wrong, you should take note. Also keep an eye out for residents who have done intubations many times but now can't get it right, residents who get orders wrong, and residents who mislabel tubes.

3. Overt sleepiness and fatigue behaviors
These are the most obvious signs of fatigue, but you must not dismiss them as routine. Such signs include yawning and nodding off during quiet moments.

4. Other people's observations and concerns
Don't trust the resident to self-report fatigue. As noted above, if the resident admits fatigue, he or she is likely past the point where he or she can deliver high quality patient care. In addition, the atmosphere of a residency program, particularly some specialties, may further discourage trainees from admitting that they are overly tired.

Your own interactions with residents can also alert you to a problem. The resident may be uncharacteristically surly or slow, or his or her eyes may not look "right." Trust your gut instinct.

That's all for this week!

All the best,

Richard Sheff, MD
Chair and Executive Director
The Greeley Company

Editor's note: For more information about resident fatigue, Watch for HCPro's book, "Fight Fatigue: A Residency Program Director's Guide to to Combat Fatigue and Reduce Risk."

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