The tiring anaesthetist

Working time regulations based on the European Working Time Directive (EWTD) were introduced to address the problem of fatigue as a contributory factor in poor clinical outcomes and doctors’ ill health. Today, all medical grades from trainees to consultants work time-based contracts that incorporate the stipulations of the working time regulations. However, the regulations cannot be regarded as a complete set of rules for designing work schedules that avoid hazardous levels of fatigue. Their incomplete nature probably owes much to a desire among policy makers to maintain some flexibility, as well as to political expediency. The failure of the regulations to take into account several key parameters known to affect fatigue, such as the sequencing of successive shifts, led to initial reports of doctors’ being required to work up to 91 hours of nights per week [1]. (Not that rules and regulations should be regarded as the only bulwark against excessive fatigue; individuals have a personal responsibility to remove themselves or alert their colleagues if they are too tired to work safely [2]). Even when doctors’ work schedules are designed using evidence-based ergonomic criteria, it still leaves the problem that each doctor works fewer hours, inevitably increasing costs and the intensity of work. Another concern is the deleterious effect the restrictions have on training. There is an increasing recognition that expertise is inextricably linked to time spent in the clinical environment [3]. That said, the chronic fatigue that is associated with excessive work hours will inevitably impair learning and teaching [4]. Thus, while doctors’ excessive working hours in the pre-EWTD era clearly needed addressing, the situation remains imperfect almost ten years after the introduction of the regulations. Nevertheless, it is becoming clear that with imaginative work-scheduling solutions, real improvements in standards of patient care and doctors’ own wellbeing are possible. According to a systematic review of studies conducted in the USA, the reduction of shifts over 16 hours was associated with improvements in patient safety, as well as doctors’ quality of life, in most studies [5]. An intervention study in the UK that involved redesigning doctors’ work schedules with shorter shifts, fewer consecutive night shifts, and a sequence of shifts designed to facilitate circadian adaption to night work, brought about a 33% reduction in medical errors [6]. The Association of Anaesthetists of Great Britain & Ireland (AAGBI) is publishing an updated edition of its guidelines, Fatigue and Anaesthetists, in 2013 [7]. It includes updated and new recommendations relating to rest facilities, the management of on-call work (with particular emphasis on the older anaesthetist) and education on fatigue. The updated recommendation that “rest facilities and on call rooms should be available for staff to nap during shifts or sleep post-call” [7] is consistent with evidence that the introduction of a night-time nap increases doctors’ sleep efficiency and decreases their fatigue [8]. However, it is notable that the doctors in that study took limited advantage of the opportunity to nap because of concerns about how it would affect continuity of care. Another potential problem is that night-time naps are associated with sleep inertia, i.e. the temporary degradation of performance in the period following waking, under certain circumstances [9]. There is also evidence that taking a night-time nap may disrupt the subsequent day’s sleep between shifts [10]. However, studies on napping within medical settings are relatively scarce. Further research is needed to understand fully the effects of naps on patient care, and also the factors underlying doctors’ ability (and inclination) to take rest breaks and naps, e.g. the availability of appropriate accommodation.