Fellowship training, workload, fatigue and physical stress: a prospective observational study

Abstract

Background: Fatigue in physician trainees may compromise patient safety and the well-being of the trainees and limit the educational opportunities provided by training programs. Anecdotal evidence suggests that the on-call workload and physical demands experienced by trainees are significant despite duty-hour regulation and support from nursing staff, other trainees and staff physicians.

Methods: We measured the workload and the level of fatigue and physical stress of 11 senior fellows during 35 shifts in the critical care unit at the Hospital for Sick Children in Toronto. We determined number of rostered hours, number of admissions and discharges, number and type of procedures, nurse:patient ratios and related measures of workload. Fellows self-reported the number of pages they received and the amount of time they slept. We estimated physical stress by using a commercially available pedometer to measure the distance walked, by using ambulatory electrocardiographic monitoring to determine arrhythmias and by determining urine specific gravity and ketone levels to estimate hydration.

Results: The number of rostered hours were within current Ontario guidelines. The mean shift duration was 25.5 hours (range 24-27 hours). The fellows worked on average 69 hours (range 55-106) per week. On average during a shift, the fellows received 41 pages, were on non-sleeping breaks for 1.2 hours, slept 1.9 hours and walked 6.3 km. Ketonuria was found in participants in 7 (21%) of the 33 shifts during which it was measured. Arrhythmia (1 atrial, 1 ventricular) or heart rate abnormalities occurred in all 6 participants. These fellows were the most senior in-house physician for a mean of 9.4 hours per shift and were responsible for performing invasive procedures in two-thirds of their shifts.

Interpretation: Established Canadian and proposed American guidelines expose trainees to significant on-call workload, physical stress and sleep deprivation.

Fig. 1: Duty hours per week of 9 senior fellows working in a tertiary pediatric critical care unit. Two 4-week blocks, totalling 48 rostered weeks, are represented. The bars reflect the number of hours worked per week for the number of weeks noted. For example, the first bar demonstrates that the fellows worked 55 hours per week for 11 of the 48 weeks; the last bar shows that 105 hours were worked per week for 2 of the 48 weeks.

Fig. 2: Number of pages received by the senior fellows during each of 35 on-call, “24-hour” shifts in a tertiary pediatric critical care unit. For example, the second bar demonstrates that, during 8 of the 35 shifts, the fellows received 20 pages per shift.

Fig. 3: Total time the senior fellows reported being asleep during each of the 35 shifts. For example, the first bar indicates that the fellows did not sleep during 5 of the 35 shifts; the last bar shows that they slept 4 hours per shift during 2 of the 35 shifts.