Work life balance

Work hours and reducing fatigue related risk

1. While there is little doubt that physicians-in-training work long hours and experience chronic sleep restriction over many years, the consequences remain unclear. There is not yet a significant body of evidence-based data clearly delineating the relationship between work patterns, sleep duration, and patient safety or practitioner well-being. On the contrary, anecdote and economics have driven much of the public debate over the legitimacy and necessity for extended work hours and any presumed impact on health care consumers and practitioners. There appears to be a small but significant group of studies for which restricted working hours were associated with self-reported improvements in variables that broadly reflect “quality-of-life” issues. For example, reductions in self-reported stress, increases in the amount and quality of personal and study time, and improved mood and affect were commonly described
2. Improving the quality of research on the relationship between extended work hours and the quality of working-life is an important professional issue, but the impact on patient safety may be more salient for the public. This topic is addressed by a second article in this issue, in which Arnedt et al (2005) report that, relative to light shifts (approximately 44 hours per week), heavy shifts (80-90 hours per week) reduced sleep and, by inference, increased impairment. This was revealed using standardized measures of neurobehavioral performance. As a relative index of the level of impairment, moderate alcohol intoxication was used as a positive control. It is important to note that the type of work also differed between conditions. Thus, the results need to be interpreted in light of the contribution of the extended work hours as well as the type of work being performed.
3. Nevertheless, heavier workload was associated with an average reduction in sleep of approximately 10 hours per week and approximately 3 hours for the 24 hours before testing. Reduced sleep was associated with significant declines in neurobehavioral performance. Moreover, the impairment associated with heavy shift work was broadly equivalent to the impairment reported for blood alcohol concentrations between 0.04% to 0.05%. Also, for heavy shift work, performance on a simulated driving task was more impaired than for a 0.04% to 0.05% blood alcohol concentration, and worker perceptions of fatigue-related impairment were limited and task specific. Although the authors acknowledge that these laboratory tests of performance have not been validated against medical tasks, the indirect implication is that medical staff working 80- to 90-hour weeks are at an equivalent or greater risk compared with an intoxicated physician. This is, without doubt, a notable finding and one that should concern those responsible for patient safety and medical training.
4. As pointed out by the authors, however, response times, vigilance, and driving performance are not measures of clinical efficacy or patient safety. It is difficult and perhaps premature to predict how the seeming equivalence for selected neurobehavioral effects of fatigue and alcohol extend to clinical decision making across diverse working conditions. Nevertheless, studies such as this should motivate clinicians and managers to reflect on the legal and scientific defensibility of current work practices.
5. It would be reasonable for physicians and other health care professionals to conclude that restricting working hours was a common-sense corollary of the research and would be prudent, if not rational, public policy. Indeed, fatigue management initiatives restricting work hours have flourished in recent years. For example, in the United States, guidelines now restrict work hours for physicians-in-training to 80 hours per week or less. The United Kingdom issued amendments to the European Working Time Directive pertaining to junior physicians. Starting in the late 1990s, the Australian Medical Association’s Safe Working Hours Project was developed and was ratified by 2002.
6. Based on the literature to date, there is little doubt that an increased likelihood of sleep restriction, fatigue, and cognitive impairment is associated with many schedules worked by medical staff. Some indirect evidence links fatigue with impaired medical decision making and reduced patient safety. The evidence of a similar link between hours of work and patient safety is, however, less clear. Most important, studies demonstrating unequivocally that regional or national regulatory restrictions to working hours improve patient safety remain to be performed. Until then, merely restricting working hours can only be considered a speculative means of managing fatigue-related risk.
7. Despite the intuitive appeal of restricting working hours, it is important to consider potential negative ramifications. Without a broad, balanced overview, it would be easy to fall victim to the law of inadvertent consequence. In some scenarios, limiting working hours may increase risk to patients and physicians. For example, restricted working hours may lead to restricted access to health care practitioners through a reduction in the labor supply, insufficient clinical preparation for the “real world,” increased sleep restriction in senior physicians, or increases in error rates due to work intensification. Each of these could result in higher overall risk.
8. It is essential to ensure that the policies to reduce fatigue-related risk do not increase risk due to inadvertent or unforeseen consequences of the policy. To minimize the likelihood of paradoxical outcomes, research and policy to address fatigue should be developed within a broader framework that explicitly also recognizes economic implications, and institutional and professional culture.

Dawson, D. & Zee, P. (2005) Work hours and reducing fatigue related risk: good research vs good policy. JAMA. 209 (9) 1104-1106.