1. Fatigue and Impairment Yvonne Murphy, MD Associate Program Director Director of Behavioral Science MacNeal Family Medicine

2. Educational Objectives: Describe at least 3 strategies for mitigating fatigue State what to do if you feel you are clinically fatigued while working at MacNeal List symptoms of depression and substance abuse Describe how to access two resources for treatment of depression or substance use for residents at MacNeal

3. Fatigue Audience Discussion: What effects might being fatigued have on your patient care or you personally?

4. Fatigue: Definition A state of exhaustion or extreme tiredness Overwhelming Globally affects functioning Different than simply being tired

5. Effects of Fatigue Fatigue impairs cognition and performance. As little as 2 hours fewer than the usual amount of sleep produces declines in performance. Worsens progressively as the length of time without sleep lengthens After 1 night of no sleep, baseline cognitive performance in residents decreases by about 25%. Multiple studies show an increase in errors, time required to perform surgery/procedures, and propensity toward accidents due to sleep deprivation.

6. Safety Your ability to safely care for patients is dependent, in part, on your being well rested or using fatigue mitigation strategies if on a long/overnight shift.

7. Signs of Clinical Fatigue Moodiness, irritability Impoverished speech or flat affect Impaired problem solving Sedentary nodding off (e.g. during conference) Medical errors Micro-sleeps (5-10 second lapses in attention) Repeatedly checking work Difficulty focusing on tasks

8. What do you do if you are showing signs of clinical fatigue while working?

9. Clinical Fatigue If you are showing signs of clinical fatigue, you must stop and alert a faculty member

10. Fatigue Mitigation Strategies Get a full night’s rest (most people need 8 hours of sleep) before any work day If you are on night float, you must sleep during the day Expose yourself to bright light before starting your shift, if possible If using caffeine, use it only when working and feeling sleepy (not when awake or on weekends) Nap during the call/shift especially if you are tired or didn’t get adequate day sleep. Shorter, more frequent napping (15-45 minutes every 2-3 hours) helps avoid sleep inertia.

11. Daytime Sleeping During Night Float try to develop a relaxing routine while driving home and preparing for bed (consider meditation, yoga/tai chi, progressive muscle relaxation, or breathing) limit exposure to bright light before sleeping avoid exercise before sleeping avoid using the computer for 1-2 hours before sleeping avoid caffeine, nicotine, and alcohol before sleeping

12. Daytime Sleeping During Night Float Discuss this with your family and friends so they do not interrupt your sleep make the room dark (use room darkening shades/blinds or an eye mask) insure it is quiet (use earplugs if needed) and without interruptions (block pager) have it cool (not too warm) avoid a heavy meal before sleeping but do not go to bed hungry

13. Fatigue and Driving After a Shift How do you know when you are too tired to drive?

14. Fatigue and Driving After a Shift Signs of Drowsy Driving: Trouble focusing on the road Difficulty keeping your eyes open Nodding off Yawning Drifting from your lane, missing signs or exits Not remembering driving the last few blocks/miles Closing your eyes at stoplights

15. Fatigue and Driving After a Shift You must nap before driving or use a taxi if overtired None of these help: Turning up the radio Opening the window Chewing gum Slapping yourself Washing face with cold water

16. Fatigue and Driving After a Shift Place your institution’s procedure for addressing a resident who it too tired to drive home here and how to access it (we have a free taxi service at our institution) Residents have been held liable in court for accidents that occurred when they drove home overtired

17. Questions about fatigue?

18. Physician Impairment

19. Impairment: Depression Major depression affects 20% of women and 10% of men (same rates for physicians) Of 45 interns here, 6-8 affected Suicide rates are higher for physicians With treatment, almost all recover SIGECAPS

20. Impairment: Substance Abuse Similar rates to general public: 14% alcohol and 6% for substances Of 45 interns here, 7 alcohol and 3 substances Top 4 for physicians: – Alcohol – Marijuana – Opioids (usually prescription) – Stimulants (Ritalin, amphetamines) Addicted physicians can continue to function at high levels for a long time before their performance at work is impaired

21. Impairment: Substance Abuse It is your professional duty to patients and your colleagues to report behavior that could indicate possible substance abuse to your program director – Isolation, withdrawl – Diminished clinical performance – Erratic behavior – Recurrent lateness or absences – Deterioration in personal hygiene or dress – Smell of alcohol on breath or writing prescriptions for stimulants or narcotics for self

22. Impairment: Substance Abuse The recovery rate for physicians who enter treatment and are monitored for 5 years is 90%. Most hospitals** and states** have physician health programs that help physicians obtain treatment and minimize effects on their career. **Insert your hospital and state name after verifying these programs exist

23. Impairment: Burnout Definition: loss of emotional, physical and mental energy Estimated 25% of physicians Symptoms: – Emotional exhaustion (lack of empathy) – Depersonalization (feeling like you are just going through the motions) – Lack of self worth and sense of accomplishment

24. Impairment: Burnout Self Assessments The Burnout Self- Test: www.mindtools.com/stress/Brn/Bur noutSelfTest.htmwww.mindtools.com/stress/Brn/Bur noutSelfTest.htm The Compassion Fatigue Test: www.isu.edu/- bhstamm/tests/satfat.htmwww.isu.edu/- bhstamm/tests/satfat.htm

25. Resources - Books Peterkin AD. Staying Human During Residency Training 5 th Ed: How to Survive and Thrive after Medical School The Medical Marriage: Sustaining Healthy Relationships for Physicians and Their Families.

26. Impairment: Resources The program director and faculty want you to succeed! If you are having difficulties, they want you to come to them so they can help. Chief residents are also a resource. Hospital insurance plans cover: (**Verify your program’s coverage) – Primary care visits – Mental health services – Substance abuse treatment

27. Impairment: Resources Employee Assistance Program (** if you have one) – FREE – CONFIDENTIAL – your use of program is never reported to the hospital or your program – Help with stress, relationship problems/divorce, parenting or childcare, financial difficulties, chemical dependency, depression or anxiety – Provides short term counseling and referrals to other services

28. Impairment: Resources How to take advantage of EAP: Call (insert number) Insert website and how to access with log in and password

29. Impairment: Resources Hospital Physician Assistance Committee – Confidential – Will provide another physician who will consult with you and provide support – Contact (insert name) directly or your program director/faculty

30. Impairment: Resources Illinois professionals health program – 24-Hour Help Line: 1.800.215.4357 – Confidential – IPHP provides screening evaluation, treatment referral, treatment monitoring, and support services. SUBSTITUTE YOUR STATE’S PROGRAM IF NOT FROM ILLINOIS

31. See What You’ve Learned Post Test