I feel like I am tired and working too hard at times. Certainly, most physicians sympathize. Some of it is self imposed, in that after I finish with my clinical obligations there is generally a round of meetings, paper work or email related to my other professional interests; group management, a local IPA, and of course CSA and ASA commitments. However, I am reluctant to give up these other tasks, since they provide a counterbalance to what I do in the OR. It is so fundamentally evident, how clinical work impacts what I do with the administrative and professional functions, and vice versa. Each plays a role in improving the type and quality of care we deliver to our patients over the long term.
The whole concept of physician fatigue has interested me since early in my career. I did my internship in internal medicine at New York Hospital, Cornell Medical Center several year before the Libby Zion case occurred there. Although I remember being tired that year, I never felt unsafely fatigued, but I did feel like I was improperly supervised. A recent article in the New England Journal of Medicine (NEJM) addresses this very issue in analyzing the Libby Zion case.
“It all began with a tragedy. In March 1984, a fatal error occurred in a U.S. teaching hospital. Eighteen-year-old Libby Zion died because of a lethal drug interaction. The cause was serotonin syndrome — a rather obscure condition in 1984. The residents caring for Zion diagnosed a viral syndrome with “hysterical symptoms.” In the intense scrutiny that followed, their misdiagnosis was attributed in part to their exhaustion, since at the time they had been at work for 18 hours straight. But was exhaustion really the cause?
What if the problem stemmed from lack of supervision? What if the intern had not yet learned to distinguish “sick” from “not sick”? On the other hand, what if the young doctor, when prescribing the fateful dose of Demerol (meperidine), had been warned by a computer alert about potential adverse interactions between Zion's inpatient and outpatient medications (which included phenelzine)? Or could Zion's death have been avoided if the intern had had a nap?
After many years in anesthesia I have come to the conclusion that being tired, per se, does not necessarily make one a dangerous anesthesiologist, if one is cognizant of ones limitations. Lack of skill, knowledge or judgment will. The authors of the NEJM article essentially come to the same conclusion and make the argument that data is necessary to support work hours rules going forward.
So where does this leave me, a somewhat tired mid- to late-career anesthesiologist? I no longer take any weekend or night call, except for the occasional weekday OB night shift. I am vigilant in my care while at work and cognizant of my limitations. I pace myself during the week and take Fridays off as often as possible. The non-clinical work, such as writing and editing for this blog, gets put into daytime and evening hours, and does not extend late into the night. I schedule plenty of time off, even if it’s just to hang around at home or go to the coast for a few days. I try to do things I enjoy, like yoga, skiing, going to the opera and wine tasting. Additionally, I no longer feel like I must do every last case in order to be considered a hard worker. Isn’t this sounding like the picture of a balanced anesthesiologist?
A busy, full and fully engaged life is tiring, I suppose. So perhaps for me, the issue is not one of being simply “tired” (like “overworked”), but rather tired because I choose expand my commitments broadly to create a life that I find enriching and rewarding. I am certainly not wishing or striving to be underworked or bored, so perhaps the character of my tired is not a danger, but a positive consequence of a gratifyingly full plate.
The holidays are here, and we can all do with a little relaxation. Take some time to reflect and relax with your families. Read a book. Catch a movie. And don’t worry too much about those fourteen-hour days, as long as you pay attention to your patients, pace yourself and find a way to give yourself a break.
Have a great Holiday Season and Happy New Year.
Editor's Note: CSA Online First will be taking a holiday hiatus for the next two weeks. We look forward to bringing you new perspectives on key issues in 2013.