“On Call” and Physician Fatigue
In the past four days, I have been on call for two sixteen-hour shifts, although I worked from Tuesday morning at 8 a.m. until Wednesday at 9 p.m. This is well over the recommended sixteen hours various reports are recommending for physicians. I have recently been pondering the Royal College’s consideration of resident work hours and these four days with my own duty hours being extended have focused my mind on their work. This is the link for the study: http://www.residentdutyhours.ca/documents/fatigue_risk_and_excellence.pdf
During the time when I am working, and especially when I am on call, I follow the tenets of this small text called: Why were the saints saints? Here is the text:
Why were the saints saints?
Because they were
cheerful when it was
difficult to be cheerful,
patient when it was
difficult to be patient;
and because they pushed
on when they wanted to
stand still, and kept silent
when they wanted to
talk, and were agreeable
when they wanted to be
That was all. It was quite
Simple and always will be.
This text was quoted in the Anglican Journal this past week, in honour of All Saints’ Day, which was yesterday. The author is unknown, but hopefully a saint. I’d like to know he or she walked the walk and not just talked the talk.
I am not going to pretend that I am always able to follow these tenets at work – especially since there are a few people reading this who might comment to the contrary – but they are my goals and, when I follow them, they smooth the way, especially in the evening and night when it is so difficult to work. They help me deal with tired parents, intoxicated adolescents and Emergency Room staff who are under even more pressure than me (and who seem to eat a lot of Hallowe’en candy). They also help me to focus the following day, which I should have booked lightly, but didn’t because, really, it does seem a better option to begin a new assessment fatigued than let someone wait another several weeks for treatment. These are choices that every doctor reading this will understand, as well as anyone who has been waiting to see a doctor for themselves or their mother, or child, or partner. I do this not because I am indispensible but because I can make things easier and this is an important value for me and for many physicians. Doing more of your own work than may be advisable for personal health is the one thing that physicians do all the time that improves the efficiency of the system. Since I believe that my own role as psychiatrist in an Outpatient Department is to be an acolyte for family doctors and primary therapists, as long as I can facilitate youth getting care, I can often complete an assessment without being at the top of my game. I can always recognize when someone is VERY SICK. Also, I assure you, and so could many other physicians, that nothing gets you to the top of your game faster than the symptoms and signs that someone is VERY SICK and needs something done RIGHT NOW.
I do not know how to add these “insights”, which I believe every doctor knows, to the current debate on physician fatigue. All physicians want balance in their lives, but no physician will accept balance at the cost of doing a mediocre job. The system still depends on many of us working more than sixteen hour shifts from time to time. Imagine: your child’s school calls to say she has suddenly developed a rash to go with the cold you thought she was starting. Do you want your family doctor to extend their day, even if they have been working since yesterday morning, or send you off to the Emergency Room? It’s likely that your family doctor, like mine, will see your child, because it’s more efficient and easier on everyone, as well as the system. It’s likely that this is what you’d prefer also.
What has physician fatigue got to do with the saints and the text I copied out? For me, when I can no longer follow those “simple” rules, it’s time for me to leave work. Maybe leaving for half an hour will do and maybe I will need to leave for longer. I do ask myself: Am I still patient? Am I still cheerful? It is a problem that the guidelines for knowing when you’ve been at work too long can be found by extrapolating from a text about saints. This is especially true because I think this is still what we expect of health care professionals, and especially doctors. The child psychoanalyst Winnicott considered what was a “good enough mother” and someone needs to consider what is a “good enough doctor”. I am not sure this “good enough doctor” is going to be described scientifically and a problem in medicine right now is that we believe that all of our evidence must come from scientifically proven facts. The art of being a physician still involves night toil and the problems that do not resolve by 6 p.m. Sometimes the answers about what to do will not come from academic journals but from older texts on how to live your life. Medicine, as Osler said, is “a way of life”.