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

From the Department of Critical Care Medicine, Hospital for Sick Children (Parshuram, Dhanani, Kirsh, Cox); and the Division of Cardiology (Kirsh), the Division of Clinical Pharmacology and Toxicology (Parshuram), and the Departments of Paediatrics (Parshuram, Dhanani, Kirsh) and Anaesthesia (Cox), University of Toronto, Toronto, Ont.

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.

This article has been cited by other articles:

				J. C. Acres Preparing physicians for the real world Can. Med. Assoc. J., September 28, 2004; 171(7): 709 - 709. [Full Text] [PDF]

				C. S. Parshuram Preparing physicians for the real world Can. Med. Assoc. J., September 28, 2004; 171(7): 709 - 709. [Full Text] [PDF]

				S. K. Howard and D. M. Gaba Trainee fatigue: Are new limits on work hours enough? Can. Med. Assoc. J., March 16, 2004; 170(6): 975 - 976. [Full Text] [PDF]

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Copyright 1995-2004, Canadian Medical Association. All rights reserved. ISSN 1488-2329 (e) 0820-3946 (p) All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association.