Fatigue and Overwork

Long and grueling work hours are a time-honored tradition in medical practice, especially for physicians in training. Although medical culture has historically considered overwork a virtue, this section will address the cultural evolution set into motion 20 years ago in response to the case of Libby Zion, an 18-year-old college freshman.^{[106] [107]} On a night in March 1984, Libby Zion was taken to New York Hospital by her parents with a high fever, dehydration, and chills. She was admitted to the general medicine ward for observation. She was never examined by an attending physician; instead, she was cared for by an intern and junior resident, both of whom had been up for 18 hours at the time of her admission. She was not observed in a critical care setting. She received meperidine (Demerol) despite previous treatment with a monoamine oxidase inhibitor. Throughout the night she became increasingly delirious and was placed in physical restraints without an interim examination by a physician. By morning she was dead.

Libby's death was attributed to the inexperience and fatigue of resident physicians who lacked the direct supervision of an attending physician. The Bell Commission appointed to investigate the case later cited inadequate supervision as the root cause of the problem, whereas a grand jury investigating the incident blamed too great a work assignment. Neither body blamed lack of sleep or long work hours as the primary cause of the incident.

Since Libby's death, much attention has been focused on physician work hours and sleep deprivation.^[108] However, studies show that inadequate supervision continues to be a major source of stress among physicians in training. When asked to describe a particularly stressful incident in their preregistration year, the number one stressor identified by house officers in the United Kingdom was the lack of supervision by superiors in situations where they were forced to take responsibility beyond their experience. Not surprisingly, these events occurred mostly at night. Only a small minority of house officers attributed stressful situations to fatigue alone, but fatigue together with work intensity combined to make "overwork" a significant factor.^[109]

Sleep deprivation and overwork are now recognized to be detrimental to physician well-being, and they may have impact on patient care as well. Overwork with its impact on sleep and personal life played a significant role in the depressive illness suffered by 28% of preregistration house officers in Great Britain.^[110] In another survey of 225 physicians, 85 reported incidents where symptoms of stress had negatively affected their care of patients. In this survey, 48.8% blamed tiredness whereas 19.5% blamed the pressure of overwork to be a significant cause of clinical mistakes and suboptimal patient care.^[111]