When is it safe to practise medicine?

College of Physicians and Surgeons of Alberta CPSA, Latest News Archive, Medical Matters, Messenger 25 Comments

It is with great excitement that I share some very important direction the College received from the CPSA Council on March 1, 2019. With Council’s support, the College will pursue a better understanding of how we can improve patient safety by exploring how concepts like physician impairment, specifically due to fatigue, can impact the delivery of safe health care.

More directly, we need to better understand the impact of physicians practising while impaired.

Now, I understand that the term “impairment” can have some very negative connotations, but I think it’s important to recognize impairment for what it is. There are physicians practising medicine who are not functioning as they should. Their impairment could be the result of fatigue, illness or injury (physical and/or mental), the treatment of those conditions, or last but certainly not least, the use of recreational drugs or alcohol.

The conversation on physician impairment began with dialogue about the legalization of recreational cannabis. This led to much of Council’s discussion on the impact of fatigue on physician performance, but I believe it speaks to the overall concept of physician impairment, which needs to be addressed.

Image source: robrogers.com

Fatigue often occurs as a result of working long or irregular hours, or doing shift or night work, but it also results from family or social responsibilities and lifestyle choices. Fatigue is also unique to different people, but there is evidence to support that fatigue is dangerous. Fatigue changes how we think and make decisions.

I think it’s fair to say it would be inappropriate for a doctor to practise medicine if they were legally intoxicated with blood alcohol concentration (BAC) above 0.08%, yet we ask doctors to perform their duties with the same degree of impairment due to fatigue. There is a great deal of published evidence to support the correlation between fatigue and performance; the vast majority of research has found that when people are without sleep for more than 24 hours, it’s the equivalent of having a BAC of 0.10%. That just can’t continue.

Fundamentally, what we’re talking about is a change in culture for doctors in Alberta and across Canada. It also means that physician leaders will need to take this seriously if we start putting accountability for quality on the agenda for health care in Alberta.

It took decades for the auto, aviation and space industries to recognize the impact of fatigue on safety, but now it is a well and widely-accepted reality of working in those industries. The same culture shift must take place in health care. If we want to take physician burnout seriously and protect patients from potentially dangerous decision making, we need to take physician impairment due to fatigue seriously.

I don’t expect this to change overnight, but the CPSA will be looking into the issue of physician impairment—from a variety of causes—much more seriously over the next year and identifying ways we, as regulators, can help change the culture to better protect patients.

Comments are appreciated,

Scott

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Graham Hunter

I am wondering how the College will deal with the fatigue of long call hours for residents and rural physicians. Very interested in the comments by colleagues and completely dismayed that this has not been dealt with in the 40 years since I started practice. Same stuff; different decade. Talk is cheap and goes on forever without any action. I certainly would not wish to be a rural physician. They must be superheroes to survive.

Scott McLeod

Good morning Graham. Thanks for reading the Messenger and taking the time to provide a comment. There is an old saying that “culture eats strategy for breakfast.” I believe that’s very true in this case. The culture of the medical profession must change and that will not happen if the only people embracing this concern work at the CPSA. As members of the medical profession we all need to recognize the issues that contribute to the problem and help find solutions. It will take physician leaders and health system leaders in all parts of the system to embrace this reality… Read more »

Tim Jordan

Continuation: 4. The quality of work provided by doctors is often sub-par, and all the competing interests of a system, does much to interfere. 5. Maximising one’s income may be of benefit to the maximiser but it often does little for the system. 6. How does one limit one’s case load in a rural ER, when one is the only Dr. available? Problems are bound to emerge? 7. Nursing often needs to take more responsibility for patient care in preference to placing all amount of pressure on the doctor to resolve issues. 8. Instilling discipline within patients is of utmost… Read more »

Scott McLeod

Good morning Tim. I can see that you are very unhappy with the health system in general and there’s not much I can do about that. Although I agree that patients can and should play a bigger role in their health and care, I do not agree your comments about stupidity. I do not believe patients are stupid. There may be times when patients make poor choices, like we all do, but that’s a different issue. As for complaints, I see them differently. I see them as an opportunity to learn from how patients are perceiving the care they’re receiving.… Read more »

Tim Jordan

Continuation: 1. CTAS 4&5 levels should be redirected from the ER upon assessment to their GP, a Walk-in clinic or an on-site, out-patient department manned by a doctor other than the one on-call for emergencies and all the others. 2. All patients should be examined THOROUGHLY upon admission. Drs. in many ER’s are unable to manage all-comers and undertake all admissions in a satisfactory manner. The key is quality. The majority of patients are poorly examined upon admission and without an assessment of all their issues, it is impossible to manage them. This is even true of our Teaching hospitals,… Read more »

Tim Jordan

Continuation: Patients are used as a back and forth, ping-pong ball. Maybe if we spent more time on trying to resolve patient issues, the level of stress would be reduced. In addition, there are all manner of interruptions by everyone wanting their pound of flesh. It is time that people began to exhibit a few more manners and support the doctor in his endeavours, in preference to causing drama, and expecting the doctor to resolve all the systems problems. Is it not time for the CPSA to provide acceptable guidance to AHS, as to the correct management of such a… Read more »

Scott McLeod

Hi Tim, thanks for taking the time to provide your comments and insights. There is no question there is a significant impact that both Society and the Health System in General have on physician burnout, but I would argue that there’s a great deal physicians do to themselves as well that don’t help. Physicians are known to work long hours, not look after their own health and overcommit themselves both in practice and in their private lives. It’s not the place of the College to tell AHS what to do, but we work closely with them to improve care for… Read more »

Tim Jordan

The greatest health benefits to patients accrues to them within the ambit of primary care. Subsequent to that, referrals to Specialists sets in motion the Law of Diminishing Returns. This Health Service has seen fit to promote the ascendency of Tertiary care over that of Primary. With a huge surfeit of Specialists, is it any wonder, that there are issues of efficiency and productivity? In addition, by and large, we have a huge number of patients who care little for their health maintenance except to encumber and over-burden the system with preventable health issues. This is wastage, and expensive, both… Read more »

Glen Armstrong

This will have an impact on Rural Practice. A lot of doctors do 24 hour call, but some also do 48, 72, and I have even seen 60 hour shifts. Not sure there is enough people to cover the shifts safely which is the main reason for the long shifts undertaken.

Every profession has a maximum of hours worked, but somehow the medical profession is not yet covered.

This will be interesting to see how this is dealt with as a profession.

Vince Paniak

I have a background in the regulatory side of fatigue management in the commercial driving field. Too many scary stories and fatalities across North America due to fatigued driving. I also know of residents and surgeons who were impaired due to lack of sleep and still were required to perform their duties. How do we put electronic hours of work monitoring on these physicians like we now do with commercial drivers?

Scott McLeod

Hi Vince, Thanks for your comments. None of this will be easy, but the first thing we need is leaders to step up and say when it’s unsafe for someone to provide care. Being aware of the issue and openly talking about it will be the first step to changing it.

Noel Corser

Obvious question – how does one definite impairment? Easier for a blood-EtOH threshold; harder for marijuana; definitely very challenging with mental/physical illness, distraction from non-work factors, fatigue! Certainly 14-hour cutoffs are very crude. Had an ambulance crew a few months ago unable to transfer a sick patient as they would exceed their hours, after a very light day (including a nap) – but “the rules are the rules”. Conversely, docs who are unsafe half way through a shift, because of what happened during the preceding (unmeasured) 24-48 hours. Might help to recognize that the reasons a doc might work while… Read more »

Chris Evans

Thank you for taking this on Scott and the CPSA Council. It will indeed be a tough nut to crack, but it’s one that needs to be cracked. As I have said to many a fellow physician “if taxi drivers have requirements in relation to fatigue, why don’t physicians?”. As you have said, this issue has been recognized in the auto, aviation, and space industries (to name only a few), so it is about time we got our house in order in relation to this very important issue. As for the rural physician asking if a tired physician is better… Read more »

Scott McLeod

Hi Chris, Thanks for providing your insights. I agree there are likely many creative solutions that we just haven’t considered yet.

Karen Lundgard

I totally agree that fatigue is a hazard but in underserviced areas and our rural areas that have recruitment problems, how do we balance the demands of the job and the needs of seriously ill patients with the fatigue of the physicians? Is a tired physician better than no physician? We know what is ideal but can we place hard and enforceable rules in place without unintended consequences?

Scott McLeod

Hi Karen, Thanks for reading the messenger and providing comments. I don’t know what’s better, because that will depend on the circumstances. I do however think we need to at least ask that question. Perhaps a better question would be… is a tired physician better now than a rested one in 1 hour? Or is a tired physician alone better than one that has back-up from a remote Dr? I don’t have the answers yet, but we need to be innovative in our thinking.

Neil Heard

Has the College had to attend to incidents arising out of this issue? There is still a place for self regulation. Physicians appear to have become far more responsible over the last few decades, with respect to impairment. If one goes back to the 70s and 80s many hospitals in OECD countries had bars at which on call physicians would hang out. This is history. Shifts have also become shorter and the individual scope of practice narrower, all without regulation. Guidelines or goals may be a good idea, so that adherence, not just by physicians but by those involved with… Read more »

Scott McLeod

Hi Neil, Thanks for taking the time to write in. I’m not saying that we can regulate are way out of this one. There is a requirement to change the culture and you can’t do that by simply applying rules. There may however be some ways the College can impact this real problem. That’s why we’re taking some time to better understand the problem and see what we can do to help shift that culture.

Rick Zabrodski

Start with the basics. The profession needs to stop treating sleep as a luxury. There is some serious cognitive dissonance going on about this basic concept. “Mistakes were made, but not by me”

Scott McLeod

Hi Rick, Thanks for the comment. I couldn’t agree more.

Sue Reid

Absolutely agree that this culture has to change. For example How can a patient give “informed consent” for an elective surgical procedure if they are unaware that either their surgeon or anesthesiologist …or both..have had no sleep in the preceding 24 hours? That is with holding significant info and Iwould argue risk. From a physician viewpoint, only when a regulating body takes the step ..via the impairment argument …to change the traditional inhuman culture of over work and fatigue will we see true change. Which will benefit the health of patients and their physicians. Very interested in how the college… Read more »

Scott McLeod

Hi Sue, Thank you for taking time from your very busy day to provide me with feedback. As you can imagine, this is a tough nut to crack. I don’t know what our best approach is yet, but we’ll find one. Take care. Scott

Juan

Impairment' represents a multi-faceted conceptualization in medical practice, as duly pointed out in this discussion piece. After years of practicing medicine, I have seen colleagues' practices disrupted by affairs with patient's spouses, alcoholism, depression, and other behavioural issues with similar underlying issues ofburnout’. I have backed out of my garage with my driver’s door open post-call – completely unaware – and peeled it off on my out way to pick up my kids from school. Like many of the topics faced in this forum of dialogue, there is little that is meaningfully addressed in terms of supportive answers. I know… Read more »

Scott McLeod

Hi Juan, Thank you for reading the Messenger and taking time to comment. I agree with you.

Scott

Thanks

I totally agree with impairment due to fatigue being a safety standard. Especially for first year Residents who are expected to be on call over 24 hrs, not blink during the night and stay for handing over and are on call for 24 hrs again the next day…. it messes up your whole sleep cycle and subsequently one walks about like a zombie, who is expected to offer excellent services and learn at the same time….