I recently was invited to a meeting where a group of residents and educators were tackling the topic (and reality) of resident fatigue. We started by reviewing the ACGME Program Requirements. When it comes to mitigating fatigue, the ACGME requirements are (in my words):

• Teach residents and faculty how to recognize fatigue, why it’s dangerous, and how to mitigate it. 
• Make sure there are adequate places in the hospital to sleep when residents are on call. 
• Arrange for alternative transportation for residents who are too tired to drive home.

They also list some strategies for mitigating fatigue; “…strategic napping; the judicious use of caffeine; availability of other caregivers; time management to maximize sleep off-duty; learning to recognize the signs of fatigue, and self-monitoring performance and/or asking others to monitor performance; remaining active to promote alertness; maintaining a healthy diet; using relaxation techniques to fall asleep; maintaining a consistent sleep routine; exercising regularly; increasing sleep time before and after call; and ensuring sufficient sleep recovery periods.”

All of these are great ideas, but it’s important to realize that there is an assumption behind them which is that fatigue is physical, and mostly the result of sleep deprivation. 

As someone who survived surgical training prior to the 80 hour duty hour regulations and who practiced for a long time, I know from personal experience that although sleep is foundational, there are a lot of different ways to be tired. It is true that physical fatigue, particularly sleep deprivation, is the primary reason residents, practicing physicians, and other healers are tired. But it’s not the only reason. Saundra Dalton-Smith, MD has thought deeply about this, and thinks there are seven different kinds of tired.

When I saw the list of seven types of rest in Dr. Dalton-Smith’s talk, it reminded me of another image, one I saw in Beyond Burnout: A Physician Wellness Hierarchy Designed to Prioritize Interventions at the  Systems Level by Daniel Shapiro and his collaborators. If you haven’t read this paper, you should. It describes using Maslow’s hierarchy of needs to develop a model of physician well-being, a model that helps identify barriers to well-being (and what to do about them).

It should be obvious, but it’s worth stating – to get to the top level (where you can achieve your full potential) you have to start at the bottom. If you are hungry, thirsty, or scared you aren’t ever going to be able to give or receive respect and appreciation. And without meeting the four levels of need below the top level you won’t be able to fully show up to heal patients and contribute.

Which brings me back to fatigue. 

I’ve known for a long time that fatigue is much more than just sleep deprivation.

I think most of us would agree that the soul crushing fatigue that comes with recurring moral distress is worse than the fatigue of a non-stop beeper when you are on call, which is worse than the fatigue you feel after an hour charting in the medical record.

So I took Shapiro’s model and asked this – What if fatigue can be thought of as a hierarchy? If the model makes sense, like Shapiro’s work, it should be able to guide us as we work to mitigate fatigue for our trainees.

 It’s a draft, but a new idea I think is worth exploring. Let me know what you think.