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September 15, 2020

Waking up to fatigue in the veterinary clinic

The hidden costs of insufficient sleep
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Much is known about compassion fatigue and its emotional toll on veterinary professionals. Less understood is how fatigue caused by insufficient sleep harms veterinarians, veterinary technicians, and veterinary assistants. Veterinary staff members may be tired after a demanding shift in the clinic, especially now with the added rigors of managing the coronavirus pandemic. And yet there appears to be little acknowledgement within the profession that such conditions are as much a danger to workplace safety as any infectious disease.

Sleepy doctor with coffee

Sleep is a function of age, according to the National Institutes of Health, so while teens need at least nine hours of sleep each night, adults require between seven and eight hours. Fatigue occurs when a person doesn’t sleep enough hours appropriate to their age group.

Signs of fatigue are hard to ignore. Lethargy. Irritability. Difficulty focusing. Chronic fatigue is a far more serious condition, described by the Mayo Clinic as “unrelenting exhaustion” that rest doesn’t remedy, and may be a symptom of an underlying medical condition, including cancer or anemia.

Even the regular, run-of-the-mill fatigue attributable to working long hours and inadequate sleep is a health threat. A study cited by the nonprofit National Safety Council, which advocates for occupational safety, found that workers who reported less than five hours of sleep were three times as likely to be injured on the job as workers who reported seven or more hours of sleep.

Jenny Burke, NSC senior director of impairment practice, likened sleep deficiency to alcohol consumption. The effects of losing just two hours from an eight-hour sleep schedule are similar to drinking three beers. “Most of us would not drink three beers and drive home, right? But we’re essentially doing that same thing when we take two hours away from a normal night of sleep,” Burke said.

When NSC surveyed more than 500 human resource officers about recognizing signs of fatigue in staff members, approximately 50% reported employees had fallen asleep at work, 57% said employees missed work because they were tired, and a third reported workplace injuries and “near misses” caused by fatigued employees. “These are just the incidents employers are noticing,” said Burke, adding that fatigue costs the U.S. economy $400 billion annually.

So essential is sleep to physical and mental well-being that the Centers for Disease Control and Prevention classifies insomnia and other sleep disorders as a public health epidemic. “We know there’s a significant amount of the population that suffers from sleep apnea and doesn’t even know it,” Burke explained. “Only 11% of actual sleep disorders are diagnosed and treated, so that leaves 89%—roughly 70 million people—who have a sleep disorder and don’t know it.”

Too busy to sleep

Little is known about fatigue and its impacts within the veterinary profession, which in recent years has turned its attention to improving the mental health and well-being of its members. It’s worth noting that fatigue is linked to depression, diminished psychological and emotional health, and burnout. Human medicine’s experience in this area may be instructive to veterinarians, veterinary technicians, and veterinary assistants.

For starters, human health care professionals have been arguing over the effects of fatigue on physician performance and decision-making for more than three decades. In 1984, 18-year-old Libby Zion died in a New York state hospital as a consequence of mistakes made by overworked physicians. Five years later, the state passed legislation mandating that residents could not work in excess of 80 hours a week or for more than 24 consecutive hours. In 2003, the Accreditation Council for Graduate Medical Education adopted similar standards for U.S. medical schools.

I don’t think clinics know what to do when they hire ER veterinarians, so they give them these crazy schedules, like overnights Friday, Saturday, and Sunday. Let’s see how long you can do that.

Dr. Armelle de LaForcade, executive secretary, American Academy of Veterinary Emergency and Critical Care

The debate reignited in 2017 when the ACGME lifted the 16-hour cap for first-year residents, allowing them to work a 28-hour shift.

This past April, as the COVID-19 virus swept across the nation, the CDC stated fatigued and overworked health care workers “can jeopardize their own health and safety, such as increasing their susceptibility to infectious diseases, needle sticks, work-related muscle injuries, and burnout, as well as committing patient care errors.”

Then in May, the American Academy of Sleep Medicine warned that physician burnout is a serious and growing threat to the medical profession. While the prevalence is unknown, the academy cited recent estimates of physician burnout approaching 50% or more, with midcareer physicians at highest risk. “Sleep deprivation due to shift-work schedules, high workload, long hours, sleep interruptions, and insufficient recovery sleep have been implicated in the genesis and perpetuation of burnout,” the AASM stated.

“It is the position of the American Academy of Sleep Medicine that a critical need exists to evaluate the roles of sleep disruption, sleep deprivation, and circadian misalignment in physician well-being and burnout. Such evaluation may pave the way for the development of effective countermeasures that promote healthy sleep, with the goal of reducing burnout and its negative impacts such as a shrinking physician workforce, poor physician health and functional outcomes, lower quality of care, and compromised patient safety.”

Long hours and little downtime are also a challenge for fourth-year veterinary students in the clinical training phase of their education. In 2019, the Student AVMA updated its duty-hour guidelines with proposals that students work no more than 80 hours a week, work no more than 24 consecutive hours in continuous on-site duty, and be provided with breaks when they are on call. SAVMA does not have the authority to enforce these guidelines but encourages all AVMA Council on Education–accredited institutions to consider following them.

Up all night

Emergency and critical care is one sector of veterinary medicine where the effects of fatigue are the most acute. Despite high demand for veterinarians and veterinary technicians to staff emergency rooms and intensive care units, veterinary practices are struggling to retain staff members and fill these high-paying positions, said Dr. Armelle de LaForcade, executive secretary for the American Academy of Veterinary Emergency and Critical Care.

Reasons for the shortage vary, explained Dr. de LaForcade, a faculty member at the Cummings School of Veterinary Medicine at Tufts University, and include job-related stress, dealing with difficult clients, and a lack of professional development in veterinary emergency and critical care that doesn’t require a residency.

Chart: Tired workers are at higher risk of injury

“Then you add to all of that having to work five overnights in a row. It takes you a day and a half to recover, but by then, you’re back at work.”

Staffing adjustments that account for these stressors are not commonplace in veterinary medicine, Dr. de LaForcade noted. Yet such a model is needed, one that allows staff members time to recover from overnight work. “I don’t think clinics know what to do when they hire ER veterinarians, so they give them these crazy schedules, like overnights Friday, Saturday, and Sunday,” she said. “Let’s see how long you can do that. But clinics have nothing else to go by and believe that if you chose emergency medicine, then you must enjoy working nights.”

Dr. de LaForcade wonders about the health costs of working second or third shift in the veterinary emergency sector. “We don’t know,” she said. “There are models in other professions that show the level of fatigue you get from working off-cycle from the rest of the world. There’s studies that show you are more prone to illness and other health issues.”

Ideally, Dr. de LaForcade said, the ACVECC and Veterinary Emergency and Critical Care Society would partner with the AVMA or other veterinary organization on a study to identify a staffing plan that encourages longevity in veterinary emergency and critical care.

Most of us would not drink three beers and drive home, right? But we’re essentially doing that same thing when we take two hours away from a normal night of sleep.

Jenny Burke, senior director of impairment practice, National Safety Council

“We need to look at practices that are retaining people and figure out what they’re doing differently,” she said. “I suspect they’re doing something like three days on, four days off, which is crazy compared to other veterinary fields, but the ER has so many stressors that that might be what you need.”

Setting boundaries

Like their colleagues in emergency and critical care, large animal veterinarians are well acquainted with fatigue. The on-call shifts, hours on the road, and handling patients weighing hundreds of pounds can easily wear a person down.

Doctor working on laptop

“Fatigue is a very real issue for equine practitioners because our clients’ appreciation is often measured by our availability to them,” said Dr. Cara Rosenbaum, who works at a four-doctor referral hospital and ambulatory center in Wauconda, Illinois.

“You may only be working 8 to 5, but then you’re on the phone till 8 o’clock at night answering client questions,” she said. 

Dr. Rosenbaum prepared herself as best she could for the demands of a career as an equine practitioner. As a student at Cornell University College of Veterinary Medicine, she was mindful of the importance of personal care and helped start a student wellness initiative at the veterinary college. After graduating in 2017, she interned at an equine hospital for a year before hiring on as an associate at the Wauconda practice the following year.

She quickly discovered there was more to learn, such as setting boundaries with clients and not being at their beck and call. Dr. Rosenbaum, who is a member of the American Association of Equine Practitioners’ Wellness Committee, says she’s also “respecting” her sleep more.

“I can tell the difference between being burned out and when I’m fatigued,” Dr. Rosenbaum said. “When I’m a little bit burnt out, if I get away from work and get on my kayak for two hours or get the dog to the dog park, I feel better. But when I’m fatigued, I can do all the things I enjoy, and I still wake up the next morning not wanting to go back to work.”

“I think we forget that there is a physical part to being a large animal practitioner that contributes to fatigue,” she continued. “I’ve had one shoulder surgery already, and if it starts hurting after having to haul a hundred pounds of equipment out of the truck each time for six appointments, it just exhausts you in a whole different way.”