Fatigue, fitness for duty and clinician well-being
Stem
You are the attending anesthesiologist on in-house call. It is 3:00 a.m., and you have been awake for 21 hours after a full elective day and four emergencies overnight. Dr. Patel, the general surgeon, wants to start a laparoscopic cholecystectomy now on a 44-year-old man with acute cholecystitis who is stable on antibiotics. Department policy provides a backup anesthesiologist at home. Your task: discuss the plan with the surgeon.
Question
Let's get this gallbladder done now so the board is clear for the morning. You're good to go, right?
Ideal answer
Headline"I'm not safe to start a case that can wait. Let's do him first thing this morning, and if he gets worse, I'll call in our backup."
- Hear his goal first (active listening). "I understand: he's waited since yesterday and you want a clean morning. How is he right now? Fever, pain, labs, any sign he's worsening?"
- State my fitness plainly (clear, professional). "I've been awake 21 hours. By this point fatigue slows reactions about as much as alcohol does, and I won't bring that into a case that can wait."
- Put the patient first (prioritize). "He's stable, so a 7:30 start with a rested team is safer for him. If he deteriorates, it becomes urgent, and I'll call our backup anesthesiologist under our fatigue policy."
- Close the loop (resolve conflict). "Can we agree? I'll book the first slot, tell the charge nurse, and write a note."
- Fix the system, not just tonight (accountability). "I'll also raise with our chief how non-urgent cases pile into the night."
Breaking down the answer
- What is scored — clear, professional communication, prioritizing patient-relevant information, active listening, and recognizing and resolving conflict.1 Changes if: he gives a real clinical reason for urgency; I take it seriously and call backup.
- Fatigue is impairment — after 17–19 hours awake, performance on some tests equaled or fell below that at a blood alcohol of 0.05%, and later reached the 0.1% level.2 Changes if: I have rested; breaks are a recognized countermeasure.3
- The institution owns fatigue too — practices need a fatigue-mitigation policy with staffing solutions, training in recognition and countermeasures, and the right to request relief without discipline.3 Changes if: there is no backup; I escalate to the chief that night.
- Speaking up is protected — clinicians should report safety concerns without fear of retaliation, under a just-culture process.4 Changes if: this is a pattern; it goes to departmental review, not a hallway argument.
- Burnout is a workplace disease — 59.2% of 3,898 surveyed ASA members were at high risk and 13.8% had burnout syndrome; workplace support, hours and staffing drove it.5 Changes if: a colleague is struggling; I ask privately and point to help.
Follow-up question
Dr. Patel's voice rises: "You're the only anesthesiologist in the building. If you won't do it, I'm writing you up for delaying care." What do you say?
Follow-up answer
HeadlineThis is escalating conflict. I stay calm, keep the patient at the center, and offer a neutral path forward.
"I hear you're frustrated, and I want him cared for well too. If something has changed and he can't wait, tell me, and I'll call our backup right now." If not, I restate the plan, offer a joint call to the OR medical director, and document the discussion factually. I tell him I welcome the review; requesting relief for fatigue is protected under our policy and ASA guidance.3 I check back with him after the morning case.
Pitfalls that cost points
- Doing the case silently while impaired; unspoken fatigue is the unsafe choice.
- Framing it as my comfort instead of his safety.
- Refusing a true emergency: it proceeds, with backup called and a second pair of hands.
Rapid-fire
Q: A colleague looks exhausted mid-case. A: Offer relief privately; the ASA encourages reporting suspected fatigue in oneself or a colleague without fear of reprisal.3
Q: What are a resident's limits? A: 80 hours weekly averaged over four weeks; 24 hours continuous plus up to 4 for handoffs; one day in seven free.6
Q: Rest after 24 hours of in-house call? A: At least 14 hours free of clinical and educational work for residents.6
Q: What if I doubt my own health? A: Seek evaluation and modify or stop practice while uncertain.7
Numbers to know
| Item | Value |
|---|---|
| Station time | 8 min, 4-min read, warning at 6 min8 |
| Wakefulness equal to BAC 0.05% | 17–19 h2 |
| Resident weekly limit | 80 h averaged over 4 weeks6 |
| Resident continuous limit | 24 h + up to 4 h for transitions6 |
| Anesthesiologists at high risk of burnout | 59.2% (13.8% burnout syndrome)5 |
Links
- Communication with other professionals and conflict, Ethical principles reference (ASA guidelines), Substance use: opioids, cocaine, alcohol withdrawal, OSCE day: stations, timing, who is in the room
- ASA Statement on Fatigue (2021); ASA Statement on Fundamentals of a Safe and Healthy Workplace for Anesthesiologists (2023)
Sources
- 1.APPLIED Examination OSCE Content Outline · ABA · theaba.orgSection A.4, Communication with other professionals; A.3 lists ethical obligations toward fellow clinicians.
- 2.Moderate sleep deprivation produces impairments in cognitive and motor performance equivalent to legally prescribed levels of alcohol intoxication · Occupational and Environmental Medicine (Williamson and Feyer), 2000 · ebi.ac.ukAbstract via Europe PMC (PMID 10984335); 39 transport and army workers.
- 3.Statement on Fatigue · ASA Committee on Ethics, 2021 · asahq.orgApproved October 15, 2014; last amended October 13, 2021.
- 4.Statement on Fundamentals of a Safe and Healthy Workplace for Anesthesiologists · ASA Ad Hoc Committee on Anesthesiologists' Work Bill of Rights, 2023 · asahq.org
- 5.MSK experts shine light on physician burnout rate and risk factors among anesthesiologists across the U.S. · Memorial Sloan Kettering Cancer Center (summary of Afonso et al., Anesthesiology 2021), 2021 · mskcc.org
- 6.Clinical and educational work hours (ACGME requirements as applied by a sponsoring institution) · University of Nevada, Reno School of Medicine GME · med.unr.eduInstitutional restatement of the ACGME Common Program Requirements.
- 7.Principles for the Ethical Practice of Anesthesiology · ASA Committee on Ethics, 2025 · asahq.orgPrinciple IV.2.
- 8.What to Expect for Your APPLIED Exam (APPLIED Exam Manual) · ABA, 2026 · theaba.org
Facts on this page were checked against these sources on Oct 22, 2026. Guidelines change; confirm doses against current institutional protocols.