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Good evening, everyone and welcome to tonight's webinar as part of our Hello, it's the Fy One series. I'm Viv. Um I'm one of the co leads at mind the bleep. Um We've got a really interesting talk on this evening all around wellbeing and maintaining a good sense of wellbeing during night shifts. But before we start, we'll just do our disclaimers and just signpost you to all of our resources specific to Fy One. Um So I'm part of a team of three with Rami Ish. Um And we've also got your D reps. Um And you may have heard about the series from them and this is part of our ongoing series, just basically designed to support you with your transition to F one you're obviously over halfway through, which is great. Um And we've just been trying to pick at speakers and talks to help support that. Um Just some quick disclaimers that all of our content, including any catch up content you're watching on youtube or Medal is designed to be viewed by healthcare professionals. Only any cases have been anonymized. Um And so any resemblance to any actual people would is purely unintentional and we do our absolute best to make sure there aren't any inaccuracies within any of our content. But if there are do let us know and you can do this via email at F I One at mind the.com um or comment on the video recording that you're watching. And we've got a full more comprehensive list of disclaimers available at our website. Um Next week we've got um our last of our sort of January February series, a prescribing tips for on call with Raia. Um And you can sign up for that and all of our future talks on med and we're hoping sort of around March and April to do a repeat ACP talk and also cover some palliative care medicine and renal medicine. So, watch out for those. Um Just a reminder that the website has got lots of really interesting articles. Um And that's also where we embed some of our talks that we've already done at the whatsapp group that you can also join to stay up to date with our advertising and one of the best ways to know about all of the different events we're running across the board. So, outside of Fy one only, um it's just by following us on medal, um I will end my um disclaimers there and just hand over to Luke. So Luke's Act Four anesthetic trainee um who is gonna be talking through some tips around night shifts and maintaining a good sense of well being very experienced at night shifts. Um And so hopefully lots to learn. Um, we've got a little bit of polls throughout the session, so I'll be, um, looking over those and sharing those, but he's happy to just have questions throughout. So if anyone has any questions they'd like to ask, do just pop it in the chat. Um, and the recording will be available on me. Um, hopefully in the next 48 hours. So, Luke, I will hand over to you. Ok. Um Good evening everyone. Um My name is Luke Austin. I'm currently an att s anesthetics CT four trainee. And it's a real pleasure to be speaking to you today as part of the mind, the Bleb F one series on this topic of night mode. How can we keep our patients and ourselves safe at night? Um We've got a nice size group. I think there's 18 people on the call so far. Um I'm gonna put the chat just up here on the right hand side. So if you do want to sort of interrupt with questions or thoughts or comments, um, as we go through, um, I'll be able to see the messages on, on the side and we can sort of have a chat about um, some of the issues as they come up or alternatively, I'm very happy to sort of talk about some of the questions or um, any ideas or comments. Um, or, um, maybe people sharing their own experiences, um, about some of these topics they might have come across in medical school or in the start of Fy One. and we can chat about some of those things at the end. Yeah. Um, so, yeah, I've, I've been quite interested in this topic of transition from medical school into Fy One for a while now. Um, and in 2023 I was lucky enough to publish this book called The Bleep Test, um which covers a range of topics about that really difficult transition as we go through the early stages of Fy one and Fy Two. Um talking about a range of things like um learning from mistakes, getting things wrong, getting things right, thinking about clinical decisions, palliative care, caring for ourselves for our wellbeing and also um a chatter about night shifts which a lot of the ideas from um this talk actually comes from. So yeah, let's start off with a quote which is not from any great medical journal. Um But actually from Dracula. No man knows till he has suffered from the night. How sweet and dear to his heart and eye the morning can be. I think anyone who's done some night shifts, either as a medical student or at the start of F one and knows that huge tiredness and fatigue that can accumulate will um you know, recognize the meaning in this quotation. I think it's really important to acknowledge and to understand that doing night shift as an F one doctor is kind of categorically different work to the work that you're required to do during the day. So gone is the sort of monotony of the regular daytime tasks of discharge letters, referrals, telephone calls, consulting other teams um and doing the blood tests and the cannulas. Um and what we're left with is the emergent and the urgent, the work which cannot wait and needs to be done and really can't be left till the morning. So I think there's all sorts of things here that mean that nights can be really challenging. We've got fewer staff, fewer senior staff in the hospital at night. And that means that the level of responsibility shouldered by new doctors is different from during the daytime, almost by definition, we're seeing sicker patients than our daytime patients would be if we're doing ward cover, we're only bleeped to see the patients who are deteriorating or who are actively unwell. We don't get called in the night to do jobs for patients who are fine. And when we think about, um, seeing patients through the front door, be that in Ed or am U or S AU again, you're likely to be dealing with a sicker cohort of patients because for the patient's point of view, usually their symptoms have to be a lot worse for them to bother to come to hospital at three in the morning. Um, and another point that's sort of just worth making around working at night. Um and working out of hours in general is that Monday to Friday 8 a.m. to 5 p.m. actually accounts for only 45 out of 100 and 68 hours in each week, which is just 27% of the time. We tend to think of daytime staffing levels as the norm and out of hours staffing is the exception. But this is an illusion. Although scheduled procedures and most key treatment decisions from consultants might take place in the weekday daylight hours. The immediate responsibility for a patient's care if they deteriorate is gonna fall to an out of hours team 73% of the time. So we need to think about whether the patients are maybe less safe out of hours and specifically whether they might be less safe at night. Oh, I just need to click there. So I was clicking on my keyboard to try and move the slide on. I actually has this button here. Ok. Um So yes, there are hospital patients less safe at night. Um So in 2010 mags and mallet retrospectively analyzed a year's worth of emergency admissions to a medium size D GH and they found that mortality was actually significantly higher for patients admitted out of hours compared with in hours and for those admitted at night compared with during the daytime, crucially though they only adjusted their data for age and sex and they didn't adjust for admission diagnosis or underlying comorbidities. So they acknowledged that it wasn't really clear to what extent those observed mortality differences could have been due to the fact that the patients admitted out of hours or in the night were just sicker to start off with. However, they did notice that the differences were still seen in late mortalities over the deaths at more than seven days since admission as well as in the overall mortality, which suggested a really strong factor, sorry, a strong role for the patient factors at admission. Any variations in the healthcare quality that was delivered around the time of admission, you'd expect them to have a much smaller effect on the deaths that occurred more than seven days down the line. So there's also this interesting research in a BMA report in 2018 suggesting that fatigue and sleep deprivation can have negative cognitive and psychomotor effects on task, performance work and memory capacity and attention. All three of which are really vital for resident doctors when they're doing night on calls. And I thought his last research finding which was, which was referenced in that BMA report is not particularly surprising, but it's still important. It's from the US. And it showed that critical care interns who did shift of more than 24 hours made more serious medical errors compared to those who worked shifts of less than 16 hours. So, um if you, I think we might have the poll here. Um So let's see if I can just create this as a poll. Um And we'll get you guys to vote. So, um I'm gonna put the options on the screen here. So if you had to guess in percentage terms, um how, what do you think the difference was between those doing the 24 hour shift compared to um those doing the less than 60 hour shift? See, so I just tap this onto the pole. Ok. So that should be on the phone now. Um, so let's give you a moment just to take a guess at that. Um, so yeah, we've got a few people who have answered. No. Oh, quite a few more people have joined the call. There's, there's 27 of us now. Ok. Give me a couple more seconds to have a guess at that one. So, yeah, so the right answer was actually 36%. Um, so there's a 36% difference in the medical errors between those two groups. Um, you know, I think clearly in the UK, we don't do shifts of more than 24 hours. So the findings of this study are not directly applicable to UK practice, but nevertheless, it tells an important story that the duration of time on shift is likely to have a really important effect on our ability to make safe decisions and to avoid making medical errors. Be those prescribing errors or perhaps errors with the procedure. Ok. So, um this was a study from way back actually in 2003. But again, some really interesting findings I thought um this, this is from an occupational medicine journal um by folk art and Tucker. And the um the industries involved were not actually just health care industries as these um data comes from shift workers in a range of industries, but I nevertheless think they're probably quite applicable to what we do. So let's look at the one on the left hand side first. Um So on the X axis, you can see hours on shift and then on the Y axis, you can see mean relative risk of making an error. And actually, for the first eight hours of the shift, there's not much difference, you know, you can go eight hours and it seems like the risk of making an error is pretty fixed. What was really clear on this graph is that for the last four hours of a long day, um where, you know, most, most hospitals you're either doing an eight hour, nine hour shift is a short day or a long day is 12, 12.5 hours. It's those last four hours in the shift that really seem to be associated with an increased risk of error. And I think this tells us something about where we need to be most vigilant and where we need to sort of build an extra checks into our practice. Um to try and avoid making errors that could harm patients. And I think, I think anything that's, you know, particularly true during a long day shift is likely to be as true, if not more true for a long night shift. So let's let's move on to the middle graph. Um So successive night shift, um, most rotors, I think, I think all rotors actually um in the new junior doctor contract, um, will not have any more than four nights put together at once. So as far as I'm aware, no rotors should have five nights in a row as a default. Um And I think this graph tells us why we can see that as we go through successive night shifts over the course of a week, the chance of making an error really increases. So by the fourth night, you're at massively increased risk of making a medical error compared to in your first night. And the third graph, I think again, absolutely fascinating is the number of minutes since the last break. It tells us that, you know, as we keep on working and we're accumulating, you know, you know, sort of psychological or cognitive fatigue. We become more and more likely to make a mistake and having the importance of taking breaks is something we'll come back to a bit later in the webinar. So, yeah, another poll for you. Um what you often um hear people saying you in, you know, in coffee rooms and staff rooms around the hospital is, oh, you know, the first night shifts a bit rough, but once I flip my body clock, I'll be fine. Um, so by the fourth night shift of the week your body will have flipped its sleep wake cycle. Is that true or false? Ok. We've got, um, eight responses so far and a bit of a split in the vote and give people a little bit longer to, to, um, give it a punt. Ok, a couple more seconds. So, yeah, a as 66% of you correctly, um, said it's actually false. You, you can't flip, um, the sleep wake cycle, um, in that amount of time. Um, so I in why we sleep, which is a really good book about these topics by Matthew Walker. Um, he talks about flying to the other side of the world, for example, going from here to New Zealand and says that actually it, for every, you know, the time difference, there is gonna be 12 hours. And he says that actually you need one day in the new country to shift your body clock by one hour. So, doing a run of four night shift, you know, you won't even, you won't even need a half way done, um, with that process. So it just isn't impossible. Um So thinking about sort of flipping the body's sleep wake cycle is, isn't a useful, um, way to approach the, the sleep physiology that's involved here. So, yeah, you cannot flip your sleep wake cycle, um, when night shifts are concerned. So here's some graphs that actually tell the story in a bit more detail about what's really going on when we come to do night shifts. Um, so we're gonna look at the top graph first and work it through and then we're gonna, which is sort of the normal situation and then we'll come on to talk about the bottom graph. Er once we consider what happens when we go onto our night shift. So um yeah, Matthew Walker talks us through these um processes in his book while we sleep. And I think the ideas originally come from this paper by Bill Bailey in 1982. So what we can see on the top graph is two processes, process S and process C process S is what's called sleep pressure and process C is our circadian wake drive. And these two things can be thought of as Yin and Yang, you know, sleep pressure is a, you know, some is the build up of time since you've woken up, the longer you're awake, the higher your sleep pressure becomes and that's mediated in the brain through the accumulation of adenosine process C or circadian wake drive can sort of roughly be thought of as you know, your circadian cortisol levels. Um the sort of the daily um cycle of those stress hormones that um sort of wax and wane throughout the day within a deer around 4 a.m. in the morning and then building up towards lunchtime and then dropping right down again as the day progresses. And when we consider that the circadian build up of stress hormones is something that's gonna try and keep you awake. And the increase in sleep pressure is something that's gonna make you want to fall asleep. You can see that it's the gap between these two lines that determines how likely you are to nod off. So you can see on the top graph when you wake up around 6 a.m. your sleep pressure. Oh, sorry, I just jumped forward there. Um Let's go back. So when you wake up around 6 a.m. your sleep pressure is very low because you've just had a good night's sleep and your circadian wake drive is low, but it's on the way up and it builds up throughout the course of the morning. So at the start of the day, the distance between process S and process C is very small. So you don't fall asleep at 10 in the morning. However, as the day wears on your sleep pressure slowly and surely increases. And the cortisol tide T turns and starts to drop off until eventually you end up with a critical gap between the two processes around, let's say 10 p.m. And you decide to fall asleep over the course of the night, you get your good night's sleep, sleep pressure comes down, reverts to normal, the circadian tide carries on. And then when the gap between those two narrows sufficiently, you wake up and the cycle begins once more. So that's the normal situation on the top graph. But now let's think about what happens when you go on to your run of night shifts, let's say a run of four night shifts. Monday, Tuesday, Wednesday and Thursday. So Monday's gonna be day one and we're gonna start work on Monday night. So what happens on the day before the day, that Monday as you go into the first night shift? No, you're gonna wake up in the morning probably. And most people will tell you and they're right that you should try and have a nap in the afternoon. So your sleep pressure's been building up because you've been awake, you get a bit of sleep in the afternoon as a nap. So you reduce it somewhat but not entirely. And then you get up, you know, 5 36 6 30 PM to be in work in the evening and your sleep pressure starts building up once more. So when we go on to night shifts, the sleep pressure is the thing that's changing. That is the thing that is highly abnormal, especially on that first night when you've had perhaps, you know, 1.5, 3 hour, you have a lucky longer nap in the afternoon. The cortisol cycle, the circadian wake drive that hasn't changed. That's just doing its thing rumbling away in the background. So as you start the night shift, what you can see is that when your sleep pressure starts to build up and up and up, as you go through the night shift and you're working eight o'clock, nine o'clock, 10 o'clock, 11 o'clock midnight, you're doing your first night shift, you end up with this enormous distance between process s and process c by the small hours of the morning, which creates really a sort of overwhelming um tiredness and fatigue and the feeling that you might feel like you just can't carry on and you really want to fall asleep. This graph also tells us about sort of two things that are anecdotally recognized by doctors doing night shifts, um which is hitting the wall in a sort of witching hour of 4 a.m. And that happens when you get this huge distance between the process S and the process C and it also explains what people think of as the second wind where most doctors would have sort of tell you again anecdotally that for some reason, they feel much better and much more able to do the job in the last couple of hours of the night shift, say between 6 a.m. and 8 a.m. than they did between maybe 4 a.m. and 6 a.m. The reason for that is that the Cortisol tide has turned. So you get that booting up of process c actually narrowing the distance between the two, despite the fact that your total time awake and your sleep pressure has continued to increase. Ok. Ok. So let's try and sort of put the physiology to one side. Um And think about some practical steps that we can all do to try and increase our own wellbeing. Um And in so doing by looking after ourselves, allow us to better look after our patients and keep our patients safer at night. I'm gonna break these down into four categories. Things we should do before the fir first night shift to minimize that sleep debt, things we should do during the night shift to focus on patient safety. What we should do between the night shifts again to look after our own sleep and health and how we get back to normality once the run of night shifts is done. So just before we come to that, um again, another question on the poll for you guys to have a guess at. Um this comes again from why we sleep by Matthew Walker and II, appreciate the answer to this question. It's gonna vary a little bit depending on how much caffeine you've had and in what volume? Um But on average, how long do we think the effects of caffeine on the body can take to wear off? Yeah. Got so we'll give people a couple more seconds to have a have a guess at that and then we'll carry on. So, yeah, the correct answer is actually eight hours, which really surprised me when I read that it was much longer than I was expecting. So, with that in mind about how long caffeine can stay in your system. Um, that tells us something about why I think it's really important that on that first morning before the first night shift, you're quite strict for yourself and don't have caffeine that morning. Otherwise it's gonna seriously impair your ability to get that crucial nap in, in the afternoon before the first night shift. Um Interestingly, you'll remember that I said um the sleep pressure of process is mediated by the build up of adenosine in the brain. And caffeine actually is a sort of competitive antagonist and adenosine receptor. Um which explains why taking an espresso uh will temporarily decrease the sensation of sleep pressure. And so what else on the first night to minimize your sleep debt? Don't set an alarm for that morning. So let yourself sleep in the reason being that, you know, if you can happily wake up at maybe 8839 or even later on that morning, if you, if you do manage to sleep longer, it's gonna reduce your total sleep pressure because you won't have been awake for so long on the day of the first night shift. Yeah. So no caffeine um on the first morning so that it can facilitate your napping later on in the afternoon. And um the bit about saying ideally in 90 minute cycles, um, comes from the fact that I think one sleep cycle is about 90 minutes. Um, and you feel much better if you wake up after a, even a sort of a round number of sleep cycles. So 90 minutes, three hours, 4.5 hours, I think during the nights, um, the goal is to, you know, recognize that this is a really difficult task we're doing, we're doing more difficult work. As we said, with sicker patients, it's cognitively more demanding and it's often during night shift where we really sort of find our feet as F ones and F twos and start feeling like we're doing proper doctoring, um, for the first time. And that represents a, you know, a particular challenge because it's where we are actually physiologically and psychologically cognitively, our most vulnerable that we're required to do some of our most difficult work. So, um, creating self checks, I think is really important, thinking about the things you're doing that are most likely to be risky. So, for example, with prescribing, that tends to be things like potassium anticoagulants, anticoagulants, and insulin and building in checks for yourself when you come to make those sort of critical prescriptions when you're pretty tired at four in the morning. Um, yeah, and beware the witching hour, beware that time around four in the morning when we just know that you're not gonna be at your best. And if you can sort of stave off a decision, um, and leave something until everyone's a bit more awake. That's usually the sensible thing to do. Um, again, planning breaks within the team will, will come on to talk a little bit more about breaks at the end. But it's, it's really crucial and, um, it can sometimes feel like it's not possible to take a break. I remember when I was an F one, I sometimes felt so overwhelmed with this huge long jobs list and bleep after bleep. And I thought, you know, I can't possibly stop for 20 minutes here. Um But actually, you know, taking a break would have been the right thing to do. Um So moving on looking at between the nights, um again, it is really hard because, you know, you, you want to actually feel like you've done something in your week other than work and done something nice. But um when you get back from the night shift, you do have to be quite strict with yourself and have a routine so that you can try and get the best daytime sleep that you can um which is difficult because it's going against your body clock, which has not flipped. Um sleep hygiene, basic measures can help here. It um investing in black outlines is a really sensible thing to do. Um Even the sleep mask, obviously, no alcohol because we know that um you know, again, really inhibits people's ability to sleep. Well, uh and limiting screen time and bright time and bright blue lights. II think this last point is, is again, quite important. And something that I sort of only got better at, as I, as I've sort of progressed through training a little bit is that sometimes you do wake up in the day and the fact that that's happening is again because this is not a natural thing for your body to be doing. Um, but if you do wake up in the day, don't give up, don't give up on your daytime sleep. Just recognize that it's a normal thing to happen. Don't panic, walk around a bit, listen to the radio over half an hour, um, or a podcast something, you know, not too exciting. Um, and then give yourself a chance to go back and get another sleep. Um, even if you only manage another hour, hour and a half, that's still, um, much better than nothing. Ok. And post nights, clearly, the goal here is to return to normality. Um, when I, you know, when I first started doing night shifts as, as, as an fy one, what would happen is I'd finish my set of weekend nights, for example, on a Monday morning and I'd sort of think, oh, terrific. You know, I'm done. Um, uh, you'd have the second wind. You're actually feeling a bit more awake now because the sun's come up and you've got all the light views going into your eyes and I think, ok. Right. Let's go and Binge a Netflix series or actually make something of the day, um, and try and power through the, the problem with that strategy is that if you've been working, which you, and you've been working really hard, which you would have been, it almost invariably fails. And around sort of 330 in the afternoon you crash, end up falling asleep for 67 hours, you wake up and it's 10 o'clock at night, you feel wide awake and you're in a whole world of hurt and it's quite hard to sort of get back into a normal routine. So I think the best strategy really is to try and get home, eat breakfast and have a nap three or 4.5 hours and then when you get up, stay up at that point and stay up until a normal bedtime. Ok. Let's carry on to the next next section. Um, so we're gonna talk about a very difficult issue. Now, which is that even at the end of the night shift, be at the first night shift or the last night shift. Um, your work isn't done and one really important part of protecting your own wellbeing on night shift is keeping yourself safe. So, um, again, another poll question for you to have a guess at from this study, um, in an association with Anesthetist national survey, what percentage of the trainees have had an accident or a near miss on their journey home after a night shift if you had to take a guess. Yes. Ok. Ok. We'll just look at this one for a couple more seconds. So, yeah, shockingly the correct answer was actually 57%. Um, and yeah, it's, it's staggering, isn't it? And I think only 12% of people, um, went for that one. So here is a, a really sort of sad story that was in the news a few years ago back in 2016, about an anesthetics trainee called Rack Patel who died in a car crash on the way home from his anesthetic night shift. Um, he was known to be tired. Um He was on the um hands reset, calling his wife and they were trying to sort of sing to help him keep awake. Um But clearly, you know, he was so tired after his run of night shifts that he ha en ended up most likely having a microsleep and falling asleep at the wheel and drove into an oncoming lorry. So II think when I heard about this story, it sort of really struck me quite hard. Um, you know, he, he grew up close to where I grew up and, you know, followed, followed a similar career path. And, you know, I think actually the truth is that his story could be any of ours and that we're all at risk due to this. So, you know, this, this survey was a big 1, 2000, 231 trainee anesthetists um were surveyed and 57% of them had, had an accent or a near miss and that's just one specialty. Um So I think, you know, it would be even more shocking to learn the numbers involved if you thought about all of the other specialties that also do night shifts. Um And, and that survey was followed up by another one of actually consultants this time rather than trainees and 45% of consultant anesthetists or pediatric intensivist in the UK and Republic of Ireland. It had an accident or commuting when fatigued. But I think really interestingly that survey found that 72% of those incidents had happened back when the consultant was a trainee, which tells us that it's in the early stages of our career when we are most vulnerable. Partly this is because trainees do the majority of the cover at night, you know, consultants do come in at night, but predominantly the hospital is staffed by trainees. And secondly, because of the way the training system works and we're in national, you know, deaneries around the nation. Um It's trainees who are likely to have greater commuting distances um because they get rotated around the hospitals in the Deanery and the greater commuting distances mean that they're gonna be doing more driving after a night shift, putting them at higher risk. Um So this is a quote from the Matthew Walker book. If you're drowsy while driving, please, please stop to carry the burden of another's death on your shoulders is a terrible thing. So II really do think, you know, in, in some deaneries, unfortunately, it's just not possible and there's no other way to get to the hospital, um, other than to drive, but for those of us who are you living and working in, in bigger cities and, and have an option to take the bus or the train um or even get an Uber back. I think it's it's a really sensible option. And if you can possibly avoid driving after a hospital night shift, then you, you really should avoid it. So we've spoken a lot so far about physical fatigue which we might encounter on a night shift. But I wanted to talk a little bit about this concept of decision fatigue, which I found quite interesting and thought was really applicable to the work we do. Um as doctors on the night shift decision fatigue is a term coined by the social psychologist Roy Bum Meister. Um for the way in which making a high volume of decisions actually causes a decrease in decision quality. The effect of decision fatigue was actually discovered almost accidentally. B Meister's research group had already demonstrated that Will Powell was a finite resource that could be depleted. Showing for example, that participants forced to resist eating candy would subsequently be less able to resist eating a plate of cookies. However, it was only when postoral um, sorry, not postoral postdoctoral. Um Fellow Jean Twenge realized that she felt the um same kind of mental exhaustion after an intense weekend of wedding planning, which had involve serial decision making, making choice after choice that the group decided to investigate the effects of deciding. And when these hunts was correct, experiments showed that forcing people to make lots of decisions in a row, reduced their willpower and crucially depleted willpower has a knock on effect on how the brain deals with subsequent decisions. So no matter how rational and high minded you try to be, you can't keep making these decisions without ending up paying a biological price. The more choices you make throughout the day, the harder it becomes um for your brain and the brain, the brain starts to look for these mental shortcuts which are referred to in the psychological literature as decision heuristics. Um So on the night shift, the reduced doctor to patient ratio that we have and the reduced staffing exacerbates this problem. And it creates this really high version of decisions and that can lead to decision fatigue and trigger the use of subconscious mental shortcuts. One of the most famous demonstrations of decision fatigue um is called the Israeli judges study. Um And essentially this was um, judges in Israel who were um assessing parole applications to see whether a prisoner would be let out on parole to go back into wider society. And what they found was that um the percentage of prisoners that were given parole dramatically decreases throughout the duration of the decision session. As the judges have to make more and more decisions after each other. Until eventually when it's nearly time for lunch and they're all tired, nobody gets given parole, they essentially just went for the default option, which was to keep the prisoner in prison and therefore protect society. And this is just, I think a graph showing what was happening in that judge's study that as they hit the meal break in the end of the decision session, the percentage of er, prisoners that got parole drops down to basically zero, they have their meal break and sort of reset the decision baseline, start a new decision session and the process repeats itself again. Really interestingly, there was a very similar study um done in Scotland, which was on their sort of Scottish version of NHS. Um, 111 where the nurses taking the telephone calls um, were studied and they found that as the nurses went through their decision session, day two showed this sort of um, reverse to the default decision. So in that context of taking the um, the call from the patient and working out, you know what their symptoms might mean, the default option was to send the person in the hospital um to be assessed and the sort of the percent. So the percentage of um times that the nurse on the telephone would actually sort of effectively discharge the patient dramatically dropped as the number of decisions they made increased over the course of the decision session. So, um here's a man who knew about decision fatigue. Um In Vogue magazine, Barack Obama said, you know, the reason I only wear blue or gray suits is to pare down the decisions. Um He knew that even deciding about the small stuff like what to wear could sort of increase his, um, psychological burden over the course of a day or a week. So he decided to pare back decisions and limit his wardrobe to a sort of a strict and, and narrow range. So, um, that's, that's easy for us. Um when we, um, just decide to wear scrubs, but what are some sort of more um detailed ways that we can think about how we can reduce our decision fatigue on a shift? II think the key here is really when it comes to taking the breaks. So we've seen in both of those studies about the Israeli judges and the nurses making their clinical decisions um for the NHS helpline that when they took a break, their decision, fatigue actually reset to baseline. So when we think about um our overwhelming sort of task burden that comes from the bleep, we can feel like we don't have time to take a break or that we just can't stop. But actually, you know, unless we're at a cardiac arrest call or a peri arrest and the patient really needs us. Right. Right. Now, the time spent taking a break will more than pay itself back in the increased efficiency that we gain with our um clinical thinking and judgment and decision making when we do return to the work. So I just sort of summarize these ideas here um in this diagram. So in the hospital at night, we have a decreased staff to patient ratio, there's less of us and we've got sick patients which gives a high workload and an increased choice burden. And that can sometimes lead to trade offs when the bleep keeps going. And you've got 56 different patients that all need assessing, you have to make a trade off and decide which one do you see first. And other studies have actually shown that um trade offs can separately reduce our willpower and therefore lead to more decision fatigue when we have decision fatigue. What tends to happen is that we either do nothing and become decision avoidant. Um or we start using these heuristics, these sort of rapid judgments um which are sort of guestimations and shortcuts that the brain likes to make, uh which you know, can be safe for very, very experienced clinicians who have got a sort of a huge number of cases in their head um to pattern recognize from. But it it is a mode of clinical reasoning that has been shown to be much less effective um and less accurate for, for junior staff members. Um or alternatively, when we're decision fatigued, we can end up reverting to the default. And I think as long as our default is, you know, an appropriate response to sort of a slow systematic review of a problem and usually escalation to the, to the senior members of the team, be that the med reg or your surgical registrar, um then reverting to a default can actually be a safe response to accumulating decision fatigue. So, yeah, thank you very much for listening to the talk this evening. Um I think the talks been recorded. So I'll just leave these references on screen for a couple of moments so that if people want to come back to us and sort of um have a look at some of these papers themselves, they can do. Um And otherwise I think it just remains for me to say and thank you very much to all the team at mind the bleep and at medal for hosting the webinar. Um If you found this talk interesting about some of the psychology behind the transition into F one and, and the work that we do, um There's, there's lots more of that in the book. Um And if anyone's got any questions or sort of comments or things they want to um ask in the poll, um then we can definitely talk through some of those questions. I if people have them. Thank you very much. Thank you so much, Luke. Um I've put the feedback form for anyone who would like to just fill the session. Um and also just a few tips around making sure that you log all of the sessions you come to on your horror, these count as non core hours. Um And this session specifically might map quite well to HLA 2.7. Um If anyone has any questions, put them in the chat, um and we'll just be here for a few minutes and if there's no questions, we'll, we'll end the, the webinar. Um So we've got a question here from Juliet, which is a very good one. Is there research or evidence on a safe ratio of doctors to patients overnight? Um So yeah, great question. I don't know of any um sort of papers um itself off hand. Um But I can tell you that there are definitely sort of national standards um put in place um in, in our, in my own specialty. So, in critical care, um there's something called um GPIX, which is sort of, I think um guidelines for the provision of intensive care services. And that um states sort of categorically um firstly, how many nurses should be present for x many number of intensive care patients. Um and also how many doctors should be um sort of staff in the unit depending on how many um patients we're caring for in ICU. Um, so I know we have that in, in critical care but ii don't know about, um, whether there's sort of any research, um, for the, for the same question when it comes to looking after, um, patients on the ward. Um, it's a great question and I don't know if anyone else has got any, any, um, insight into that one. Mhm. Yeah, I guess what it sort of partly comes down to is that, um, you know, there, there's different patients need sort of different, um, um, di different patients, sort of need different levels of care, don't they? And II guess the sort of the, the right sort of inverted on the right number of doctors to be looking after so many patients would probably depend on the patient population you're caring for. Uh, you know, so for example, if you're looking after, you know, elderly care rehab wards, um, where most of the patients are sort of more or less fine and have medically fit for discharge and waiting for, um, you know, sort of, um, social care or a package of care in order to be discharged. Um, you could look after a much higher number of those, um, safely than you could at the other end at the right, other end of this spectrum intensive care patients. So I guess you've got those sort of two extremes and everything in between. So, um, it probably would depend on sort of type of ward, wouldn't it? And the, the type of patients we're looking after. Um, so Viv said, um, GPS are recommended maximum of 25 patients a day. Um, yeah, it would be interesting, wouldn't it sort of know, um, for different demographics of patients? What's the sort of number that we should or should not safely be looking after at one time? Oh, it was a great question here from Edmund. Um, how does working in teams versus alone affect decision fatigue? Um So I think that I can sort of think of a, a few ways in which that, that might work out. So I think the first thing would be breaks um if you're working alone, um which, which does sometimes happen um in cer in certain specialties. Um And you don't have lots of colleagues, then you can't, you, you've got only yourself to plan your breaks with and if something happens, then you might, your break might be interrupted. Whereas it, the larger the team, um you know, which sometimes happens in, for example, like medical wall cover. Um There's much more likely to be somebody who can perhaps hold your bleep for half an hour whilst you go for your break. Um And I think your ability to actually sort of effectively take the breaks that you should be on a night shift, um is, is gonna be greater when you've got more people um in your team. And, and we know that taking breaks is one of the most powerful ways to um reduce decision fatigue. II guess the other sort of thing about working in teams is that um a problem shared is a problem halved. And um often, you know, when you discuss a clinical problem in a, in a group, the, the right answer is a sort of makes itself apparent a lot more easily. And I think, I think sort of um having a low threshold to discuss, even with, even with another colleague of the same grade. Um I II sort of found incredibly helpful when I was an F one. because between a group of you, you're likely to see some different perspectives and different angles on a problem. And I think the sort of the burden of the decision making can, can feel less. Um So Juliet has said um one med reg 500 D GH medical beds feels completely unsustainable. Um Yeah, II think that's a really a really valuable point. Um You know, there are definitely and I'm sure we've all got anecdotes around the country of ratios that do feel unsafe and do feel unsustainable. Um and sort of, you know, trying to accumulate evidence and um looking into the the effects that this burden of care and the sort of the burden of decision making can have on one practitioner in a night shift is really, is really important. And I think it's definitely something that can be presented to try and argue for um increased staffing and, and safer provision of services. Um The, the Association of Anesthetists has quite a lot of um material on fatigue at night. Um They ran a campaign a few years ago called the Fight Fatigue campaign. And I think a lot of the resources um are freely, freely available online that, that people can access. Um So Edmund is asking um interest interested to know if there's data to back this up about um sharing decisions. Um And also um why we sleep when Matthew Walker, does the bleep test have an audio book? Um Actually a really interesting question. It does not currently, but um it's gonna come out in May. So I think um May the 20th the bleep test is gonna have an audio book which will be on Spotify and audible um read by a professional narrator, happily not by me. Um So you don't have to listen to me for the whole duration of the book. But um yeah, that's gonna be on Spotify um in May and Viv's posted a helpful link here to um some er RCP guidance about um safe medical staffing.