Saccadic Eye Movement Metrics Reflect Surgical Residents' Fatigue

Objective:Little is known about the effects of surgical residents' fatigue on patient safety. We monitored surgical residents' fatigue levels during their call day using (1) eye movement metrics, (2) objective measures of laparoscopic surgical performance, and (3) subjective reports based on standardized questionnaires. Background:Prior attempts to investigate the effects of fatigue on surgical performance have suffered from methodological limitations, including inconsistent definitions and lack of objective measures of fatigue, and nonstandardized measures of surgical performance. Recent research has shown that fatigue can affect the characteristics of saccadic (fast ballistic) eye movements in nonsurgical scenarios. Here we asked whether fatigue induced by time-on-duty (∼24 hours) might affect saccadic metrics in surgical residents. Because saccadic velocity is not under voluntary control, a fatigue index based on saccadic velocity has the potential to provide an accurate and unbiased measure of the resident's fatigue level. Methods:We measured the eye movements of members of the general surgery resident team at St. Joseph's Hospital and Medical Center (Phoenix, AZ) (6 males and 6 females), using a head-mounted video eye tracker (similar configuration to a surgical headlight), during the performance of 3 tasks: 2 simulated laparoscopic surgery tasks (peg transfer and precision cutting) and a guided saccade task, before and after their call day. Residents rated their perceived fatigue level every 3 hours throughout their 24-hour shift, using a standardized scale. Results:Time-on-duty decreased saccadic velocity and increased subjective fatigue but did not affect laparoscopic performance. These results support the hypothesis that saccadic indices reflect graded changes in fatigue. They also indicate that fatigue due to prolonged time-on-duty does not result necessarily in medical error, highlighting the complicated relationship among continuity of care, patient safety, and fatigued providers. Conclusions:Our data show, for the first time, that saccadic velocity is a reliable indicator of the subjective fatigue of health care professionals during prolonged time-on-duty. These findings have potential impacts for the development of neuroergonomic tools to detect fatigue among health professionals and in the specifications of future guidelines regarding residents' duty hours.

[1]  D. Robinson.  The mechanics of human saccadic eye movement , 1964, The Journal of physiology.

[2]  A. Fuchs,et al.  Further properties of the human saccadic system: eye movements and correction saccades with and without visual fixation points. , 1969, Vision research.

[3]  W. Dement,et al.  Quantification of sleepiness: a new approach. , 1973, Psychophysiology.

[4]  H. Collewijn,et al.  Precise recording of human eye movements , 1975, Vision Research.

[5]  Lawrence Stark,et al.  Overlapping saccades and glissades are produced by fatigue in the saccadic eye movement system , 1975, Experimental Neurology.

[6]  L. Stark,et al.  The main sequence, a tool for studying human eye movements , 1975 .

[7]  S. Hart,et al.  Development of NASA-TLX (Task Load Index): Results of Empirical and Theoretical Research , 1988 .

[8]  O Quirin,et al.  A Measure of Physician Mental Work Load in Internal Medicine Ambulatory Care Clinics , 1990, Medical care.

[9]  M. Johns,et al.  A new method for measuring daytime sleepiness: the Epworth sleepiness scale. , 1991, Sleep.

[10]  R. L. Kaplan.  The Libby Zion case. , 1991, Annals of internal medicine.

[11]  J. Samkoff,et al.  A review of studies concerning effects of sleep deprivation and fatigue on residents' performance , 1991, Academic medicine : journal of the Association of American Medical Colleges.

[12]  Jacob Cohen,et al.  A power primer. , 1992, Psychological bulletin.

[13]  M. Bradley,et al.  Measuring emotion: the Self-Assessment Manikin and the Semantic Differential. , 1994, Journal of behavior therapy and experimental psychiatry.

[14]  G. R. J. Hockey.  Compensatory control in the regulation of human performance under stress and high workload: A cognitive-energetical framework , 1997, Biological Psychology.

[15]  H. Gr.  Compensatory control in the regulation of human performance under stress and high workload; a cognitive-energetical framework. , 1997 .

[16]  E. Heath.  Borg's Perceived Exertion and Pain Scales , 1998 .

[17]  A. Darzi,et al.  Assessing operative skill , 1999, BMJ.

[18]  Warren D. Smith,et al.  Performing laparoscopic surgery is significantly more stressful for the surgeon than open surgery , 2001, Surgical Endoscopy.

[19]  F. Møller,et al.  Binocular quantification and characterization of microsaccades , 2002, Graefe’s Archive for Clinical and Experimental Ophthalmology.

[20]  D. Sparks.  The brainstem control of saccadic eye movements , 2002, Nature Reviews Neuroscience.

[21]  B. Barzansky,et al.  Sleep loss and fatigue in residency training: a reappraisal. , 2002, JAMA.

[22]  Ralf Engbert,et al.  Microsaccades uncover the orientation of covert attention , 2003, Vision Research.

[23]  G. Fried,et al.  Development and validation of a comprehensive program of education and assessment of the basic fundamentals of laparoscopic surgery. , 2004, Surgery.

[24]  T. Grantcharov,et al.  Randomized clinical trial of virtual reality simulation for laparoscopic skills training , 2004, The British journal of surgery.

[25]  Guang-Zhong Yang,et al.  A Study of Saccade Transition for Attention Segregation and Task Strategy in Laparoscopic Surgery , 2004, MICCAI.

[26]  L. Aiken,et al.  The working hours of hospital staff nurses and patient safety. , 2004, Health affairs.

[27]  Ralf Engbert,et al.  Microsaccades Keep the Eyes' Balance During Fixation , 2004, Psychological science.

[28]  Sanjay Saint,et al.  Systematic Review: Effects of Resident Work Hours on Patient Safety , 2004, Annals of Internal Medicine.

[29]  D. Munoz,et al.  Look away: the anti-saccade task and the voluntary control of eye movement , 2004, Nature Reviews Neuroscience.

[30]  Ralf Engbert,et al.  Microsaccade dynamics during covert attention , 2005, Vision Research.

[31]  K. Fujii,et al.  Visualization for the analysis of fluid motion , 2005, J. Vis..

[32]  Ralf Engbert.  Microsaccades: A microcosm for research on oculomotor control, attention, and visual perception. , 2006, Progress in brain research.

[33]  Sandra G. Hart,et al.  Nasa-Task Load Index (NASA-TLX); 20 Years Later , 2006 .

[34]  Denis G. Pelli,et al.  ECVP '07 Abstracts , 2007, Perception.

[35]  Daniel J Scott,et al.  Design of a Proficiency-Based Skills Training Curriculum for the Fundamentals of Laparoscopic Surgery , 2007, Surgical innovation.

[36]  Guo Zhaojiang,et al.  Fatigue among Clinicians and the Safety of Patients , 2008 .

[37]  Stephen L Macknik,et al.  Microsaccades counteract perceptual filling-in. , 2008, Journal of vision.

[38]  W. Ghali,et al.  Does surgeon fatigue influence outcomes after anterior resection for rectal cancer? , 2008, American journal of surgery.

[39]  A. Mangram,et al.  Resident fatigue: is there a patient safety issue? , 2009, American journal of surgery.

[40]  Lucian Panait,et al.  The role of haptic feedback in laparoscopic simulation training. , 2009, The Journal of surgical research.

[41]  Bin Zheng,et al.  Measuring mental workload during the performance of advanced laparoscopic tasks , 2009, Surgical Endoscopy.

[42]  Tamsin J. Sleep,et al.  Assessment of fatigue in intraocular surgery: analysis using a virtual reality simulator , 2010, Graefe's Archive for Clinical and Experimental Ophthalmology.

[43]  Michael J Schwartz,et al.  Eye Metrics as an Objective Assessment of Surgical Skill , 2010, Annals of surgery.

[44]  Kristian S. Gould,et al.  Improving the saccade peak velocity measurement for detecting fatigue , 2010, Journal of Neuroscience Methods.

[45]  M. Kramer.  Sleep Loss in Resident Physicians: The Cause of Medical Errors? , 2010, Front. Neur..

[46]  D. Edelman,et al.  FLS skill retention (learning) in first year surgery residents. , 2010, The Journal of surgical research.

[47]  José J. Cañas,et al.  A neuroergonomic approach to evaluating mental workload in hypermedia interactions , 2011 .

[48]  B. Bridgeman,et al.  Microsaccades and Exploratory Saccades in a Naturalistic Environment , 2011 .

[49]  Adoración Antolí,et al.  Main sequence: an index for detecting mental workload variation in complex tasks. , 2011, Applied ergonomics.

[50]  Erik D. Reichle,et al.  Lexical and Post-Lexical Complexity Effects on Eye Movements in Reading. , 2011, Journal of eye movement research.

[51]  Drew Dawson,et al.  Effects of fatigue on surgeon performance and surgical outcomes: a systematic review , 2011, ANZ journal of surgery.

[52]  David B Kaber,et al.  Effect of visual displays and locations on laparoscopic surgical training task. , 2012, Applied ergonomics.

[53]  Xoana G. Troncoso,et al.  Microsaccadic Efficacy and Contribution to Foveal and Peripheral Vision , 2012, The Journal of Neuroscience.

[54]  D. Mastin,et al.  Excessive Daytime Sleepiness, Sleep Hygiene, and Work Hours Among Medical Residents in India , 2012 .

[55]  M. Osaka,et al.  High working memory performers have efficient eye movement control systems under Reading Span Test , 2012 .

[56]  T. Foulsham,et al.  Comparing scanpaths during scene encoding and recognition : A multi-dimensional approach , 2012 .

[57]  S. Galetta,et al.  Residency Training: The King-Devick test and sleep deprivation , 2012, Neurology.

[58]  Joshua T. Gaunt.  Microsaccades and Visual-Spatial Working Memory , 2012 .

[59]  R. Ebstein,et al.  Dopaminergic Polymorphisms Associated with Time-on-Task Declines and Fatigue in the Psychomotor Vigilance Test , 2012, PloS one.

[60]  Eva Siegenthaler,et al.  Reading on LCD vs e‐Ink displays: effects on fatigue and visual strain , 2012, Ophthalmic & physiological optics : the journal of the British College of Ophthalmic Opticians.

[61]  M. Rothmund,et al.  Call-associated Acute Fatigue in Surgical Residents—Subjective Perception or Objective Fact? A Cross-sectional Observational Study to Examine the Influence of Fatigue on Surgical Performance , 2012, World Journal of Surgery.

[62]  Nick Sevdalis,et al.  The impact of nontechnical skills on technical performance in surgery: a systematic review. , 2012, Journal of the American College of Surgeons.

[63]  Leandro L. Di Stasi,et al.  Towards a driver fatigue test based on the saccadic main sequence: A partial validation by subjective report data , 2012 .

[64]  Davis Coakley,et al.  Simultaneous recordings of ocular microtremor and microsaccades with a piezoelectric sensor and a video-oculography system , 2013, PeerJ.

[65]  Michael B. McCamy,et al.  Microsaccade and drift dynamics reflect mental fatigue , 2013, The European journal of neuroscience.

[66]  Marcus Nyström,et al.  Fit-for-duty test for estimation of drivers' sleepiness level : Eye movements improve the sleep/wake predictor , 2013 .

[67]  Michael B. McCamy,et al.  The effects of fixation target size and luminance on microsaccades and square-wave jerks , 2013, PeerJ.

[68]  S. Martinez-Conde,et al.  Neuroscience and Biobehavioral Reviews , 2022 .

[69]  Drew Dawson,et al.  Look before you (s)leep: evaluating the use of fatigue detection technologies within a fatigue risk management system for the road transport industry. , 2014, Sleep medicine reviews.