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Should sleep-deprived surgeons inform patients of their condition?
A medical student is participating in a complicated abdominal surgery by holding a retractor. He was up all night the previous night. He falls asleep and slides down to the floor. A nurse drags the student out of the way, and a resident takes over the retractor.
This story was recounted by an anonymous physician in a recent CNN story1 discussing an editorial published in The New England Journal of Medicine suggesting that sleep-fatigued surgeons should disclose their condition to patients. Negative outcomes associated with sleep deprivation happen more often than falling asleep, said Charles A. Czeisler, PhD, MD, FRCP, chief of the Division of Sleep Medicine at the Brigham and Women's Hospital in Boston, Massachusetts, and professor of sleep medicine at Harvard Medical School.1 Czeisler co-authored the editorial with Michael Nurok, MD, PhD, an anesthesiologist and intensive care physician at the Hospital for Special Surgery, New York City, and medical ethicist.
Facilities "have a responsibility to minimize the chances that patients are going to be cared for by sleep-deprived clinicians," and elective surgery is the place to start, the authors said. In fact, in the editorial, Nurok and Czeisler argue that sleep-deprived physicians should not be permitted to proceed with an elective surgery without a patient's informed, written consent acknowledging the surgeon's condition.2 Sleep-deprived physicians should be required to inform patients of the potential hazards that can come with this impairment, they maintain. If patients opt to proceed as planned, the informed consent form should be signed on the day of the procedure in front of a witness, they wrote. Patients should be given the opportunity to go ahead with the procedure, proceed with a different physician if possible, or reschedule, according to the editorial.
CNN points to one survey in which 80% of patients who were to undergo elective surgery said that if their doctor was sleep-deprived, they would request a different doctor.1
"Elective surgery is the low hanging fruit because there is no urgency to doing it and it can be rescheduled, ideally as a priority with institutional support," Nurok says. "It's a nice place to start to think about policy approaches."
The problem already is being addressed in some areas. For example, some busy practices prohibit scheduling surgeries for physicians on post-call days. "A lot of institutions are not going to be able to take that leap immediately, so as an interim step, we believe that patients need to be informed," Nurok says.
Keep in mind that certain specialties, including neurosurgery and cardiac surgery, might receive a lot of routine night calls, says Jeffrey M. Rothschild, MD, MPH, assistant professor of medicine, Harvard Medical School, Physician, Department of Medicine, Division of General Medicine, Brigham and Women's Hospital, Boston.
"I think in cases where they got less than four to six hours of sleep, patients should be informed," Rothschild says. (For more on disclosure, see story, below.)
Additionally, many healthcare facilities require employees to report suspected physician impairment, which would include exhaustion, sources point out. Many question whether employees are willing to report physicians in such cases, however. Concerns about sleep-fatigued surgeons have gotten the attention of the Sleep Research Society and the American Academy of Sleep Medicine, which say legislation is needed.
The downside to disclosure
Nurok notes that changing practices goes against the culture of surgery which says that you work when you're fatigued, but he says facilities are rethinking this culture.1 Also, many surgeons believe that the training enables them to perform at the top of their game despite stresses such as fatigue, Nurok says.1
L.D. Britt, MD, MPH, FACS, president of the American College of Surgeons, says, "People have to realize, surgeons are professionals." Britt maintains that surgeon fatigue is not a frequent problem. "I don't know of a case where the surgeon is so fatigued, there's been a mistake in surgery. I haven't seen it personally as a major problem." (For information about liability, see story, below.)
Britt points to the difference between "fatigued" and "exhausted." "No one wants an exhausted surgeon," he says. However, most surgeons don't receive eight hours of sleep at night. "Should I tell all patients I didn't get a good night's sleep even though I have good outcomes?" Britt asks.
Disclosing sleep fatigue "will be confusing and troubling for patient and surgeon," he says. "Some cases I easily can do fatigued," he says. Other, more complex cases could not be performed well, Britt says. "Surgeons should make that call, and they do."
Mandatory disclosure is "unwarranted," he wrote with Carlos A. Pellegrini, MD, FACS, chairman of the college's board of regents, in an accompanying comment to Nurok's editorial. Surgeons are likely to view the proposal for disclosing fatigue as "oppressive and insidious," they wrote. "Many other factors including marital difficulties, an ill child, financial worries, and so on negatively affect performance. Are we going to demand full disclosure of these problems as well?"
Instead, surgeons should be trained to understand the relationship between fatigue and their mental and physical capabilities, Britt and Pellegrini wrote. They should use this knowledge to decide whether to disclose their condition, reschedule the operations, or seek assistance, they wrote.
However, people who are sleep-deprived are often not able to accurately assess their degree of self-impairment, according to Nurok. He compared asking surgeons to decide whether they're fit to perform elective surgery after having been up all night to a bartender asking drunks whether they can drive home safely.1 However, Nurok acknowledges that "there's not a cookie cutter answer."
"We're hoping we've started a debate and interest in policy around this," he says. Elective surgery should be leaders in this area, Nurok says. "It doesn't have to be done," he says. "There's no urgency. And the situation can be optimized." (For recent research on surgeons and sleep fatigue, see abstract and commentary, below. )
What are the cons of fatigue disclosure?
Might be 'burdensome' and 'damaging'
Adding the surgeon's sleep fatigue to informed consent "might prove burdensome to patients and physicians and damaging to the patient-physician relationship," acknowledge the authors of a recent editorial in The New England Journal of Medicine proposing that approach as an interim measure to address the problem of surgeons' sleep fatigue.1
The editorial authors identify several barriers that might make informed consent and surgery rescheduling unpopular with patients and physicians. Patients might have made logistical provisions for their surgery and might be unhappy if they have to reorganize their schedule again. Clinicians might lose cases to colleagues and thus income. Departments and institutions might lose income if patients reschedule and seek treatment elsewhere.
However, the costs might be offset by improved surgical outcomes, says Michael Nurok, MD, PhD, an anesthesiologist and intensive care physician at the Hospital for Special Surgery, New York City, and medical ethicist. Nurok adds, "You may save money if you have zero complications."
Adding sleep fatigue to the informed consent may be necessary until institutions take the responsibility for ensuring that patients rarely face such dilemmas, the authors maintain.
"This is where the biggest impact is, and it is the most efficient way to deal with this problem: Create a policy around it," Nurok says. The real answer? The "institutions should say to a surgeon, 'on your post-call day, we're not going to allow you to schedule routine procedures,'" he says.
Nurok acknowledges that such a policy could be more challenging for a rural facility where there are no other surgeons in the area and where surgeons most often do not get called in overnight. However, policies could be targeted for elective cases on post-call days in busy, urban centers, Nurok suggests.
Is there liability with sleep fatigue?
There is the possibility of liability when surgeons perform more surgery "than common sense would dictate that they can do," says Steven Levin, lawyer and founding partner, Levin & Perconti, Chicago.
"From my viewpoint as representing patients, if an injury occurs, and if it's related to a doctor operating when he's too tired to operate, there will be unquestionably a large settlement or verdict," Levin says.
The law holds all professionals to a standard of reasonableness, he says.
The facility might be liable if managers and/or administrators had a reason to know that the surgeon was operating in a less-than-optimal state, he says. Liability could arise if they observed that the surgeon appeared to be tired or if the surgeon had poor record of complications that wasn't otherwise explained, Levin says.
"Just like a truck driver shouldn't drive and endanger people when he is too tired, a surgeon shouldn't operate when he is too tired," Levin says.
Are complications related to sleep the prior night?
Abstract & Commentary
By Frank W. Ling, MD, Clinical Professor, Department of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, is Associate Editor for OB/GYN Clinical Alert, also published by AHC Media.
Synopsis: The complication rate for procedures performed by attending surgeons and obstetricians was not greater among those who worked overnight.
Source: Rothschild JM, et al. Risks of complications by attending physicians after performing nighttime procedures. JAMA 2009;302:1565-1572.
Conducted in a 700-plus bed tertiary care, urban academic teaching hospital with a trauma center and referral center for high-risk obstetrics, this retrospective cohort study involved the procedures of 86 surgeons and 134 OB/GYNs between 1999 and 2008.
Cases performed between midnight and 6 a.m. were considered "overnight," and "sleep opportunity" was defined as the time between the end of the overnight procedure and the start of the first scheduled morning procedure. The study was conducted to see if sleep opportunities correlated with surgical complications among attending surgeons and OB/GYNs. The complication rates among post-nighttime procedures were compared with those of controls. Also, complication rates in post-nighttime procedures performed by physicians with more than six-hour sleep opportunities were compared to those performed by physicians who had sleep opportunities of six hours or less. Nearly a thousand obstetrical and more than 900 surgical cases were identified as post-nighttime, and these were compared to almost 4,000 obstetrical and more than 3,500 surgical control cases.
There were complications in 101 post-nighttime cases (5.4%) and 365 control procedures (4.9%; odds ratio [OR], 1.09; 98% confidence interval [CI], 0.84-1.41). Among the post-nighttime complications, they occurred in 6.2% of cases in which the sleep opportunity was six hours or less compared to 3.4% of cases where the sleep opportunity exceeded six hours (OR, 1.72; 95% CI, 1.02-2.89). In addition, complication rates in post-nighttime procedures performed after working more than 12 hours was higher, but not significantly, than after working 12 hours or less (6.5% vs 4.3%; OR, 1.47; 95% CI, 0.96-2.27).
The conclusions of this article, from one single study site, are that there were not higher complication rates for surgeons and gynecologic surgeons who had worked overnight, although the complication rates were slightly higher among the post-nighttime procedures done if sleep opportunities were less than six hours. Surgeons did have a higher complication rate if sleep opportunities were limited, though the rate was not increased for OB/GYN attendings.
Is that reassuring? It can be, particularly if you're one of those surgeons who works inconsistent and unpredictable hours. Throughout our training, the issue of long hours and sleep deprivation has always been there, particularly with the implied concern that daytime activity could be adversely affected by nighttime emergencies/unscheduled procedures. On the other hand, if you are someone looking to debunk these data, one can simply (and correctly) point out that this was only one study site, it was retrospective in nature, and the outcome measures were not defined appropriately. It was also done at a tertiary care facility, which certainly could be very different from community hospitals that most physicians utilize in their respective practices. Nevertheless, there is not a statistical difference in the surgical complication rates whether or not the surgeon had done other procedures the night before.
Likewise, much more study is needed before being able to determine the critical amount of rest/sleep that a surgeon needs to avoid increasing the complication rates after a nighttime procedure. Prospective data are needed. There might not be, in fact, a specific number of hours of rest that is needed. That is unlikely to stop boards, commissions, governmental agencies, etc., from declaring that certain guidelines must be in place to protect the welfare of patients. In fact, who can argue with regulations that protect the patient? We're all practicing this business called medicine for that primary reason, i.e., the patient. The controversy arises when the good intentions of those making the rules run into the good intentions of those trying to render quality health care.
The results of the 2003 decision by the Accreditation Council for Graduate Medical Education to limit resident duty hours to 80 hours per week have yet to be fully appreciated. Since that time, further tweaking has occurred, with more refinements to defining how those hours may be counted. Even greater reductions are in play, with first year residents being limited differently than upper level trainees. On the other hand, the topic of hours of attending physicians has not been addressed, with this article adding to the discussion. I raise the topic of resident duty hours because it is germane to practitioners as they look at their newly graduated younger colleagues and how they practice. Some might adapt well to an unregulated practice pattern with unlimited practice hours. Others either might choose not to adapt or find that the rigors of such a schedule are stressful and/or difficult to manage.
Of greater importance are patient safety topics that we can all do something about. First, we all can have back-up plans for what we do. Self-awareness of fatigue also plays a critical role. It's OK to be tired and admit to it. It has been reported that fatigue played a role in up to 16% of preventable adverse events in one study.1 Another study came to different conclusions for cardiac surgeons who performed procedures within a 24-hour period after an overnight case. In that study, there was no difference between surgeons who were or were not sleep-deprived.2
Perhaps a series of questions could cause each of us to consider this controversy:
Does the practice routinely avoid scheduling elective surgery the day after someone has been on call the night before?
The topic of patient safety in the operating room would not be complete without touching on a couple of other topics. What effect has the surgical "time out" made? You can be your own judge. Maybe it's not a bad thing, even if it seems as though it shouldn't be necessary.
What about patient safety elsewhere? I'd like for each of you to think about your practice. Answer these questions to see how things stack up within an environment that you, as the practitioner, have a greater degree of control:
What we do in our respective daily activities should be based on good medicine first, but with a healthy dose of patient safety in mind at every turn. Let's lead the way and show the government, insurers, and anyone who wants to watch us that physicians take this topic seriously.