Researchers urge doctors to disclose sleep fatigue before surgery
(CNN) -- Medical institutions should put into place policies to minimize the likelihood of a sleep-deprived doctor performing elective surgery, researchers said Wednesday in an editorial.
Absent such policies, sleep-deprived doctors should -- at a minimum -- tell their patients about their sleep status prior to performing any elective surgery, and offer those patients the opportunity to postpone the procedure or select a different surgeon, said the editorial, published in the New England Journal of Medicine.
Examples of the dangerous effects of sleep deprivation are not tough to find.
"Once, when I was a med student, assisting in a complicated abdominal surgery case by holding a retractor, the student opposite me (that is, holding the other side of the patient open) fell asleep and slid down to the floor," said one doctor, who did not want to be identified because he did not want to embarrass his colleague. He noted that he and the other student had both been up all night the night before. "One of the nurses simply dragged the student out of the way and a resident who was scrubbed in took over holding the retractor. No harm to the patient at all, but it was odd."
But falling asleep in the surgical suite occurs far less often than do negative outcomes associated with sleep deprivation, said Dr. Charles A. Czeisler, 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.
"The level of impairment is profound well before you get to the point of being so exhausted that you fall asleep," he said.
Czeisler cited a study that compared performing surgery after a sleepless night to driving with a blood-alcohol of 0.1%, a level considered legally drunk in all 50 states and the District of Columbia.
The risk extends to the most senior physicians. A study published last year in the Journal of the American Medical Association showed that patients of sleep-deprived faculty surgeons faced an 83% increased risk of complications, the authors said, citing massive hemorrhage and organ injury as the most common examples. They defined a sleep-deprived doctor as one who had had less than a six-hour opportunity for sleep between procedures during a previous on-call night.
And general surgeons who performed elective surgery during the day after working the previous night had a 171% higher risk of serious complications, the same study found.
Czeisler pointed to a 2006 survey he co-wrote that questioned nearly 3,000 residents in their first postgraduate year of training. One in five admitted having made a fatigue-related mistake that injured a patient.
The risk of such mistakes was increased 700% in months that the interns were working shifts that lasted at least 24 hours, Czeisler said.
And one in 20 admitted having made a fatigue-related mistake that resulted in the death of a patient, he said. During months when residents worked a 24-hour shift more than once a week, that represented a 300% increase in risk of fatalities, he said.
Such findings should have surprised no one familiar with previous data on the subject. A 2001 study in BMJ, formerly known as the British Medical Journal, showed that sleep deprivation doubles error rates. And it found that one in four surgeons who had stayed up all night the previous night made four times as many mistakes.
Since then, the Accreditation Council for Graduate Medical Education has restricted first-year residents' work hours to no more than 16 hours of continuous work followed by at least eight hours off duty, but physicians in their second year of training and beyond face no such restrictions.
Few institutions have imposed restrictions on doctors on call to ensure they don't wind up being scheduled for surgery the next morning, said Dr. Michael Nurok, lead author of the NEJM study.
Patients are not likely to find out unless they ask, said the anesthesiologist and intensive care physician at the Hospital for Special Surgery in New York. "These things aren't talked about -- patients often are uninformed when their clinicians are sleep-deprived," he said.
Patients could call their doctor's office well before the scheduled surgery and ask whether he or she is scheduled to be on call the night before, Czeisler said.
In one survey, 80% of patients preparing to undergo elective surgery said they would request a different provider if told their doctor was sleep-deprived.
But changing current practice would require changing a longstanding practice that helps keep hospital costs down, facilitates scheduling of hospital personnel and supports the perception among many surgeons that their training helps them do top-notch work despite such stresses, Nurok said. "For a long time, it's been part of the culture of surgery and medicine that working while fatigued is what you do and part of medical training should be to learn how to manage that."
Still, he noted, with the recent data, institutions "are reconsidering."
Should institutions fail to act, "we think that, ultimately, legislation will force them to," he said.
In an accompanying comment, the American College of Surgeons acknowledged that fatigue can adversely affect surgeons' cognitive and technical performance, but disagreed with the proposed solution.
"We believe that the solution the authors offer -- mandatory disclosure -- is unwarranted," wrote Drs. Carlos A. Pellegrini, chairman of the college's board of regents, and Dr. L.D. Britt, president of the group. Its members include about half of the nation's 80,000 to 100,000 surgeons.
"Rather, we maintain that surgeons should be trained to identify and address this problem."
They added, "Surgeons who meet the ACS's standards of professionalism and ethics are committed to delivering safe surgical care in an optimal environment, to acting transparently, and to accepting accountability for patient outcomes. Professionals of this caliber are likely to view the authors' recommendation that surgeons be required to disclose the number of hours they have slept as oppressive and insidious. 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, they statement said, surgeons should be trained "to understand how fatigue degrades their mental and physical capabilities. They should learn to use this knowledge to determine whether they should disclose their condition to their patients, whether operations should be rescheduled, and whether they should seek assistance. This approach will allow surgeons to tackle the problem in a meaningful and dignified manner."
The ACS executives referred to an example cited in the editorial -- a doctor scheduled to perform an elective colostomy the morning after having worked all night.
"Because this procedure is relatively simple, many surgeons could successfully complete it with or without a good night's sleep," they said. "Conversely, most surgeons who have been working 24 hours straight would be hard-pressed to safely perform highly complex procedures, such as liver transplantation or limb reconstruction."
Czeisler was unpersuaded. "The adverse effects of fatigue on performance are greatest when an individual is performing a routine, highly overlearned task, whether it be automobile driving, piloting an airplane, doing something you've done over and over again," he said. "So the suggestion that a 'relatively simple' procedure would be less susceptible to the effects of fatigue is completely erroneous."
He added, "Asking a surgeon to decide whether they're fit to perform elective surgery after having been up all night would be like a bartender asking somebody who's legally drunk whether they can safely drive home."
Other countries have already made moves to limit the risk associated with working while exhausted, he said, citing the European Union, which limits the number of consecutive working hours to no more than 13, followed by at least 11 hours off.
Nurok questioned the ACS' call for surgeons to be trained in how to recognize fatigue, saying he was aware of no data to support the suggestion "that physicians can be trained to understand how fatigue degrades one's capabilities such that, when they are fatigued, they can make a good decision about operating or informing a patient. We know that sleep-deprived individuals do not self assess their impairment accurately."
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