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January 18, 2011

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Fatigued surgeons should alert patients, experts propose

Dec. 29, 2010
Courtesy of the Hospital for Special Surgery, N.Y.
and World Science staff

Sleep-de­prived sur­geons should alert pa­tients of their con­di­tion be­fore go­ing ahead with a non-urgent sur­gery, an edit­orial in a lead­ing med­i­cal jour­nal pro­poses.

The article in this week’s is­sue of the New Eng­land Jour­nal of Med­i­cine ar­gues that such opera­t­ions should­n’t pro­ceed with­out pa­tients’ writ­ten con­sent.

While regula­t­ions ex­ist to lim­it work hours for doc­tors in train­ing, fully trained physi­cians usu­ally face no such re­stric­tions. The writ­ten-con­sent ap­proach “might prove bur­den­some,” the ed­i­to­ri­al ac­knowl­edged, as well as “dam­ag­ing to the patient-phy­si­cian rela­t­ion­ship,” yet the im­port­ance of hav­ing a well-rested surgeon out­weighs these draw­backs.

“This shift may be nec­es­sary un­til in­sti­tu­tions take the re­spon­si­bil­ity for en­sur­ing that pa­tients rarely face such dilem­mas,” the au­thors wrote. 

Stud­ies have shown that sleep de­priva­t­ion im­pairs per­for­mance as se­verely as al­co­hol in­toxica­t­ion, they not­ed. A 2009 study in the Jour­nal of the Amer­i­can Med­i­cal As­socia­t­ion showed a sig­nif­i­cant in­crease in the risk of com­plica­t­ions in pa­tients who un­der­went elec­tive, or non-essential, day­time surg­eries per­formed by at­tend­ing doc­tors who had less than a six-hour chance for sleep dur­ing a pre­vi­ous on-call night. And sleep-de­prived peo­ple of­ten can’t ac­cu­rately as­sess their own de­gree of im­pair­ment.

“It is clear from sur­vey da­ta that pa­tients would want to be in­formed if their phy­si­cian was sleep de­prived and that most pa­tients would re­quest a dif­fer­ent provider,” said Mi­chael Nurok, an an­es­the­si­ogist and in­ten­sive care phy­si­cian at Hos­pi­tal for Spe­cial Sur­gery in New York who is first au­thor of the ed­i­to­ri­al.

Some hos­pi­tals take steps to min­i­mize the chance that a sleep-de­prived sur­geon will be sched­uled to con­duct an elec­tive opera­t­ion, the au­thors wrote, but not enough is be­ing done. “As an in­ter­im step, we be­lieve that pa­tients need to be in­formed,” Nurok said. 

The ed­i­to­ri­al ar­gues that sleep-de­prived physi­cians should be made to in­form pa­tients of their con­di­tion and the po­ten­tial haz­ards it en­tails. If pa­tients opt to go ahead, they should have to sign a con­sent form be­fore a wit­ness. If not, they should re­ceive a chance to ei­ther pro­ceed with a dif­fer­ent doc­tor if pos­si­ble, or re­sched­ule.

The ed­i­to­ri­al au­thors not­ed sev­er­al prob­lems that might make the sys­tem un­pop­u­lar. Pa­tients may be up­set about scut­tled sched­ules, es­pe­cially in cases where they had to make lo­gis­ti­cal prepara­t­ions for a pro­ce­dure. Doc­tors may lose cases and in­come to col­leagues. De­part­ments and in­sti­tu­tions may lose in­come if pa­tients re­sched­ule a treat­ment else­where. And ad­min­is­tra­tive costs may mount.

Yet im­proved out­comes and few­er com­plica­t­ions may off­set these bur­dens, they added. “New poli­cies are need­ed,” Nurok said.

* * *

Sleep-deprived surgeons should alert patients of their condition before going ahead with a non-urgent surgery, a leading medical journal has editorialized. The editorial in this week’s issue of the New England Journal of Medicine argues that such operations shouldn’t take place without patients’ written consent. While regulations exist to limit work hours for doctors in training, fully trained physicians face no such restrictions. The written-consent approach “might prove burdensome,” the editorial acknowledged, as well as “damaging to the patient-physician relationship,” yet sleep-deprived surgeons pose enough of a risk that the drawbacks are worth accepting. “This shift may be necessary until institutions take the responsibility for ensuring that patients rarely face such dilemmas,” the authors wrote. Studies have shown that sleep deprivation impairs performance as severely as alcohol intoxication, they noted. A 2009 study in the Journal of the American Medical Association showed a significant increase in the risk of complications in patients who underwent elective, or non-essential, daytime surgeries performed by attending doctors who had less than a six-hour chance for sleep during a previous on-call night. And sleep-deprived people often can’t accurately assess their own degree of impairment. “It is clear from survey data that patients would want to be informed if their physician was sleep deprived and that most patients would request a different provider,” said Michael Nurok, an anesthesiologist and intensive care physician at Hospital for Special Surgery who is first author of the editorial. Some hospitals take steps to minimize the chance that a sleep-deprived surgeon will be scheduled to conduct an elective operation, the authors wrote, but not enough is being done. “As an interim step, we believe that patients need to be informed,” Nurok said. The editorial argues that sleep-deprived physicians should be made to inform patients of their condition and the potential hazards it entails. If patients opt to go ahead, they should have to sign a consent form before a witness. Or, they should receive a chance to either proceed with a different doctor if possible, or reschedule. The editorial authors noted several problems that might make the system unpopular. Patients may be upset about scuttled schedules, especially in cases where they had to make logistical preparations for a procedure. Doctors may lose cases and income to colleagues. Departments and institutions may lose income if patients reschedule a treatment elsewhere. And administrative costs may mount. Yet improved outcomes and fewer complications may offset these burdens, they added. “New policies are needed,” Nurok said.