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Wake Up Call for Sleep-Deprived Surgeons and Their Patients

When headed for surgery, many people research the procedure and any alternatives, their surgeon, the hospital and the anesthetist. They know the probable recovery time and the chances for adverse effects. What they almost certainly do not know is how much their surgeon has slept before the operation. A recent New England Journal of Medicine (NEJM) article has people close to the issue debating whether this information should be made available to patients. The perspective piece cites a previous study that showed a significant increase in the risk of surgical errors in daytime elective procedures performed by sleep-deprived surgeons.

Patient Disclosure

Michael Nurok, an anesthesiologist at the Hospital for Special Surgery, Charles Czeisler, chief of the division of sleep medicine at Brigham & Women’s Hospital, and Lisa Soleymani Lehmann, director of the hospital’s Center for Bioethics, authored the article. They are proposing a mandate requiring surgeons to inform elective surgery patients whether they have received inadequate sleep the previous night. The authors also recommend that hospitals implement policies designed to minimize the likelihood that a clinician would perform elective surgery while sleep deprived. For example, physicians would not be scheduled for elective procedures the day after they are due to be on-call all night.

They also suggested that patients should be allowed to inquire about the amount of sleep a clinician has had the night before their procedures. Patients should be informed and given the opportunity to proceed or to reschedule, and in the event a clinician is sleep deprived, institutions should facilitate priority rescheduling of elective procedures.

Surgeon Self-Regulation

Although no one disagrees that performance suffers with sleep deprivation, three representatives from the American College of Surgeons (ACS) wrote a response saying the solution is to train surgeons to understand how fatigue diminishes their mental and physical ability. Ultimately, surgeons should make the determination whether to disclose their condition to patients, write L.D. Britt, David Hoyt and Carlos Pellegrini, president, executive director and chair of ACS, respectively.

While conceding that no one wants an exhausted surgeon to operate, Britt says that there is no definitive way to define fatigue, meaning that mandatory disclosure would be based on an arbitrary threshold. Dr. Michael Marks, an orthopedic surgeon, raises the concern that personal matters such as financial problems, marital problems or child problems can all affect a surgeon’s concentration and ability on the day of surgery.

A Judgment Call

The ACS surgeons write that many surgeons could successfully complete “relatively simple” procedures with or without a good night’s sleep. Hoyt likened a 30- to 45- minute procedure to driving home, saying it is a judgment call.

But it’s the routine tasks that are especially susceptible to the adverse effects of sleep deprivation, because people become overly confident in their ability to perform these tasks.

According to the NEJM article, sleep deprivation can impair psychomotor performance as severely as alcohol intoxication. And in the context of surgery, the consequences can be just as severe for the patient. Some evidence shows an 83 percent increase in the risk of complications in daytime elective surgical procedures performed by attending surgeons who had less than a six-hour opportunity for sleep between procedures during a previous on-call night. Complications include:

  • Massive hemorrhage
  • Organ injury
  • Wound failure

The Accreditation Council for Graduate Medical Education restricts trainees in their first postgraduate year to 16 continuous hours of work, which must be followed by at least eight hours off duty, but no such regulations exist for fully trained surgeons. The Sleep Research Society has endorsed model legislation that provides for mandatory disclosure to patients of the extent and potential safety impact of sleep deprivation if a surgeon has been awake for 22 out of the prior 24 hours.

Surveys indicate most patients would be concerned for their safety if they knew their doctor had been awake for 24 hours and 80 percent would request a different provider in such circumstances. Patients who have undergone elective or emergency procedures and suffered surgical injuries or complications should speak with a medical malpractice attorney. Investigation and inquiry may reveal medical malpractice and a lawyer can help obtain compensation for damages, including medical expenses, lost wages, and pain and suffering.