Surgeon FatigueJan 7, 2014
Woman: The Scope Health Care Radio presents A Physician's Take, medical care professionals talking about health care issues that affect us all.
Man: Dr. Tom Miller and Dr. Robert Glasgow on surgeon and physician fatigue and the effects on patient care.
Dr. Tom Miller: Rob, today I wanted to talk to you about a study that was published in the first week of November in the Journal of the American Medical Association refuting, at least to some degree, the idea that sleep fatigue impacts a surgeon's performance. Can you give me a short summary of that study?
Dr. Robert Glasgow: It's a follow up to a study done in 2009 published, I believe, in the New England Journal of Medicine that suggested that surgeons who had inadequate sleep the night prior to elective surgery had a higher rate of complications associated with those elective operations the day following. This study was a study to try to address that issue and to contribute further to the literature.
What they found was no differences in any of those outcome measures. This, in a sense, refutes that original article back in 2009. The reason that's important is in response to that article and some other suggestions elsewhere in the medical literature there was this notion that sleep deprivation had some effect on surgical performance. This was probably one of our best studies to date refuting that notion.
Dr. Tom Miller: What should surgeons or patients take away from this study? I mean can patients relax a little in regards to how well rested their surgeon must be before starting an elective surgery, or should surgeons worry a little bit less about being up the night before in terms of worrying about complications?
Dr. Robert Glasgow: I think the bigger issue here is the whole concept of what it means to be an impaired physician and really being at your game when you're providing a service to a patient. Obviously, sleep deprivation is one tangible thing that we all understand, that every human being can relate to.
I think what you're hearing in this study and there are four other studies that have looked at the same question. Two were in the cardiac surgery literature where patients had cardiac or heart surgery, arguably a lot more complicated than gallbladder surgery, by surgeons who had been up the night before and found the same results--that there were no differences in terms of the risk to the patient.
The take home message here really isn't that sleep deprivation is a meaningless issue. I think the real concept is what does it mean to be impaired.
Dr. Tom Miller: It's interesting, that point, Rob. I think almost all would agree that monotonous tasks performed under conditions of extreme fatigue are prone to higher error rates. It's like driving a car, or piloting a ship or a plane, or working on an assembly line. But, it was stated in the editorial that surgery is anything but monotonous and therefore not really prone to errors when the surgeon is fatigued. What do you think about that? Do you agree with that?
Dr. Robert Glasgow: I think that is true, but I also don't want to come across as somebody standing here thumping my chest that I can do anything even if I've been awake for four days. We all agree that that's unreasonable.
The surgical profession has been compared a lot to other high performance environments like airline pilots. There's a lot of research that shows that where airline pilots have issues is in exactly what you refer to. It's in the monotonous part of a flight where they fall asleep and so on.
Surgery, and in this model in all fairness a relatively straightforward procedure, there's actually data to show that the ability to perform tasks, in other words to have a cognitive task and to execute that task into a measurable physical action, is not impaired by sleep deprivation.
This is done using virtual reality simulators and quantifying people's performance after sleep deprivation. But, it's very clear that there is something different to tasks that demand a cognitive act and a physical act compared to sitting on an airplane or a boat or a car.
Dr. Tom Miller: Yeah. Some advocacy groups believe, and you've heard this, that a surgeon's decision about fitness to operate should be relegated to policy kind of in the same way that an airline pilot's are regulated on flight hours. Do you think that's going too far?
Dr. Robert Glasgow: I think in this circumstance it is. We've regulated our resident work hours. What's really being suggested here is that we need to regulate attending physician work hours, mandatory sleeps, mandatory naps, and things like that. I do think that's taking this one step too far.
I don't think you can mandate that for one big reason: the cost would be tremendous. There's actually a study that suggested if you limited attending physician work hours it would cost an additional $1 million per life saved to the cost of health care. We simply can't afford that.
The surgical societies and most medical societies look at this very, very critically. I think here the real message is we as surgeons need to be attentive to this notion of what does it mean to be impaired and to be able to educate ourselves. Like, listen, I'm very, very tired, if I was awake all night a gallbladder is probably okay, but I would not embark on a 12 hour complex esophageal reconstruction case. That would not be reasonable.
One of the things about this study is you don't know where that happened in this study. There may have been surgeons who were awake all night who walked into the pre-op area and simply said listen, I'm too tired, or I had a really bad night because of a family crisis, or whatever the factor is, and said we need to reschedule your surgery. I think that's the message. It's recognizing what does it mean to be impaired and for us as professionals to act appropriately.
Dr. Tom Miller: Let's talk a little bit about residency training or physicians in training. There's been a lot about regulating their hours. You and I know that, and nationally most house staff, most physicians in training are held to an 80 hour workweek. That came on the heels of a case back in the first part of the last decade.
Basically, a percentage of our profession, I think they believe that mandatory limits on the number of hours a physician in training can work are unduly restrictive. Do you think this study supports that position?
Dr. Robert Glasgow: Where there's been data to suggest that sleep deprivation contributed to a bad outcome, when you actually look at the bad outcome, for example the Libby Zion case, there's no link between sleep deprivation and actually what happened.
Dr. Tom Miller: My opinion of the Libby Zion case is it was an issue of attending oversight. There weren't attending . . .
Dr. Robert Glasgow: I very much agree.
Dr. Tom Miller: . . . [inaudible 00:07:09] . . .
Dr. Robert Glasgow: I very much agree.
Dr. Tom Miller: . . . to help them. It was not so much, in my opinion, an issue of residency fatigue as it was the lack of attending oversight.
Dr. Robert Glasgow: Yeah. But I think to extrapolate what we're doing with the residents to the attending physicians is a little bit of a reach. When I was in surgical training I consistently worked over 120 hours a week and some weeks in excess of 150 hours a week. Any reasonable human being would say that that's unreasonable. It is extremely rare that an attending physician even approaches our current resident limit of 80 hours a week.
Dr. Tom Miller: Any final comments for our listeners?
Dr. Robert Glasgow: I think these are important things to consider as professionals, again, this notion of what does it mean to be impaired, what are the factors that influence your ability to perform. I will tell you I've been a regular practitioner of operating at night time. I'm a general surgeon. The reason the study was done with general surgeons is we're the people that operate at night time.
These aren't the issues. Sleep deprivation is not the issue that is distracting and affecting my performance. There are other issues that are pervasive across every discipline--work life stress, whatever the case may be.
Dr. Tom Miller: I think that's totally correct. I mean fatigue has other aspects besides the outcomes of the procedures that are being done. It impacts people's lives in different ways. Thanks very much for your time, Rob. I appreciate it.
Dr. Robert Glasgow: Thank you, Dr. Miller.
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