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Over the years regulations have developed to limit the hours of hospital interns and residents. Because someone putting in a 100-hour workweek might not be at their best when deciding which medication to prescribe or when inserting a Foley catheter. But doctors who have finished their training don’t face any restrictions in their hours. Now The New England Journal of Medicine argues in an editorial that sleep-deprived physicians set to perform elective surgery should have to get the informed consent of the patient. [Michael Nurok, Charles Czeisler, and Lisa Soleymani Lehmann, "Sleep Deprivation, Elective Surgical Procedures, and Informed Consent"]
Sleep deprivation can impair motor skills as much as alcohol intoxication can. The editorial cites a 2009 study in the Journal of the American Medical Association that found an increase in the risk for complications in patients who had elective surgery performed by surgeons who’d had the chance for less six hours of sleep during a previous on-call night.
The editorial’s authors note that such consent represents a new responsibility for patients in making decisions about their care. It could damage the patient-doctor relationship. But, they say, "This shift may be necessary until institutions take the responsibility for ensuring that patients rarely face such dilemmas."
—Steve Mirsky
[The above text is an exact transcript of this podcast.]
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8 Comments
Add CommentGood luck ever having a hysterectomy. OB/Gyns don't have the luxury of delivering babies when they want to, the babies kind of make that decision. Knowing when one is too tired to operate may be like knowing when one is too drunk to drive, by the time that level is reached, it is too late to make a sound decision. Until the public and the medical profession choose not to make doctors supermen, doc's will always try to rise up and do more than they probably should. On the other hand, there are doc's I know who could be awake for 3 days straight who would do better surgery than some who have slept for as long as they wanted. The problem with some studies is that identifying a problem doesn't translate into finding a very good solution.
Reply | Report Abuse | Link to thisMedical professionals in training and medical professionals in practice have an ethical duty to maintain a lifestyle that enables them to practice safely and competently. This includes obtaining rest, sleep (6-9 hours), and recreation. Laws and practices which are inimical to the same are inherently unethical and destructive to the ends of providing BOTH the optimum quality and quantity of health care possible. The training for physicians in the USA involves an extremely unreasonable long and arduous educational and practice preparation with the result that there are not enough physicians. The following Hippocratic Oath speaks for itself in regard to this issue:
Reply | Report Abuse | Link to this"I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement: To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art.
I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.
I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion.
But I will preserve the purity of my life and my arts.
I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art.
In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves.
All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal.
If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot."
Doctors at Johns Hopkins need to disclose a lot more than sleep deprivation: http://collateral-damage.net
Reply | Report Abuse | Link to thisI was a general and vascular surgeon for forty years. Residency at a well known institution was never as demanding as practice in a small town. "The Community" expected 24H coveage even when I was the only surgeon in town. Generally there were two of us. Even with two surgeons life was call every other night and every other week-end. If I took off two week-ends in a row then coming back to town would be two or three week-ends in a row of call. I retired at age 55 because I just couldn't handle the time commitment anymore. I wrote the state board about the problem of fatigue and was ignored.
Reply | Report Abuse | Link to thisTwice when I was on call for extended periods of time and had to take time off I was criticized by the hospital board for letting the "Community" down. This town wanted to maintain a level 2 trauma rating but simply didn't have the people or the staff to do so in a reasonable manner.
Several times a third surgeon would be recruited but lasted only a short time because the income was generated from elective cases not the ER. A review of a 90 day period of ER call netted my partner and me about 15 cents for each hour of coverage or about $324. The life cost was priceless.
Back then I was still under the illusion we were super-people who could stand stresses mere mortals could not survive.
In 2001 I retired from practice and began working for two major companies helping to reduce costs. Early on I learned I could not change the system. What we could change was quality of care our employees received.
Quality care is not practiced by a fatigued provider. Were I to become a hospital administrator tomorrow these are the reforms I would instigate;
1. No more call than every fourth night and week-end.
2. No pay for extra call.
3. Require quarterly vacations of at least 10 days.
4. Small hospitals network with larger hospitals for emergency coverage.
5. Require at least two approved CME courses appropriate to area of expertise per year. No investment stuff or 3 hours of daily didactics in Palm Springs.
6. Small hospitals must realistically understand their resources and services.
7. No elective surgery after active night call.
I still believe training programs must produce enough stress to produce a sense of responsibility but at no time should patient care be endangered. State boards need to actively become involved in issues of fatigue.
This article is not about science!
Reply | Report Abuse | Link to thisIt is about politics, in the administration of hospitals. It has very human appeal, of course, but that not satisfies who is seeking scientific news.
Medicine hopefully will never become pure science.
Reply | Report Abuse | Link to thisI can imagine the following scenario: Patient admitted to hospital at 5 AM for hysterectomy at 7. Patient's employer arranging for her to be out 6 weeks. Husband took off work, sister came from 300 mi away to take care of the kids. Her OB-Gyn surgeon up all night with delivery decides to ask patient if the bags under his eyes are sufficient reason to cancel her operation (and also screw up the OR schedule.). Who are we kidding?
Reply | Report Abuse | Link to thisI contest the wisdom of making decisions - scientific, medical or ethical based on an oath created 4 millennia ago when those practicing “medicine” could not have conceived of current practice. In truth we ignore many aspects of the Hippocratic oath – that pledge “sworn to Apollo” and “witnessed by the gods”.
Reply | Report Abuse | Link to thisAs a frequently over-tired practitioner, I can attest to an ability to operate with a lack of sleep that far exceeds my ability to read, participate in lectures and conferences, see patients in clinic or for that matter drive an automobile. Most surgeons, I know, make the same observation. There is a level of heightened attention when operating that amplifies the senses and enables one to perform at a high level even when sleep deprived. Naturally there are limits and operating when exhausted is unwise. We all need to be aware of when to ask for help and when to cancel the schedule; these determinations come from experience and derive from common sense, they vary amongst individuals and cannot be legislated.