Thursday, December 30, 2010

Sleep-Deprived Surgeons: Idealism and Reality


An editorial in the this week’s New England Journal of Medicine proposes that sleep-deprived surgeons should tell patients that information and obtain written consent from patients acknowledging that they have been so informed. This article garnered a “hat trick” of coverage as it was featured by Science Daily, Medpage Today and Eurekalert. First, let’s look at the coverage. Understanding that these three sites simply rehash press releases, they do tend to resemble news reports. Only Medpage Today, while publishing a photo [at right] of a seemingly fatigued surgeon, chose to mention a rebuttal to the editorial by the American College of Surgeons [ACS]. One the other hand, CNN Health published a somewhat balanced report that included excerpts from the ACS response but follow-up answers were forthcoming only from one of the editorial’s co-authors and not the ACS spokespersons.

I would point out that this sentence from the proposal, “In surgery, there is an 83% increase in the risk of complications (e.g., massive hemorrhage, organ injury, or wound failure) in patients who undergo elective daytime surgical procedures performed by attending surgeons who had less than a 6-hour opportunity for sleep between procedures during a previous on-call night” is grossly misleading. The JAMA paper cited says no such thing. Yes, there is an increased risk of complications but the paper does not specify exactly which complications occurred. They may in fact have been minor complications. Of course, “massive hemorrhage, organ injury, or wound failure” sounds much more dramatic.

Although the rebutting ACS leaders made a decent point that issues such as marital problems, a sick child or financial difficulties might also degrade performance and are not subject to disclosure, the argument that surgeons should be trained to recognize fatigue was extremely weak and was deftly parried by one of the co-authors of the proposal. You can read those comments in the CNN Health article.

Now, what do I think of the proposal? In a perfect world, the idea of a surgeon telling patients that he is sleep-deprived would be wonderful. Alas, we don’t live in a perfect world. The reality is the proposal is highly impractical. The example cited in the proposal was that a surgeon who was up all night had an elective colostomy scheduled for 9 a.m. The proposal’s authors would mandate that he inform the colostomy patient that he is sleep-deprived and offer the patient the option to postpone the procedure or have another surgeon perform it. What is involved in postponing the case? The patient may have taken laxatives to prepare the bowel for surgery. She may have had lab work done, taken time off from work, arranged for child care, have important business three weeks later etc. The hospital’s operating room likely would go unused for the two hours originally booked for the colostomy.

Having another surgeon operate on the patient would mean loss of a fee for the tired surgeon. [I know that shouldn't matter but it's not a perfect world.] And just which surgeon is going to be sitting around doing nothing that morning and hoping a colleague was sleep-deprived? Assuming another surgeon was readily available, how does the conversation between the patient and the new surgeon go? “Hi, I’m your new surgeon. I’m not sleep deprived. By the way, what’s wrong with you? Oh, you need a colostomy.” Does the patient have a chance to Google the new surgeon? Is the new surgeon on the patient’s insurance panel? What if the patient doesn’t bond with the new surgeon in the 10 minutes she has had to get to know him? Can she ask for a third surgeon to be introduced? Will all of this take so long that the original surgeon might have had a chance to take a nap and now be refreshed? How long of a nap is long enough?

Maybe the solution is for every hospital to establish a surgical hospitalist service to do all the acute care surgery. This would allow some surgeons to focus on elective surgery exclusively. This too would cost significant money in terms of supporting the hospitalist service and loss of income and new patients for surgeons who no longer take call. Also, where are all these surgical hospitalists going to come from? [Full disclosure: Skeptical Scalpel is a surgical hospitalist.]

Bottom line. I see no way that the proposal that a sleep-deprived surgeon must obtain informed consent from patients is practical in today’s medical setting.

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