Night Call

What do you think about these two posts that mention diametrically opposite perspectives on night call that were published within the last few days?

On September 7, 2011, NPR posted a story about a trauma and burn surgeon named James Jeng, who was on duty at Washington Hospital Center on September 11, 2001. He cared for a number of seriously burned victims from the Pentagon. In discussing the intensity of the post-burn care of these patients, he said this:

I had fallen into an automatic rhythm of 36 hours on, 12 off in-house duty. Every other night, then, I would get home to be with my family.

This, of course, is against all the new rules but somehow Dr. Jeng and the patients got through it despite the potential detrimental effects of “decision fatigue” and sleep deprivation.

On September 3, 2011, the following from M. Schoen, MD appeared on Sermo, a website devoted to physician issues:

In my group most of the new docs joining in the past couple of years are refusing to take internal medicine night call. These are both docs who are subspecialists (but who also practice medicine) and docs who are only internists. Meanwhile the bulk of the night call is being taken by the older docs (of whom 7 of the 25 or so docs are over 60). The group refuses to consider what will happen in the future when there will be no one to do night call. Is it common for groups to allow this? And what will happen down the road? 

This has attracted 286 comments with most of them deploring the situation.

So where is this all going? I think I know, and it’s not a good place.

Do Surgeons Suffer From "Decision Fatigue"?

What is “decision fatigue”? An article in yesterday’s NY Times Magazine describes “decision fatigue” as what happens when people are forced to make numerous decisions in short time periods. Israeli parole boards apparently grant parole to prison inmates much more frequently earlier in the day vs. later. It has something to do with overwhelming their ability to make choices, causing them to eventually opt to do nothing. Many social psychologists have experimented with this phenomenon and found it also affects willpower negatively. Repletion of glucose helps reverse the problem.

This prompted Paul Levy (@Paulflevy), who is an “Advocate for patient-driven care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement,” to tweet, “Good article in Times: [NY times link] Query: Has anyone seen studies linking surgical error rate to the time of day?”

The answer is, “Yes.” But if the question had been, “Anyone seen any good studies linking surgical error rate to time of day?” the answer would have been, “No.”

Many studies on the purported effect of time of day on surgical outcomes have been published. The results are inconclusive. Some say there is no effect. Some say there is an effect on morbidity; i.e., surgery at night results in more complications and longer hospital lengths of stay. Some say there is an increase in early, but not long-term, mortality. In one study of critically ill non-surgical patients, those admitted at night actually fared better than those admitted in the daytime.

The studies are all retrospective, and there are many confounding variables. With or without emergency operations, it is not clear that time of day is an important cause of adverse outcomes. The impact of the number and complexity of surgeon decisions has not been addressed in any study.

I discussed surgeon fatigue and complications in high-risk surgery in a previous blog. (There is no difference in mortality rates by time of day of the procedure.) Besides fatigue, a very controversial subject, other potential confounders include system issues (number of physician staff, level of supervision, nurse experience and numbers, ancillary service availability, consultant availability), patient co-morbidities and whether a case is truly elective or urgent (not a raging emergency, but not a case that can wait until the next day).

In most instances, a surgeon does not have to make numerous complicated decisions in a short time. It is unlikely that decision fatigue plays an important role in the incidence of errors.

Here’s something that a lot of people do not understand. A bad outcome is not necessarily someone’s fault. There are times when, despite everyone’s best efforts, a patient suffers complications or even death.

References available upon request.