UK doctors' work hours limits are a fraud

The other day someone tweeted a link to a story that was headlined "NHS junior doctors have little time to eat or sleep." The article—from the Herald in Edinburgh, Scotland—told of a manual from the NHS (National Health Service) that advised trainees to keep water and a food bar handy because they would rarely have a chance to eat.

The manual, which also told the junior docs to "be prepared for dehydration and hunger," is no longer posted on the Internet.

A man whose daughter, a junior doctor, was killed in an auto accident on her way home from the hospital blamed it on the fact that she had worked a long shift. For the record, she had worked a 12-hour shift overnight.

Of junior doctors, he said, "They are under intense pressure, they are working excessive hours, they are getting no respite."

I retweeted the link to the story with a question wondering how it could be that conditions are so bad in the UK. After all, I thought the European Working Time Directive (EWTD) stated that trainees in the European Union could only work 48 hours per week.

A flood of tweets in response soon explained the true situation to me. I was amazed, and you will be too.

It seems that the so-called 48-hour work week is a sham. Trainees can work only 48 hours per week, but it's averaged over 6 months—6 months!

What hospitals apparently do is work the junior docs like dogs and then give them a week off so that the average is 48 hours.

Here are quotes from some of the UK physicians:

That's the key; as long as they give you a week off and the average is ok, all bets off

What the working rules are & what occurs (& are paid for) are 2 very different things.

In my case, was asked to do the 36 hr shift by hospital manager and consultant.

Upcoming survey results from Association of Surgeons in Training show majority [of trainees] come in on their time off.

Shorter shifts with no more doctors means more shifts. Gaps in rotations mean longer shifts

It's not much different to how it was before, just lower pay now!

The Herald piece also said that a survey of 4913 junior doctors in Scotland … "found almost 20% were short of sleep because of their shift patterns and more than half worked beyond their rostered hours daily or weekly [emphasis mine]. Some 40% described the intensity of work as heavy or very heavy." In an editorial, the Herald said, "In practice, the [EWTD] directive is being broken every day in hospitals across the country."

The understatement of the millennium was made by the chairman of the Scottish Junior Doctors Committee, who said, "Although all the rotas [rotations] are compliant with the European Working Time Directive they are not necessarily in the spirit of what the law intended." No kidding?

He also said that junior doctors could be scheduled to work up to 12 days in a row without breaks and confirmed that they sometimes "struggle" to find time to eat.

Some of those who responded to my tweet said they would much rather work a scheduled 24 hours in a row than the life-disrupting shift work that the "48-hour" week has resulted in.

What is my point?

We have all been led to believe that all is well with the 48-hour work week in Europe—clearly not so.

And let's just keep ratcheting down the hours here in the US so we can achieve the same nirvana enjoyed by the trainees over there.

As always, I welcome your comments.

Sleep deprivation, surgeons, operations, and outcomes

A new paper found that surgeons who performed elective laparoscopic cholecystectomies after having operated the night before had outcomes similar to those when they were presumably well-rested.

The retrospective study involved 331 surgeons who did 2078 cholecystectomies after operating the night before and 8,312 when not operating the night before. Outcomes both were matched for each surgeon.

Comparing outcomes after operating the night before to not found rates of conversion to open - 2.2% vs. 1.9%, risk of iatrogenic injuries - 0.7% vs. 0.9%, and death - 0.2% vs. 0.1%, respectively. None of those differences were significant.

The abstract concluded, "These findings do not support safety concerns related to surgeons operating the night before performing elective surgery."

This paper is the latest of several that show similar results.

So case closed, right?

As much as I hate to say this, the paper does not prove that sleep deprived surgeons don't have more complications than when they are well rested. What it does prove is that conversion rates, not complication rates, are the same whether the surgeon got adequate sleep the night before or not.

In the paper, which was published in JAMA, the authors said, "Although not always considered a complication, conversion to open cholecystectomy may serve as an aggregate end point for many complications."

I disagree. I know of no previous study confirming that conversion of a laparoscopic cholecystectomy to an open procedure is a marker for complications. Instead, I believe it is a sign of good judgment. The sooner a surgeon recognizes that he can't safely do the procedure laparoscopically, the better off the patient is. A surgeon should never be discouraged from converting a case to open.

The study probably included enough patients to support its conclusion that there is no difference in conversion rates, but it is underpowered to detect a difference in iatrogenic injury rates or mortality because those events are so infrequent. To conclude that there is no difference in iatrogenic injury or mortality rates is what is known in statistical circles as a "Type II error" or failure to reject a false null hypothesis. The two null hypotheses in this situation were that there is no difference in 1) iatrogenic injury or 2) mortality rates when surgeons are rested or not.

In other words, the rates of iatrogenic injuries and deaths may not really be different, but the lack of a difference could simply be due to the fact that there were not enough subjects in the study. Iatrogenic injuries and deaths occur so infrequently with laparoscopic cholecystectomy that a study would need a lot more patients in each group to conclude that sleep is not a factor.

Most media coverage of the paper did not question its findings. Even Atul Gawande was hooked. Yesterday he tweeted "New @jama study of daytime surgery by surgeons who operated during night before: found NO increased complications."

Better studies on the effects of sleep deprivation on surgeon performance are needed before the issue is settled.

Lack of sleep prompted pilot’s breakdown. System error?

You may recall the incident back in March during which a JetBlue pilot raved about Jesus, al-Qaida, sins in Las Vegas and other things causing the co-pilot to lock him out of the cockpit.

According to the Associated Press story, the pilot, who had to be subdued by passengers, “had a brief psychotic disorder due to lack of sleep.” At a recent trial, he was declared not guilty by reason of insanity of the crime of interfering with a flight crew. The diagnosis of psychosis from sleep deprivation was made by a forensic neuropyschologist who testified that the psychosis lasted a week.

The article goes on to say that the FAA is still investigating and has not decided if any official policy changes will be made. A previous rule change requiring pilots to have 8 hours of uninterrupted sleep opportunity will go into effect next year. The current rule says a pilot must get 8 or 9 hours of rest but does not specify “sleep opportunity.”

This episode is making me nervous because it sounds like a “system error” may be invoked when the cause may simply have been human error.

I say this because it seems more likely to me [disclaimer: I’m not a forensic neuropsychologist] that the pilot might just have gone nuts for no good reason. That does happen occasionally. The problem with the sleep deprivation argument is that JetBlue said the pilot “did not fly March 24 or March 25, and worked a round-trip flight March 26 that gave him 17 hours of off time leading into the flight March 27.” Also if sleep deprivation can make one psychotic, just about every doctor I know must be crazy.

He had 17 hours of time off, which seems like more than enough time to rest. In fact, a “sleep opportunity” of 8 hours would have comfortably fit into that window of time with a little dinner and a TV movie thrown in. If he didn’t take advantage of the allotted time to rest, it was his choice. He already may have been unstable.

This reminds me of a recent blog I wrote about a paper on supposed medical errors caused by sleep deprivation. Orthopedic residents in that study, whether working day or night shifts, averaged only about 6 hours of sleep per 24 hour period despite having ample “sleep opportunity.”

Stay tuned. Let's see if the FAA falls for the old "system error" fallacy.

See more of my posts on system error here.

Resident fatigue & medical errors

The media frenzy about the latest entry in the resident fatigue research sweepstakes was predictable. There were many websites carrying the story with the usual misleading headlines, hand-wringing and “Oh, the humanity” quotes. There are too many such articles to cite them all. Here are a few.

Fox News Tired surgical residents may up error risk, study suggests
LA Times Study finds residents often fatigued
Daily Briefing Despite new rules, residents' fatigue continues to cause errors
MedPage Today Too little sleep makes Jack a dull surgeon
Orlando Personal Injury Legal Blog [one of many such blogs] Fatigued Hospital Residents Make More Mistakes

If one takes the time to read the paper, one will find the following:

• It studied only 27 orthopedic residents.
• It did not study medical errors but rather sleep and wakefulness.
• The amount of time that a resident moved his arm was measured by a device. The movements were then converted into “predictions” of fatigue which were then extrapolated into levels of risk of error.

Regarding the results, here are some important issues:

• Although residents working night shifts got less sleep than those working in the daytime, the difference was only 0.6 of an hour [36 minutes] and was not statistically significant, p = 0.08.
• When awake, all residents were fatigued about half of the time.
• More than 25% of the time, all 27 residents allegedly worked in a mental state equivalent to a blood alcohol level of 0.08% because of fatigue.
• Due to their pervasive fatigue, night-float residents were predicted to have a 24% increased risk of medical error, and even day shift residents had a 19% increased risk of medical error (P=.045).

This leads to some questions:

• Why are day shift residents so tired?
• Why do day shift residents get only 5.7 hours of sleep per night?
• If day shift residents are tired and night shift residents are even more tired, what is the solution?
• Could it be that a facetious suggestion I made in a blog that residents should work like sailors aboard ship in rotations of 4 hours on duty and 8 hours off duty is not so unrealistic?
• Will this paper be cited by plaintiffs’ lawyers?

What do you think?

Worst research study of the year (so far): America’s 10 most sleep-deprived jobs

Somehow this slipped by me a few days ago. And it was in the New York Times of all places. A column called “Economix” featured a report entitled “America’s 10 most sleep-deprived jobs.”

It seems the mattress company known as “Sleepy’s” commissioned a survey to find out which jobs were associated with the least and the most sleep. You could probably name a few of the occupations that cause people to be sleep-deprived. But some were surprising. Here they are with the amount of sleep claimed by people in those jobs.



Are you buying this? Home health aides? I can’t resist the urge to point out that they may occasionally catch a few winks on the job. Lawyers? Too many jokes to fit into a blog of fewer than 500 words.  Economists? If they’re up at night, what are they doing? Certainly not fixing the economy. Maybe they are talking to financial analysts or secretaries.

I think we may have a problem with methods here. I was unable to find much about the details of the study as the link provided by the Times went only to the National Health Interview Survey website and not the survey itself. The only other major news organization that carried the story was “MattressZine, The Premier On Line Mattress Magazine.” It had very little to add to the Times piece except for this shocking finding from the survey:

“Some workers also tend to oversleep or aren’t fully prepared to get up from bed, even as their alarms go off in the day.”

Alert the Nobel Prize for Economics Committee.

The Times report said that over 27,000 people were interviewed. They were asked about the average number of hours of sleep they got and what they did for a living. Could it be that the estimates of sleep were flawed? How many hours of sleep did you average last week?

The time difference between the amount of sleep stated by the #1 most sleep-deprived home health aides and that of #10 secretaries was 11 minutes. The statistical significance of the different times can’t be stated because we don’t know how many people were questioned in each job category, nor do we have the mean times and their standard deviations. Even if there was a statistically significant difference, is an 11 minute difference a clinically meaningful one?

Oh, there’s one other thing. Ranked at #8, #9 and #10 on the list of those who get the most sleep are engineers, aircraft pilots and teachers. Their average amount of sleep was 7 hours and 12 minutes, a whopping 4 minutes longer than secretaries, #10 on the list of the most sleep-deprived.

Bottom line. This survey is to research as hot pockets are to gourmet food.

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.

Surgeons Are Not Pilots or Long-Distance Truck Drivers

I have blogged before about the inappropriateness of comparing surgeons to pilots [here and here]. Recently, I have seen some comments that lump surgeons, pilots and truck drivers together. Commenters are in high dudgeon about those three occupations working long hours citing the fact that pilots and truck drivers have strict rules about how many consecutive hours they can work and surgeons do not.

There are several problems with the comparison. Long-distance truck driving involves many hours of boring work. When driving a long distance on a straight interstate highway, most people have had the experience of realizing that they have just covered 10 miles and do not recall a thing about the scenery or the traffic. Except for taking off, landing and occasionally telling the passengers to fasten their seatbelts, flying a modern airliner can be equally boring. The planes fly themselves, hence the name “automatic pilot.”

Being a surgeon has no similarity whatsoever to piloting or driving. When a surgeon is on call for 24 hours, he rarely is awake the entire time. When he is, he is not doing monotonous, sleep-inducing tasks. For example, I might get a call at 2 a.m. to see a patient with appendicitis. I go to the hospital, examine the patient, schedule the surgery, perform the surgery and go back home. None of those activities is boring or repetitive.

Let’s say that while I am waiting for the operating room team to set up the case and have dictated my history and physical exam findings and written admitting orders, I have nothing to do. If I put my head down and take a 15 minute nap, no harm is done. This is not the case if a truck driver or pilot falls asleep on the job. Even if pilots are distracted by other things such as playing with their laptop computers and overflying their destination by 150 miles or receiving oral sex in the cockpit [no pun intended], the plane flies along without incident.

I suppose I am overstating the obvious, but neither of the two activities described above is possible while performing surgery.

So please, stop comparing surgeons to pilots and truck drivers.

Sleep Deprivation, Blogging, and Anonymity

Last week a guest post on KevinMD by Felicity Billings, MD suggested that attending physicians should have restrictions on the hours they work. She recounted a story about a presumably tired cardiac surgeon (“Dr. Lewis”) who had been awake for more than 24 hours. An anesthesiology fellow, she wanted to tell his next patient how tired he was but did not. Fortunately, the case went well. She stated, “All the research has shown one thing: sleep-deprived doctors are bad doctors.” This elicited several comments including one from me pointing out that all research has shown no such thing. In fact recent papers have found that there is no difference in the outcomes of complex cardiac and thoracic cases done by sleep-deprived surgeons.

Today amednews.com posted a story entitled “Anonymous posts: Liberating or unprofessional?” by Kevin B. O’Reilly. It’s an interesting look at the controversial subject of anonymous blogging and tweeting. I was interviewed for the piece and explained why I prefer to remain anonymous. 

So what do these two events have to do with each other?

I Googled Felicity Billings, MD and found out many things. She works at Brigham and Women's Hospital in Boston. She blogs at “One Case at a Time.” She has written many other posts with rather detailed patient information which she apparently feels she has de-identified adequately. In one instance and to her credit, she obtained permission from a patient and his sister to write about his case.

When I first started blogging, I expressed my concerns regarding such detailed posts involving patients. I pointed out that a smart plaintiff’s attorney could ask a physician if she blogs or tweets. If she says “yes,” I believe everything she has written would be discoverable. Just imagine for example that a patient who had the heart transplant surgery had a late complication and in the deposition phase of a malpractice suit, it came to light that the subject of her post, “Dr. Lewis,” had been awake for 24 hours before doing the surgery.

I choose to blog anonymously for the reasons stated in the amednews.com article. I have avoided writing patient-specific blogs and tweets, because even if de-identified, they may come back to haunt me.

Operative Mortality Rates and Sleep Deprivation

To add some spice to the never-ending debate on the effects of sleep deprivation on surgeons are two recent papers published in respected journals.

“Prospective evaluation of consultant surgeon sleep deprivation and outcomes in more than 4000 consecutive cardiac surgical procedures” was published ahead of print in Archives of Surgery in May. This was a prospective study of the sleep patterns of six consultant [senior attending] cardiac surgeons in Canada over a six-year period. Of the over 4000 cardiac operations performed, there was no difference in the rates of mortality or complications whether the surgeon had less than 3 hours of sleep, 3 to 6 hours of sleep or more than 6 hours of sleep.

“Association of operative time of day with outcomes after thoracic organ transplant” appeared in the Journal of the American MedicalAssociation on June 1. This was a retrospective study of over 27,000 heart or lung transplant operations divided into two groups based on whether their procedures were performed from 7 am to 7 pm (days) or 7 pm to 7 am (nights). Almost exactly 50% of the operations were performed during each time period. Mortality rates at 30 days and one year were not statistically significantly different whether the procedure was done during days or nights.

Even the most ardent crusader against “tired surgeons” would have to admit that these are well-executed studies of rather complex operative procedures. In addition, there are not enough transplant or cardiac surgeons around to allow for shift work. As shown by the data in the transplant paper, half of all such procedures occur at night. Someone has to perform these operations when the organ and the recipient are available, not the next day.

The transplant paper was the subject of a New York Times blog and it drew the usual number of ridiculous comments. I don’t know why I read them because they are so infuriating. Here are some of the more inane ones:

“This is part of the "doctors are superhuman" myth that is simply unsupported in the real world.” Never mind the data.

“Are the ‘qualified surgeons’ in the business of eliminating possible competition, for example?” In response to the fact that there are not that many transplant surgeons.

“A heart transplant in the US costs roughly $145,000. Figure the chief surgeon makes $100K and 9 "helpers" make $5K each for a 5-hour operation. That works out to be $10,000/hr for the doc and $1,000/hr. for each assistant.” And the hospital does not receive any payment?

“Surgery requires superb eye-hand coordination which deteriorates with fatigue. Airline pilots have co-pilots and extensive mechanical controls on the plane and on the ground. Transplant surgeons do not.” Never mind the data.

Feel free to add your own comments [preferably not infuriating, and ...watch your math].