Tuesday, March 8, 2016



The debate of mandatory Surgeon work hour restrictions seems to recycle more and more. The opinions range from a demand for regulation of work hours to “"Just from me and probably for my own reasons- I have never understood, nor agreed with these kind of comments about fatigue, burnout, stress, etc. Stress is the pablum of productivity. Bordom produces mediocrity.” The recent ACS  community post on this subject brings back several conversations I have had over the past year.

In August 2015, Dr. Carlos Pellegrini, reissued a consensus statement for the American College of Surgeons on “addressing surgeon fatigue and sleep deprivation”. Here he conceded that the evidence regarding sleep deprivation in health care is equivocal at the moment, but advised “I believe a balanced and reasonable approach is needed in addressing this issue.” In this statement he implored surgeons to partner with their Health Care enterprises to work out a viable solution based on sound judgment. He expressed to me the need to for us to be able to simultaneously assure there are surgeons available to our institutions and to provide “support for institutions and systems supporting surgeons who believe they are tired”.   In addition, he and I discussed via email the fact that measuring sleep deprivation in surgeons is difficult at best due to no effective means of measuring the sleep character of surgeons who are not on call and theoretically getting a good night’s sleep (i.e. what other stressors occurred causing a restless night or fatigue).

Later in August 2015 Dr. Nancy Baxter’s group (from Toronto) published in NEJM their results of a review of procedures whereby Surgeons were at the hospital seeing patients between the hours of Midnight to 7am and subsequently performed major operations during dayshift the rest of that day, with no significant morbidity or mortality compared to surgeons doing the same operations but without working during that 7 hour window. This paper has been grossly misquoted all across the internet. Fortunately, Dr. Baxter was gracious to discuss this paper with me. She clarified that their group concluded that “sleep loss resulting from the provision of overnight medical care did not measurably affect the short-term outcomes of elective procedures performed the next day.” Next they stated that “broad-based policy shifts in duty hours may not be necessary..” But most of all she clearly states that “the effect of profound sleep loss may warrant further study AND it remains important for physicians to critically assess the effects of ALL sources of fatigue…” She pointed out to me that to their group, the entire spectrum of issues that affect our ability to care for patients should be assessed more fully before we institute blanket policies. A surgeon who is not up performing patient care the night before may be more stressed over other issues and sleep less soundly than one who was up all night. Likewise, a surgeon who was up at night prior to a day in the OR may actually find his awareness and acuity has been heightened for the first 6 hours of the day and then exhausted at the end of the day when no further patient care is required. As we discussed, there is undoubtedly a given degree of sleep deprivation that will cause decrease effectiveness in decision making and manual skills in the field of surgery, but it does not appear to be a static period of time, as it likely varies with other physical and mental factors of the physician, the type of care being provided the night prior, the type of care being provided the following day and the total length of wakefulness. Driving a car after being up all night and working all day is a boring tedious task and has been shown by several to be dangerous (at least in residents, per Tan), but does that necessarily translate to being dangerous in the OR?  Distractions in the Operating room are not a minor matter but, as Ann Wheelock and I discussed this Summer, are very serious and can completely impact the potential for error and injury during a procedure.

Shortly after that conversation I was fortunate to have Dale Roberts (Air Transportation Division, flight standards service, FAA), Tom Nesthus, Chester Piolunek (Aviation Safety Inspector AFS-220, Air Carrier Operations Branch) and Steve Hursh talk to me. They all run, work for or advise the FAA Pilot Sleep Deprivation Protocol Program. (Turns out that Dale Roberts has a wife who is a nurse so he has first-hand knowledge how medical professionals work in sleep deprived conditions.) We discussed things currently in use in aviation including the PVT (Pilot psychomotor vigilance task test), use of actigraphs, alternatives to mandatory restrictive rules including the use of split duties and naps (the FAA states they recommend these be used by pilots who are on long flight patterns and would otherwise not be able to conform to mandatory restrictions- but pilots say all they do is “look at their partners eyes to see if they are ok to go on”) and other thoughts on measuring sleep deprivation and methods to overcome this in a reasonable process. The FAA has some data on pilot fatigue but draws a lot of their research from other fields.

Then in October 2015 a panel discussion covering Sleep was presented at the ACS Clinical congress. I will not rehash that meeting but want to bring up a concern by a surgeon in rural practice. He had a partner but found himself enduring 2 years of the only surgeon on call over 280 nights per year and when he said he was not on call, if he refused to come in, he was being threatened with EMTALA violations by other hospitals and the staff at his hospital.

Dr Pellegrini cautions us against taking sleep deprivation and its effect on fatigue and concentration lightly. He reminded me that sleep deprivation will eventually diminish concentration and skill in any professional. He also reminded me that studies that refute this tend to highlight short term outcomes, but what about long-term outcomes (i.e. Cancer recurrence) when we operate after a sleep deprived night? It is clear, that fatigue, sleep deprivation and other stressors make any professional distracted and error prone at some point. At what point that occurs is what surgeons need to be at the forefront in defining. We simply cannot allow any outside agency to make that determination for us.

Kenneth A. Lipshy, MD, FACS

                Govindarajan A, Urbach DR, Kumar MM, Murray BJ,  Juurlink D, Kennedy E,  Gagliardi A, Sutradhar R,  Baxter NN. Outcomes of Daytime Procedures Performed by Attending Surgeons after Night Work. N Engl J Med 2015; 373:845-853

  • The American College of Surgeons. Pellegrini CA. Addressing surgeon fatigue and sleep deprivation. Bull Am Coll Surg.2015;100(8):72-74.

  • Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ. March 2000;320(7237): 745–749.

           FAA Fact Sheet – Pilot Fatigue; http://www.faa.gov/news/fact_sheets/news_story.cfm?newsId=11857

  • Roehrs T; Burduvali E; Bonahoom A et al. Ethanol and sleep loss: a “dose” comparison of impairing effects Sleep 2003; 26(8):981-5.

  • Nurok M, Czeisler CA, Lehmann S. Sleep Deprivation, Elective Surgical Procedures, and Informed Consent. N Engl J Med 2010; 363:2577-2579.

  • Rothschild JMKeohane CARogers S, et al. Risks of complications by attending physicians after performing nighttime procedures. JAMA2009;302:1565-1572

  • Tsafrir Z, Korianski J, Almog B,  Many A, Wiesel O, Levin I. Effects of Fatigue on Residents’ Performance in Laparoscopy Jnl Am Col Surg 2015; 221(2):564-570

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