Should Sleepy Surgeons Disclose Fatigue to Patients?

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Heading in for elective surgery can be a nerve-racking experience. People tend to worry about who's taking care of the kids, how much work they'll miss or how much pain and discomfort the operation will bring on. They don't generally stress over whether their surgeons have had enough sleep.

But some doctors believe patients should think about how much sleep their surgeon got the night before, and should be told if the surgeon may be sleep-deprived so they can decide whether to go through with the surgery that day or reschedule it.

"We have data that show that sleep deprivation affects clinical performance, and we also have data that show that patients want to be informed if their surgeon didn't get enough sleep, so it's become a patient advocacy and safety issue," said Dr. Michael Nurok, lead author of an article on sleep deprivation and informed consent in the latest issue of The New England Journal of Medicine.

Nurok, who is also an anesthesiologist at the Hospital for Special Surgery in New York, alluded to a past study published in the Journal of the American Medical Association that highlighted some of the risks posed by surgeons who operate in a sleep-deprived state.

"When looking at procedures done when a surgeon has less than six hours of sleep, there's an increased risk of bleeding and organ damage," he said.

Nurok said he hopes to draw attention to the need for patients, doctors and medical centers to become more aware of the hazards posed by sleep deprivation. He and his co-authors believe that medical institutions should prohibit surgeons who have been on emergency call all night from scheduling elective procedures the next day, and institutions should also make it easier to reschedule surgeries.

He acknowledged, however, that there are a number of barriers that could make it difficult to enforce regulations against surgeons operating on too little sleep, among them the "culture of surgery" and the current demands of the health care system.

"The culture of surgery [meant] to forge ahead and not complain about things like lack of sleep," said Dr. David Cronin, an associate professor at the Medical College of Wisconsin in Milwaukee. Complaining about lack of sleep "was looked down upon as ... a sign of weakness."

In general, people don't always judge their own level of fatigue very well, and surgeons are no different.

"As with everybody, they could be impaired and not even be aware of it," said Nurok.

But other surgeons believe the decision to disclose should be up to the physicians. They told ABC News they've been in several situations where they've been too tired to perform surgery and opted out, offering the patient the chance to reschedule or have another surgeon operate.

"I believe the vast majority of surgeons want the best for their patients and are aware enough of their own abilities to make this call," said Dr. John Byrne, chairman of the department of cardiac surgery at Vanderbilt Heart and Vascular Institute in Nashville, Tenn.

"If he needs to disclose how much sleep he got the night before then they should be obligated also to disclose did they party, drink, have sex, have a good breakfast, meditate. All those have been shown to improve manual dexterity and thinking," said Dr. Valluvan Jeevanandam, professor of surgery at the University of Chicago Medical Center.

Health Care System Presents Barriers to Disclosure

The many demands placed on surgeons and other health care providers make the prospect of having to reschedule elective surgery very daunting.

"The patient may have rearranged their life to take time off from work, arrange child care, etc. The surgeon may have booked the case and follow-up period long in advance or around other obligations," said Cronin. "The operating room schedule would become unmanageable if cases started to be canceled on a more frequent basis. The cost of health care may actually increase."

The medical community has taken some steps to address the problem of extreme fatigue among doctors. The Accreditation Council for Graduate Medical Education recently restricted first-year medical residents to a maximum of 16 hours of work a day, followed by at least eight hours off. But some physicians say this policy has been counterproductive for surgeons.

"I think it is clear from the resident work-hour regulation experience that fewer work hours does not translate into more sleep or more study," said Dr. David Euhus, a professor at the University of Texas Southwestern Medical Center in Dallas. "In the current environment, residents are prohibited from coming to a patient's aid if they have already used up their hours, so more and more of this falls to the staff surgeon alone."

Surgeons Should Be Trained to Spot When Sleep Deprivation Poses Risk

In an accompanying editorial, the American College of Surgeons agrees that sleep deprivation can have an adverse effect on clinical performance, but it says that rather than institute mandatory policies that require disclosure or prohibit surgeons from working if they haven't clocked enough zzzzs, surgeons should be trained to recognize when a fatigue poses a risk to patients.

"Surgeons should be trained to understand how fatigue degrades their mental and physical capabilities, wrote Dr. Carlos Pellegrini, a professor and chairman of the department of surgery at the University of Washington at Seattle, and co-authors. They should learn to use this knowledge to determine whether they should disclose their condition to their patients, whether operations should be rescheduled and whether they should seek assistance."

Pellegrini and his co-authors also believe that sleep-deprived surgeons can easily perform simple surgeries, so there doesn't need to be a restriction on those types of procedures.

But Nurok said routine surgeries can pose risks if surgeons haven't had enough sleep.

"It's usually routine and highly overlearned tasks that are susceptible to sleep deprivation and decreased performance," Nurok said.

"We need to address it as a society," he said. "There are no 'one size fits all' ways to deal with this."