Do Sleepy Surgeons Have a Right To Operate?

Hugh Pickens writes "BusinessWeek reports that a commentary from the New England Journal of Medicine calls on doctors to disclose when they're deprived of sleep and not perform surgery unless a patient gives written consent after being informed of their surgeon's status. 'We think that institutions have a responsibility to minimize the chances that patients are going to be cared for by sleep-deprived clinicians,' writes Dr. Michael Nurok, an anesthesiologist and intensive care physician. Research suggests that sleep deprivation impairs a person's psychomotor skills — those that require coordination and precision — as much as alcohol consumption and increases the risk of complications in patients whose surgeons failed to get much shuteye."

Comments

Develop a test

[StripedCow]

Why not develop a test (perhaps a video game) which a surgeon should pass before entering the surgery room?

Re:Develop a test

[Toth]

Ten or so years ago, our trucking division experimented with such a program. It ran on a PC and had a controller with a single knob which could be rotated left or right.

You used the knob to keep the cursor in the center spot on the screen. The cursor would become more difficult to control during the test (about 30 seconds)

Drivers would sign in for the first time and establish a baseline for themselves by taking the test multiple times until the program indicated that a baseline was established. (About a dozen attempts, I think)

Once a baseline was established, a driver had to pass the test before starting his shift. If he failed, he had to see a supervisor.

I tested it on myself. After two (unmeasured) shots of vodka, I would have had to see a supervisor were I a driver.

An additional advantage was that you would also fail the test if you had the flu, were sleep-deprived or emotionally unfit to drive.

The program never went into full production at our place. Currently drivers are tested when hired and after any accident or delivery process incident.

I forget what it was called (I tried googling). I thought it was "fair". If you couldn't pass the test, you probably shouldn't drive a truck that day.

If you smoked a joint a week ago, it wouldn't affect the test but if you were up all night watching movies, you'd likely fail.

Re:Develop a test

[Dr_Barnowl]

Please don't diss NHS doctors. Having been in exactly that position, a junior doctor too tired to do a proper job, I can tell you that the major reason the NHS is in such a world of pain originates from the top down, not the rank and file.

The NHS has for some time been dependent on the goodwill and vocational motivation of it's healthcare professionals, because they sure as hell ain't motivated by the working conditions, pay, and benefits.

The real problems in the NHS stem from multiple sources, including the increasing cost of healthcare consumables (increasingly expensive technology and pharmaceuticals), the costs of revolting profiteering (aka the "Private Finance Initiative"), targets set by politicians, an excess of managers, a decrease of basic common sense and an increase of feelings of entitlement amongst the UK population (I've seen people turn up in A&E (ER) depts for things as basic as a cold or a knee graze).

Yet despite all this, we still achieve better health outcomes than the USA despite spending a quarter per-capita what they do on healthcare. Does this mean we are more than four times as competent?

The story itself is from the New England Journal of Medicine - so has originated from doctors themselves, trying to improve the care that patients receive by fighting against the market forces that increasingly try to reduce medical professionals to the same depth as any other druge worker stuck in a poverty trap.

Re:Develop a test

[FatalChaos]

Part of the problem with this is that any video game (or other) test that is reasonably quick is going to be reaction based. Surgery is not about quick reactions. I've watched open heart surgery, and it took a good 4-5 hours to complete. Surgery is about slow, slow precision, and by the time you could test for that, the patient is probably already screwed. Think of it this way: go to a hospital, and ask who are there best surgeons. You'll find out a lot of them are at least in their 40s, if not 50s and 60s. When was the last time you found ANY 40, 50, or 60 year old who was a legit gamer?

Re:Develop a test

[MMC Monster]

The problem is that most of the best surgeons are in their 40s or higher.

This is because the younger ones don't get the sheer number of cases required to be a great proceduralist. Why not? Well, it's mostly because they're required to go off shift after 24 hours, or 12 hours if they're on for a 24 hour shift the next day, etc. Who scrubs in on those cases? Well, the hospitals are hiring more physicians assistants to take up the load.

This is what the director of surgery at a major New York City teaching hospital told me earlier today.

Re:Develop a test

[FiloEleven]

Sounds like a form of impairment testing, which is a pretty big win for everyone but has not been widely implemented. Employers who have used it found that it consistently reduced accidents, and employees like it since they don't have to pee in a cup--a demeaning and annoying procedure. It should also be cheaper for employers: even at a couple thousand bucks for the machine and software you used, the payoff in reduced accidents and mishaps along with not having to pay drug testing companies all the time means it'll pay for itself in a very short period of time.

It doesn't unfortunately seem like it's going to catch on anytime soon. Most companies haven't heard of it, and my guess is that most who have are waiting for it to gain a reputation before thinking about making the switch themselves.

Re:Develop a test

[Shotgun]

You would think it would be a big win for everybody. You would be wrong.

It's a BIG loser for the dispatchers and salesmen. When I hired on for RTC, they gave us an indepth class on how to get more driving hours in a day. It involved sleeping and driving in four hour shifts. Now, WHY would they do this?

Because, clients would gravitate to the company that could deliver on time. There were penalties, up to and including simply refusing to accept the load, for not delivering on time. Salesmen would indiscriminately put tickets for hauls in. No consideration was taken for capacity. Dispatchers were responsible for seeing that the loads got hauled. Dispatchers could say something along the lines of, "Yeah. That's not possible. Trucks don't move that fast." Dispatchers who said something along those lines would end up asking, "You want fries with that?"

The bottom man on the pole was the driver. He got handed a ticket that said he had to haul a load 1000 miles by noon tomorrow. He could say something along the lines of "Yeah. Given our current space-time continuum and the laws of the Interstate Highway System, that is not physically possible." The next thing he would say is, "You want fries with that?"

The impairment testing would document that a driver was unfit to drive, something most drivers know already. After an accident, the first thing the insurance company would ask for is to see the results of the impairment test, and then deny the claim because the driver had been turned around with a forged log book after a 1500 mile marathon run.

Impairment testing is a win for everyone, except for the people that would be responsible for installing them.

Re:Develop a test

[leromarinvit]

Impairment testing is a win for everyone, except for the people that would be responsible for installing them.

Sounds like a good candidate for a law then, doesn't it?

This is just another waiver

[santax]

Come on, so you get into the ER, need treatment right away, you're gonna tell the only doc available to first get some sleep? Don't think so. The hospital/doc should have made sure that the staff is fit enough to even be on watch. This will just mean: yes sir we are very sorry you lost your kid due to bad handling from are doctor, but look here: that is your signature. So you can kiss that lawsuit goodbye. Hospitals shouldn't have people who are sleepdrunk on the watch. Simple as that.

Re:This is just another waiver

[nbauman]

I agree. If the surgeon's abilities are impaired for lack of sleep, he shouldn't operate, and it's the responsibility of the surgeon and the hospital to enforce that rule.

They can't dump the responsibility on the patient, especially by shoving an informed consent form under his hand in the 15 minutes before surgery. The patient isn't qualified to evaluate that risk.

This wasn't a BusinessWeek article, btw. It was a HealthDay rewrite of a New England Journal of Medicine article http://www.nejm.org/doi/full/10.1056/NEJMp1007901 [free]. The NEJM article more clearly made the important point that hospitals shouldn't get into these situations in the first place by letting surgeons schedule elective surgery after a night of being on call. Here's the hypothetical case from the original article:

A surgeon on overnight call responds to an 11 p.m. call from the hospital, where a patient has presented with an acute abdomen. After working up the patient for several hours, the surgeon decides to call in an anesthesiologist and perform a bowel resection. By the time the procedure is completed and the operative note has been dictated, it is time for morning rounds. The surgeon has not slept all night and is scheduled to perform an elective colostomy at 9 a.m. Does the surgeon have an obligation to disclose to the patient the lack of sleep during the past 24 hours and obtain new informed consent? Should the surgeon give the patient the option of postponing the operation or requesting a different surgeon? Should the hospital have allowed the surgeon to schedule an elective procedure following a night he was scheduled to be on call? Should it allow a surgeon to perform elective surgery after having been awake for more than 24 hours? What potential unintended consequences of disclosing a clinician's sleep deprivation should be considered?

Re:This is just another waiver

[demonlapin]

Harder than you think. On-call duties don't just include doing surgery. I'm an anesthesiologist, not a surgeon, but I did play one for a month as an intern, so I may be able to give you a bit of an idea how things work.

The way to reduce call is to increase the number of people in your group. Larger group = less frequent call. HOWEVER, larger group = larger number of patients admitted to multiple hospitals to care for overnight, and less familiarity with those patients. If you're in a 3-man group, and you're on call every third night, you'll get to know your partners' sicker patients better. If it's a 10-man group? You'll rarely see the same patient twice, and there will be a lot more of them. In the 3-man group, you'll have a manageable list of patients, and given the number of things that happen in an average night, you'll probably get a bit of rest. The bigger the list of patients, though, the more likely you are to get called about something during the middle of the night. Maybe the primary surgeon forgot to write an order for Tylenol for the patient; maybe the patient is constipated and wants something for it (an astonishingly common complaint); maybe they want a sleeping pill. Doesn't matter; you've got to take a call and deal with it.

Furthermore, surgeries are scheduled by days of the week - you will have (e.g.) one room on Mondays, two rooms on Tuesdays, and one room on Friday afternoons. Regardless of what night you're on call, that's when you can operate. Since surgeons only make money when they operate, there is an enormous incentive not to miss an operative day. Since the hospital only makes money from ORs that are in use, if you don't use your operative time you'll lose it. Cancelling a day of surgeries has enormous costs - you already have a nurse anesthetist, a scrub tech, a circulating nurse, and housekeeping personnel scheduled to work there. Do you send them home early, effectively docking their pay for something that isn't their fault? Or do you pay them to do nothing?

Re:This is just another waiver

[countertrolling]

Truck drivers have more sensible rules.

But a doctor can usually only kill one person at a time. Depending on the cargo, a truck driver can take out a pretty large area.

Re:This is just another waiver

[alphastrike]

I agree. Being a resident I have some additional points to add on to your arguments. It may seem simple to reduce work hours, but it's over-simplified solution to a very complex problem.

Resident physicians are physicians who have finished medical school. They have a MD behind their name but are still in training. Say that hospital A has a training program for doctors. In order for the community to recognize the doctors graduating from hospital A's program is competent, hospital A must get approval from the ACGME(Accreditation Council for Graduate Medical Education).
The ACGME evaluates the program intermitently to assure the program's training fits the acceptable standards. Say the Residency program has 5 residents per year.

Right now the ACGME has a limit that no resident physician can work over 100 hours per week.(Let me point out that is actually 2.5 full time jobs). Say the ACGME drops that to 80 hours per week. Now suddenly you need more residents. If all 5 residents work 20% less, they will need at least 2 more residents per year to make the schedule happen. If the program have 20 residents, they'll need 6-7 more residents to make it happen. The ACGME however, might not approve of this. All hospitals have a patient load. If your residents are barely getting enough experience, diluting the load by adding more residents might put the training program below standard. Thus the ACGME can deny your request for additional personnel.

So the ACGME is forcing hospital A to reduce work hours, yet at the same time refuse to approve more residents. What do you do? Hire some physician assistants? Their average salary is more than 150% of an average resident, and they work far less hours. As a hospital/group who is trying to make profit, it would be less than ideal. Like the "don't ask don't tell system" it's easier if they just didn't report the work hour violations.

So if the problem is sleep, if you set thinigs up so residents work only 12 hour shifts instead of a 24 hour shift(call) then it would be okay right? No so. Continuity of care is not as good. A nurse sign out to the next nurse when their shift is done, but they have upwards of 6-8 patients on the floor. When a physician sign out to his/her relief, you are talking about any where from 10-50 patients. The more hand offs = more room for error, so you are trading exhaustion for hand off errors. Plus you have to now staff nights, which increases the number of staff needed. Previously when one person is staffing you now require 2 to provide 24 hour coverage.

The ACGME is making work hours more strict, but is the hours the surgical resident working really going down? Are they going to scrub out of a 12 hour case early so they can go home? no. Are they going to come in late and miss the next day's cases? no. Are they willing to lengthen their training from 5 years to 8 years because of a reducting of work hours and cases? hell no. Are they going to report their own program, have it shut down and end up having to look for new place to train? Again no. So most of the time they just don't report it when they work over their limits.

The institution try to fix the problems on the surface. The real problem lies in the cost of hiring medical personnel, the large debt from medical education, and the sharp difference in wages between a resident physician and an attending physician. Medical care when treated as a business is going to be squeezed for profit like any other business. Work hours is one of the scenarios where patient care and profit clash.

NO

[zero.kalvin]

Any other question ?

Trust a doctor

[pehrs]

Asking me to sign a waiver should a surgeon about to cut me open be tired seems only like a CYA policy. I can't make an informed decision, and I am most likely in distress and need of the surgery and saying no would delay it.

I am already putting a huge amount of trust in his abilities, and that includes him being able to decide if he skilled and in shape to do the operation or not. If I can't trust my doctor to make that decision I can't trust him to operate at me anyway. Therefor this seems completely pointless.

I

Re:Well, of course, it should be the other way aro

[Anonymous Coward]

Killed five people while she was at it. Good for her! Now she has a shitty BMW to show for it!

Re:Would Patient Consent Work?

[kyrio]

That must have been a really big motorcycle in order to get into it!

this is just dumb

[Triv]

Your relationship with your doctor is based on trust and consent - you don't ask your taxi driver to submit to a breathalyzer before he drives you home, so why should you ask your doctor how he's sleeping? If you don't trust your doctor to be operating on you in good condition, you need to find yourself a different doctor.

Proper rest

[Anonymous Coward]

You know, in a country where even truck drivers have regulations requiring proper rest, you'd think there'd be some sort of standard for medical practitioners of any kind. Of course, if any politician ever tries it those AMA campaign donations will dry up like the Gobi Desert.

Re:Proper rest

[couchslug]

I get some great reactions from medical folks when I mention that the Air Force generally enforces a 12-hour shift limit for aircraft maintainers, even in wartime. Tired people fuck up, and anyone who pretends otherwise is full of shit.

The medical world should borrow two things from military aircraft maintenance. Limit shifts to 12 hours except in emergencies where manning is insufficient, and CHECKLISTS.

Pilots, who are at least as studly and narcissistic as physicians, KNOW ignoring checklists is a great way to fuck shit up. That's why it is PUNISHED.
They also know, even with training, that no one can remember every detail of every complex task they have to perform. From maintainers to aircrew to the folks in the control tower, checklists are considered orders to be obeyed.

Physicians have little time to see each patient, so they have to match symptoms with their concept of a "template" for a particular malady. Checklists are ideal for this sort of thing.

As to the civilian custom of working interns to exhaustion, that's just stupid. The military can train enough folks for wars, the civilian side of the house should "militarize" medical care (including quality control and open chain of command for complaints) and get shit done.

Re:Proper rest

[dkleinsc]

3 cheers for checklists! My sister is studying nursing right now. Those checklists are life-savers.

I also have friends who are or recently have been medical residents. That kind of pressure, with shifts that last well over 12 hours, is quite simply an abusive labor practice.

Re:Proper rest

[bill_mcgonigle]

The military has a culture that's designed to take ego out of the decision processes. Perhaps imperfect, but the danger is recognized and dealt with. Now, try working at a hospital...

Actually, it would be interesting to compare military hospitals with civilian and see how they rate on important measures.

Re:Proper rest

[couchslug]

Proper checklists aren't constraints, they are reminders of proper procedures. There is even a saying in aircraft safety, "add but don't take away".

Pilots can fly highly complex combat missions and adapt to changes on-the-fly, yet basic procedure checklists reinforce memory. The pilot doesn't always read the checklist verbatim while doing a task, but does have it available to supplement his skill.

Have some Atul Gawande:

http://www.npr.org/templates/story/story.php?storyId=122226184

""We brought a two-minute checklist into operating rooms in eight hospitals," Gawande says. "I worked with a team of folks that included Boeing to show us how they do it, and we just made sure that the checklist had some basic things: Make sure that blood is available, antibiotics are there."

How did it work?

"We get better results," he says. "Massively better results.

"We caught basic mistakes and some of that stupid stuff," Gawande reports. But the study returned some surprising results: "We also found that good teamwork required certain things that we missed very frequently."

Like making sure everyone in the operating room knows each other by name. When introductions were made before a surgery, Gawande says, the average number of complications and deaths dipped by 35 percent.

"Making sure everybody knew each other's name produced what they called an activation phenomenon," Gawande explains. "The person, having gotten a chance to voice their name, let speak in the room -- were much more likely to speak up later if they saw a problem."

article's title

[underqualified]

"Doctors Urged to Admit Fatigue Before Performing Surgery"

I wish we had something similar in my previous company.

"Developers Urged to Admit Fatigue Before Fixing Bugs"

Here's a crazy idea.

[BlueParrot]

How about ensuring doctors work humane shifts as opposed to trying to squeeze every penny out of the system?

This is not just a problem with the US btw. I've spoken to doctors from lots of different countries, including Sweden, the US and England.
In general they are overworked, get little time to recover between shifts, and are expected to work overtime as part of the job description.

That's not going to be good for either doctor or patient.

Re:Here's a crazy idea.

[bill_mcgonigle]

There are several things that need to be done. They're mostly interdependent, so in no particular order:

1) stop the hazing culture in medicine
2) striate the practices. The concept of an Uber-doctor is antiquated. (LPN's and PA's are starting to help here). Cooperating teams is the smarter approach.
3) decrease doctors' hours
4) decrease doctors' salaries
5) get the government out of licensing doctors and medical schools (the chronic shortage is purposeful)
6) get the AMA out of dictating government policy for licensing doctors and medical schools (the chronic shortage is purposeful)
7) destroy the third-party payer system
8) get the States out of regulating insurance
9) privatize medical charities (the Shriners are a great example)

The current system is not designed to produce the best patient care, and that's all that needs to be said. In most industries we praise the "customer first" approach, even for ultimately stupid and inconsequential stuff. We know by experience that if the customer is placed first that the rest of the business succeeds, but somehow fear that approach when it comes to one of the most essential industries.

Re:Doctors/Nurses do not get speeding tickets

[neapolitan]

This is simply not true.

If you are legitimately speeding (safely) to perform an urgent operation, the police may escort you to the hospital, enter with you, verify you are about to do an operation, then leave you without a ticket (it happened to several of my colleagues, usually late at night.)

Just being pulled over and showing your hospital badge / white coat is not going to help you 99+% of the time. *Especially* if you were driving in a dangerous fashion. One of my friends has a funny story on how he tried it after being pulled over, and his ID says:

".... ..., MD
DERMATOLOGY"

The police officer laughed and gave him the maximum fine.

an institutional illness

[tverbeek]

Part of the problem is the medical profession's method of "training" physicians by putting them through an extended period of hazing: working around the clock, being awakened at random intervals, etc. Many of the ones who get through it develop the delusion from it that they can do the work properly under any conditions, especially sleep deprivation. It's a badge of honor for them, and they will engage in all sorts of denial and rationalization to keep at it.

Re:an institutional illness

[Kilrah_il]

I can assure you that most doctors I know, me included, know that the long hours endager our patients. We do not take pride in taking someone to the OR at 4AM while barely being able to tie our shoelaces correctly. It is not pride, but necessity.
The present situation is that doctors need to work a lot. Why? Lack of personnal, lack of money lack of resources (Actually, it can all be summed up in: Lack of money). The reason is not important. The bottom line is that a doctor needs to operate a patient. Ideally, he should be wide awake. Unfortuntly, sometimes this is not the situation, even for elective surgeries.
We shouldn't point the blame at the doctors, but at the system.
Yes, it's nice to tell horror stories of what I have to do in the middle of the night after 20 hours of working without a minute of sleep. But every doctor I know will have the situation changed to 8 hour shift at the first chance possible.

Re:an institutional illness

[Kilrah_il]

First of all, I was talking about the medical system. I order to have doctors working shorter hours, you need to have more doctors -> more money.
Secondly, in the US doctors might make a lot of money, but in Israel (where I am from) and many other countries, the doctors' salary isn't so lucrative. I am not saying I am starving, but considering how much I work, it's pretty disgracing. If I wanted to have a good salary, I would have gone to IT (yes, you read that right).
I will make good money, but only 15 years from now, when/if I have a private clinic, otherwise my salary will be above-average but I will not be making as much as you might guess.

Some doctors in my hospital do cancel elective sur

[olddoc]

I am an anesthesiologist. When I am on overnight call I am always off the next day. Our group of Anesthesiologist strongly believes this is the right thing to do. On overnight call I don't come in until 3pm because 24 hours it too tiring. The motto of the American Society of Anesthesiologists is "Vigilance" You can not be vigilant if you are sleep deprived. On several occasions I have seen heart surgeons who are up at night with emergencies call off scheduled, elective cases in the morning. Perhaps we just have a good bunch of surgeons here, but all of the OR team (nurses, perfusionists, Anesthesiologists...) think it is the right thing to do.

Re:Would Patient Consent Work?

[TapeCutter]

"Fortunately, the stay was covered, which was lucky because my insurance company only covers one of the local hospitals for things which aren't trauma care or preapproval."

As an Aussie who enjoys cheap and effective universal health care, I cannot for the life of me understand why Americans are not outraged by that sort of bullshit.

Re:Economics vs Health

[chooks]

MRIs are pretty much universally better

This is a common misconception but is not true. Which imaging modality to use depends on the clinical scenario. MRIs have the downside of taking a long time, requiring the patient to be relatively still during this time, and being in an enclosed space (which some patients refuse to go into - hence the development of "open" MRI patients). And yes, they are expensive. CTs in contrast (pardon the pun) are quick, much cheaper, and do an excellent job of visualizing things like blood which is important in stroke management, trauma, etc...In the acute setting, your patient might die in the MRI machine while a CT scan would give you all the information you need in a much timelier fashion.