Surgeons criticize editorial calling for sleep deprivation policies

Authors detailed consequences of a clinician’s sleep deprivation, saying patients scheduled for elective surgery should know of possible impairment.

A recent New England Journal of Medicine editorial by physicians from three medical institutions called for patients’ informed, written consent whenever a surgeon is sleep-deprived prior to performing elective surgical procedures.

The bottom line, according to Michael Nurok, MD, PhD, an anesthesiologist and intensive care physician at New York’s Hospital for Special Surgery, and first author of the article, is that policies are needed in this area.

“Patients should just not be exposed to sleep-deprived physicians in elective cases and hospitals should prohibit surgeons from scheduling elective surgery on the day after they have been on call in the urban centers, because there is a likelihood in those centers that surgeons will not have adequate sleep and that would likely affect their performance the next day,” he told Orthopedics Today.

Time for change

The widely reported adverse effects that sleep deprivation has on clinical performance need to be addressed, just as regulations have been put on the work hours put in by physicians in training, Nurok and colleagues from Boston’s Brigham and Women’s Hospital and Harvard Medical School noted in their Dec. 30, 2010 editorial.

Michael Nurok

Nurok and co-author Lisa Soleymani Lehmann, MD, PhD, are both ethicists and their co-author Charles A. Czeisler, PhD, MD, is a sleep expert.

Nurok and colleagues noted that not letting sleep-deprived physicians proceed with surgery without such consent protects the patient’s interests.

“As an interim step, the doctrine of informed consent says that any patient needs to understand the risks, benefits and alternatives to any procedure they’re about to undergo,” Nurok said. “Given the increasing data about the adverse effects of sleep deprivation, it seems clear that there is an increased risk. So surgeons, we believe should be disclosing this information to patients if they plan to operate on a day when they are sleep-deprived.”

Care decisions

Nurok and colleagues wrote that what they propose would “represent a fundamental shift in the responsibility patients are asked to assume in making decisions about their own care and might prove burdensome to patients and physicians and damaging to the patient-physician relationship,” but they noted that until such institutional changes are made to protect patients, such a shift may be necessary.

Among studies indicating that sleep deprivation impairs psychomotor performance as severely as alcohol intoxication is a 2009 Journal of the American Medical Association study, which showed a significant increase in the risk of complications in patients who underwent elective daytime surgical procedures performed by attending surgeons who had less than a 6-hour opportunity for sleep during a previous on-call night. Nurok said the growing body of data on adverse effects of fatigue on performance, along with a 2010 study by Blum and colleagues supporting the fact that patients want such disclosure from their surgeons, constituted the main scientific evidence behind their editorial.

Nurok admitted the topic is both complex and emotionally charged and the current medical work system permits this sort of “crazy” medical booking to occur.

Lesson: Residency work hour restrictions

Norman A. Johanson

“We have been keenly aware of the issue in residency training because it has affected our training and the way we conduct our programs,” said Norman A. Johanson, MD, orthopedic department chair and director of the orthopedic surgery residency program at Drexel University College of Medicine, Philadelphia. Sleep is important to a surgeon’s cognitive function and is a major concern during orthopedic training and afterward, he said.

However, due to problems surrounding the medical training work schedule rules and their seeming inability to improve that situation, coupled with shrinking resources in health care, Johanson wondered what the bottom-line of instituting Nurok’s recommended policy changes might be. “The cost of implementing the system such as that advocated in the NEJM article is at the outset prohibitive and the necessity of doing so, based on that article is questionable,” Johanson told Orthopedics Today.

Many of the responses sent to the authors of the editorial about approaching the problem through increased disclosure echoed those Orthopedics Today received from surgeons, the American Academy of Orthopaedic Surgeons (AAOS), American College of Surgeons (ACS) and Orthopaedic Trauma Association (OTA).

Disclosure questioned

Some physicians claimed the amount of sleep they get is a personal matter or said the situation is one they can and do self-regulate. Others worried about what else they may be asked to disclose, such as other life stresses or having a drink the day before operating.

Commenting on earlier version of this article on ORTHOSuperSite.com, John M. Grobman, MD, who works at a 90-bed community hospital in New Hampshire, took issue with the implications for greater disclosure, but generally favored changing these practices from the top down. “To discuss this is a good thing,” he said in a phone interview. “You need to be honest with your patients. That’s what this boils down to.”

Grobman was also concerned about related liability issues. Orthopedics Today Orthopedic Medical Legal Advisor columnist B. Sonny Bal, MD, JD, MBA, an orthopedic surgeon, said he has never seen a malpractice case where an error occurred due to sleep deprivation. “The system has checks and balances and people within themselves, and professionals particularly, have reasonable checks and balances to modulate their behavior and work in the best interest of the patient. By and large, the system work reasonably well,” he said.

Bal added, “This is definitely an educational opportunity and the best way to make changes is to present the data from the airline and hazardous industries showing that there is impairment and poor performance related to stress or sleep deprivation. I think that will enhance the knowledge of professionals and would have the biggest bang for the buck.”

Need for consent

Nurok said that having policies against operating when sleep-deprived actually supports the physicians who would be affected. “If hospitals prohibit it, you don’t need to worry about the disclosure issue,” he said.

Further complicating the matter, people who are sleep-deprived are often not able to accurately assess their degree of self-impairment, Nurok said.

He and colleagues stated in the editorial that patients who decide to proceed after the surgeon discloses being sleep-deprived should sign a consent form the day of surgery before a witness.

College of Surgeons letter

L.D. Britt

In a letter to the editor in the same issue, ACS officers, including ACS President L.D. Britt, MD, MPH, called the editorial “timely” and proposed that medical organizations provide members with more and better training in identifying and addressing the situation. “However, we maintain that a call for mandatory disclosure essentially eliminates the necessary judgmental latitude surgeons should possess to determine their fitness for providing optimal patient care,” they wrote.

Britt told Orthopedics Today he feels the true sleep deprivation problems among surgeons are infrequent and a surgeon’s disclosure that they slept less than 6 hours to patients and their families might be confusing. Furthermore, he called for a better definition of sleep deprivation and its clear connection with adverse outcomes in the surgical profession.

“This is not driven by science and data. This whole 80-hour work week for trainees had no science behind it at all. We have not seen any better patient outcomes or better trainee performance on exams and so forth to support that any modifications of hours has made a difference,” said Britt, who questioned whether new sleep deprivation policies would prove any more successful.

AAOS: Rely on training, ethics

AAOS spokesperson Michael R. Marks, MD, MBA, orthopedic surgeon and vice president of business development at Norwalk Hospital in Conn., said, “We, as physicians, understand that patient safety is really the number one issue. As orthopedic surgeons we are trained extensively in that. The AAOS was on the forefront with the ‘Sign Your Site’ program and surgical time outs, so that we really understand that issue. The problem that most of us have is when you begin to legislate and try to come up with a one-size-fits-all solution. Really what we need to do during training and in practice is make sure that physicians truly understand that fatigue has a detrimental effect on both their cognitive and technical performance. The surgeon should try and work within his or her schedule to minimize the fact that they may be up or get minimal sleep the night before performing elective surgery.”

Marks disfavors excessive regulation and legislation and supports empowering patients to learn about risks related to their procedure and exercise their right to ask their orthopedic surgeon if he or she feels capable to do the operation. “We really need to make sure that we’re encouraging our physicians to maximize their professionalism and ethical behavior, but this doesn’t require regulation and legislation,” he said.

OTA responds

In light of possibly increased burdens upon those left handling “call” should new sleep policies be adopted, OTA President Timothy J. Bray, MD, and the OTA presidential line provided the following statement to Orthopedics Today: “The OTA shares the concern of others about the potential for sleep deprivation, both acute and chronic, to have a negative impact on quality of surgical care.

“We believe surgeons should take steps where possible to avoid situations where they need to perform elective surgery when sleep deprivation is likely. We also believe that surgeons should disclose sleep deprivation to their patients if surgical intervention is planned.

“We do not believe that governmental regulation in this area is in patients’ interest. We believe such regulation has a higher likelihood, particularly in smaller communities, of limiting access to emergency services than it does of ensuring quality of care,” Bray said. – by Susan M. Rapp

References:

• Blum AB. BMC Med. 2010;8:33.
• Nurok M. N Engl J Med. 2010;363:2577-2579.
• Pellegrini CA. N Engl J Med. 2010;36:2672-2673.
• Rothschild JM. JAMA. 2009;302(14):1565-1572.

• B. Sonny Bal, MD, JD, MBA, can be reached at 204 N. Keene St., Suite 102, Columbia, MO 65201; 573-449-7369; e-mail: balb@health.missouri.edu.
• Timothy J. Bray, MD, can be reached at c/o Linda Ellenwood, 555 N. Arlington Ave., Reno, NV 89503; 775-788-5283; e-mail: drtimbray@sbcglobal.net.
• L.D. Britt, MD, MPH, FACS, FCCM, Brickhouse Professor and Chairman, Eastern Virginia Medical School, can be reached at 757-446-8964; e-mail: brittld@evms.edu.
• John M. Grobman, MD, can be reached at 14 Maple St., Suite 100, Gilford, NH 03249; 603-526-9100; e-mail: jgrobman@opa.com.
• Norman A. Johanson, MD, can be reached at 245 N. 15th St., MS 420, Philadelphia, PA 19102; 215-762-3511; e-mail: norman.johanson@tenethealth.com.
• Michael R. Marks, MD, MBA, can be reached at Norwalk Hospital, 34 Maple St., Norwalk, CT 06856; 203-852-2613; e-mail: Michael.marks@norwalkhealth.org.
• Michael Nurok, MD, PhD, can be reached in the Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th St., New York, NY 10021; 212- 606.1206; e-mail: nurokm@hss.edu.
  Disclosures: Bal, Bray, Britt, Grobman, Johanson, Marks, and Nurok have no relevant financial disclosures.