Adrenal Fatigue » 2010

By Katherine Hobson

No one disagrees that sleep deprivation hurts physicians? performance. The question is what to do about it.

Two very different approaches to one specific issue, what to do about an elective surgery when the surgeon scheduled to operate is short on sleep, are featured in the current New England Journal of Medicine.

A Perspective piece argues that the consequences of sleep deprivation are so dire ? the authors cite a previous study showing an 83% increase in complications in patients whose daytime elective surgeries are performed by surgeons with less than a 6-hour sleep opportunity between procedures the previous night ? that self-regulation is not sufficient. Instead, ?we recommend that institutions implement policies to minimize the likelihood of sleep deprivation before a clinician performs elective surgery and to facilitate priority rescheduling of elective procedures when a clinician is sleep-deprived,? they write. For example, elective procedures wouldn?t be scheduled for the day after a physician is due to be on all-night call.

And the authors suggest that patients be ?empowered to inquire about the amount of sleep their clinicians have had the night before such procedures.?

?We think patients should be informed and given the choice to reschedule or to proceed,? says Michael Nurok, an anesthesiologist at the Hospital for Special Surgery and one of the piece?s authors. (The others are Charles Czeisler, chief of the division of sleep medicine at Brigham & Women?s Hospital, and Lisa Soleymani Lehmann, director of that hospital?s Center for Bioethics.) And, Nurok tells the Health Blog, it?s fine to proceed ?if [patients] understand that there?s an increased risk of problems.?

No way, say three representatives of the American College of Surgeons, whose letter to the editor responding to the piece appears in the same issue of the NEJM. The solution is to train surgeons ?to understand how fatigue degrades their mental and physical capabilities. They should learn to use this knowledge to determine whether they should disclose their condition to patients, whether operations should be rescheduled and whether they should seek assistance,? they write.

Czeisler tells the Health Blog, however, that ?people are woefully inadequate at assessing the effects of sleep loss.?

We asked two of the surgeons who authored the letter, L.D. Britt, president of the ACS and David Hoyt, the group?s executive director, about that. (The other author is Carlos Pellegrini, chair of the ACS.)

Boyd says surgeons are smart and professional enough to learn to ?have a conversation with yourself? when they are short on sleep and assess their preparedness for surgery. Or, they can consult other members of the surgical team for guidance, he says.

?No one wants an exhausted surgeon to operate,? says Britt. But he says there?s no clear-cut way to define fatigue, and that ?mandatory disclosure? based on some arbitrary threshold isn?t appropriate. If doctors are supposed to disclose their sleep patterns, what about other things that might affect performance, such as financial worries or a fight with a spouse?

The surgeons also write that in the case of a ?relatively simple? procedure such as an elective colostomy, ?many surgeons could successfully complete it with or without a good night?s sleep.?

?If you know you?re going to do a 30- or 45-minute procedure, it?s like driving home,? says Hoyt. ?It?s a judgment call.?

Czeisler says that routine, highly-overlearned tasks ? like a routine surgery or car trip home from work ? are the ones that are most susceptible to the adverse effects of sleep deprivation. ?People are so confident in their ability to perform that they are ignoring the weight of the world?s literature on this topic,? he says.

What do you think?

Further reading:

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