“You promised. You promised me. I cannot wait any more,” the full term pregnant woman wailed. Her obstetrician replied, “I know you have been waiting, without food, for hours. We have worked hard to get this baby for you, and it is safer to wait until tomorrow. I have been in the operating room since 3 a.m. with a difficult case. I am exhausted. This is no time for me to do more surgery, and look after you and your baby. You will be my first patient tomorrow.”
This is the real conversation between my wife and her obstetrician “planning” the cesarean section for our third child. A secondary benefit to this “safety” discussion was that the baby would be born on April 2nd, rather than April 1st! The year was 1978, more than 30 years ago.
The question of good surgical practice in regard to sleep deprivation and surgeon exhaustion has been around for a long time, and is certainly not a new phenomenon. Although objective data are nice to have, and may be confirmatory, they are not needed to resolve these issues – experience, common sense, and consideration for social responsibility are all that is needed.
A recent New England Journal of Medicine article (cited below) highlighted the issue of sleep deprived surgeons. It made the point that the working hours of medical residents in their first postgraduate year are restricted to a maximum of 16 hours of continuous work followed by a minimum of 8 hours off duty. There are no such regulations for fully trained physicians. The risks of operating on patients when sleep deprived can be compared to the risks of driving while intoxicated (DUI). In surgery, there is an 83% increase in the risk of complications (e.g., massive hemorrhage, organ injury, or wound failure) in patients who undergo elective daytime surgical procedures performed by attending surgeons who had less than a 6-hour opportunity for sleep during a previous on-call night.
The article recognizes that many patients would prefer to change surgeons or postpone elective surgery if they knew their surgeon was sleep deprived. Surgeons and hospitals may lose money when procedures are cancelled. However, the authors stressed the ethical obligation of surgeons to inform their patients of the risks, and the responsibilities of the hospital to enforce policies about not operating when sleep-impaired.
The NEJM article on this subject makes useful recommendations, but it could have gone further. The management of practice patterns is not only the domain of the individual surgeon, nor just for the profession to provide advice and guidance. Speaking as a surgeon, I believe we increasingly need senior hospital management and Boards of Directors of institutions to more fully face their social responsibility to act in the public interest. In an era when much professional behavior is shrouded in unnecessary and self-serving secrecy, it is essential for Boards of Directors to more fully accept that an important part of their role to society is on behalf of the community which they are required to serve.
If these premises are accepted, then Boards of Directors, through their senior management, should establish clear and unambiguous Standard Operating Procedures (SOPs) about the rules concerning “on-call” hours and associated clinical conduct. These must cover the common eventuality of physician sleep deprivation and exhaustion in regard to continuing clinical practice in general, and the needs of the operating room in particular. These conditions should form part of the contractual, and therefore legally binding, relationship between the surgeon, the institution and the patient.
Fixing the Problem
1. A surgeon who is on call for a hospital must not have on-call duty or patient clinical activity in another hospital for the total period involved.
2. A surgeon should not arrange elective surgery following a 24 hour on- call period.
3. A surgeon should not undertake elective surgery when, during the previous night, he/she has not had an appropriate period of rest (probably 6 hours – to be defined), or if, for any reason, the surgeon feels exhausted.
4. If there are circumstances in which sleep deprivation or exhaustion have occurred, and the surgeon feels the need to operate on an elective patient, the patient should be so informed. Both parties should be required to sign an informed consent document before surgery commences (as recommended in the NEJM article.)
5. A parallel set of standard operating procedures could be developed to consider the need for urgent/emergent surgical interventions when the surgeon is sleep deprived or exhausted.
Part of our professional responsibilities as surgeons is to make sure that we are all involved in “clinical outcome improvement.” Arranging for this surgeon performance issue to be addressed at individual, at professional, and at institutional levels would be a step in the right direction.
For those surgeons who are already conducting their clinical practice with these concerns in mind, there would be little to change. For the rest, patients and society need mandates for our protection.
For more information on sleep impairment see
Surgeon L. Peter Fielding, MD FACS FRCS received his medical degree from the University of London (with Honors) and Advanced Surgical Training in Gastrointestinal Surgery. He is a Fellow of the American College of Surgeons. He holds or has held senior academic appointments in the role of Clinical Professor of Surgery at Yale, Rochester, U Penn and Penn State Universities. He is experienced in medical staff credentialing, and the provision of medicalegal opinions. For over two decades, he has provided expert witness services for both plaintiff and defense attorneys.
A version of this article with specific guidance for patients appears in Avoid Medical Errors Magazine, Issue 3. Get your free digital subscription at www.avoidmedicalerrors.com.