Editor’s note: The following is the second in a series of excerpts from Being Well and Staying Competent: Challenges for the Surgeon, a guidebook issued earlier this year by the Board of Governors’ Committee on Physician Competency and Health. The complete document is posted on the American College of Surgeons members-only Web portal at www.efacs.org.
To the best of the knowledge of the members of the Board of Governors of the American College of Surgeons (ACS), no surgeon has ever woken up in the morning thinking, “How can I harm a patient today?” Yet, as we look at the effects of sleep deprivation upon ourselves and upon our surgical colleagues, we may unwittingly be causing harm to the patients we serve. Historically, sleep deprivation among surgeons was not viewed as a serious problem; however, the topic has been receiving more serious consideration since 1988 in the aftermath of the 1984 Libby Zion case, which is discussed later in this article.
In years past, surgeons were taught to care for patients even if they had little sleep and were fatigued. Before the mandatory 80-hour residency workweek, surgical residents and attending surgeons were trained to ignore the effects of sleep deprivation and to care for their patient’s needs at the expense of obtaining renewing and invigorating sleep. Anecdotes and memories of physicians falling asleep during rounds or while driving home are well-known. For most surgeons, it has been a point of pride to be able to work long hours and still provide good care.
Over the last several decades, the effects of sleep deprivation have been studied in several nonmedical occupations and professions.1 Sleep deprivation-related impairments in cognitive and motor performance have been equated to alcohol intoxication in multiple studies showing 24 hours without sleep to be equivalent to a blood alcohol level of 0.1 percent, or the standard for legal intoxication.2 Additionally, evidence of the deleterious health effects of sleep deprivation continues to increase. Included in this ever-lengthening list are the enhanced risks of diabetes, impaired cognitive function and mood, weight gain, endocrine alterations, and so on. Sleep deprivation has been studied extensively among long-distance drivers and airline pilots; these studies have led to mandatory federal regulations and oversight limiting duty hours in those professions. Several major national and international catastrophes have been attributed to poor cognitive function in sleep-deprived workers, specifically the Three Mile Island and Chernobyl nuclear power plant catastrophes, as well as the space shuttle Challenger disaster.3
The effects of sleep deprivation upon health care professionals were essentially ignored until “the Libby Zion case in 1984 triggered the formation of a commission to investigate supervision and work hours of residents in New York hospitals.”4 This particular medical catastrophe resulted in New York State guidelines and subsequent Accreditation Council for Graduate Medical Education (ACGME) requirements for medical and surgical house staff work hours and rest periods. These ACGME limits were subsequently revised and made more restrictive in 2011 (see table).1 The work-hour limits were mandated after significant study looking at the effects (or lack thereof) of sleep deprivation upon medical and surgical residents in the U.S.5-10
|Types of duty-hours limits||2003 ACGME limits||2011 ACGME limits|
|Maximum hours of work per week||80 hours averaged over 4 weeks||No change|
|Maximum shift length||30 hours, with 24 hours for admitting new patients and then 6 hours to complete work, transfer care and education||PGY-1: 16 hours
PGY2+: 28 hours; 24 hours for new admissions; 4 hrs to complete work, transfers and education; strategic napping strongly suggested
|Maximum inhospital on call frequency||Every third night, on average||Every third night, on average|
|Minimum time off between scheduled shifts||10 hours||8 hours mandatory (10 suggested)
14 hours after 24-hour shift
|Maximum frequency of inhospital night shifts||Not addressed||Maximum 6 consecutive nights on night float|
|Moonlighting||Internal moonlighting counted in 80 hours||All moonlighting counted in 80 hours
PGY-1 not allowed to moonlight
|Limit on hours for exceptions||88 hours for select programs with educational rationale||No change|
Although this article focuses on the effects of sleep deprivation on the practicing surgeon, not surgical residents, the ACGME work-hour restrictions are worth mentioning to frame the issue in a historical context. It is counterintuitive to think that attending surgeons are any less susceptible to the negative consequences of sleep deprivation than surgeons in training. Therefore, it is surprising that few studies have been conducted to evaluate the results of sleep deprivation on attending surgeons.11 The effects on judgment, mood, hand-eye coordination, and so on are equally likely to affect the practicing surgeon as the resident surgeon. Most studies analyzing technical performance of surgical skills have demonstrated more errors, longer times for task completion, and less efficiency in using instruments when a surgeon has gotten too little sleep. In fact, it is arguable that as the practicing surgeon ages, the effects of sleep deprivation may be more pronounced.
More study needed
Although anecdotal reports exist of fatigued health care workers causing specific harm to patients, most often these incidents have been viewed as isolated events that are not reflective of a widespread problem within the health care system.12 In late 2002, an article by Gaba and colleagues in The New England Journal of Medicine contrasted and compared the effects of sleep deprivation and the potential harm to patients between resident physicians and attending clinicians. Even in this study, it was noted that “no study has proved that fatigue on the part of healthcare personnel causes errors that harm patients.”13 Moreover, a subsequent 2009 article addressing operative complications in both the surgical and obstetrical disciplines demonstrated that “procedures performed the day after attending surgeons and obstetricians/gynecologists worked at some point during the night were not associated with significantly increased complication rates compared with control cases that were not preceded by nighttime work.”14
Although the surgical literature contains minimal reference to actual objective complications occurring as a result of sleep deprivation among practicing surgeons, perhaps more surprising is the paucity of information pertaining to the effects of fatigue on surgical judgment. Understandably, no objective measuring tools are available to evaluate surgical judgment when the surgeon is well-rested versus sleep-deprived. Clinical judgment is a subtle skill, and fatigue may contribute to errors in interpretation of radiologic studies or perhaps a decision to delay operative intervention rather than immediately take the patient to the operating room. Further, in the present system, any effects of fatigue that result in bad outcomes would be self-reported.
Gaba and colleagues also note the lack of pressure from “market forces to address the issue of fatigue among clinicians.” The authors state, “The problem of fatigue-related risks in medicine will not be solved simply by limiting residents’ work hours. A comprehensive strategy should include changes in organizational culture and operational safeguards, as well as provisions for ensuring that the workload of clinicians is acceptable. Although residents have been the focus of the debate, the strategy should ultimately apply to experienced clinicians as well, especially since older persons are more likely than younger persons to be adversely affected by sleep deprivation.”13
With the ongoing changes in market forces (more employed clinicians, decreasing reimbursement, increased patient expectations, and mandates for comprehensive use of the electronic health record) health care systems and hospitals currently have no incentive to limit surgical clinicians’ work hours. Many hospitals and many surgeons have left the issue of sleep deprivation to the individual surgeon. However, the individual surgeon may be conflicted and unable to rationally evaluate his or her level of sleep deprivation. Indeed, “competing interests…self-image, peer pressure, and financial pressure…can be difficult to weigh in a state of fatigue.”15
Other authors have suggested that the patient should make the decision as to whether a surgeon “without adequate sleep” should perform an elective scheduled procedure the day after that surgeon has been on call.16-18 Some leaders of the ACS rightfully question whether each and every patient scheduled for surgery can make an informed decision on the day of surgery as to whether the surgeon is capable of proceeding with the proposed procedure after being up all night caring for other patients. As with the surgeon, multiple competing factors (scheduled work time off, child care arrangements, financial issues, and so on) may color the surgical patient’s judgment.15
Systematic approach needed
Fatigue-related risks of harm to the surgical patient will not be eradicated by simply limiting surgeons’ work hours or by leaving this issue to the individual surgeon, who may be incapable of making a rational decision in a fatigued state and, although there may be exceptions, generally, the individual patient should not be placed in the position of deciding whether to proceed with surgery under circumstances that are out of his or her control. Rather, a coordinated and systematic approach to the issue of surgical sleep deprivation will provide the best set of safeguards for the surgical patient. This line of attack should include the individual surgeon, the surgical department, the medical staff, and the hospital administration. Furthermore, given the regional variations of surgical practice within our country, solutions to the issue of sleep-deprived surgeons should be adaptable to the institutional needs and constraints.
The following guidelines are intended to be general and adaptable to the various models of surgical practices in all communities. However, the goal is to address and reform potentially unsafe work practices and to safeguard the surgical patient as well as protect the individual surgeon’s well-being. Enforcement of these practices should be a cooperative non-punitive effort between the individual surgeon, the surgical department, the medical staff, and the hospital administration.
Hospital administration: Whereas the hospital administration has the authority and the responsibility to provide a safe environment for both the surgical patient and for all surgical health care workers within their institution, it should provide an objective means to evaluate each surgeon’s level of sleep deprivation, depending on the situational circumstances. The hospital and the operating room nurse manager should institute a method of identifying significant sleep deprivation among operating surgeons. Although this method will vary depending on the clinical situation, it should ensure that a surgeon performing elective surgery has had, at a minimum, four hours of uninterrupted sleep before commencing elective surgery. Furthermore, the hospital should establish operational safeguards to prevent a fatigued surgeon from commencing surgery and mandating that the operation be delayed or rescheduled.
If an elective operative procedure must be delayed, it should be rescheduled as soon as possible to minimize the inconvenience to the patient, the patient’s family, and the operating surgeon. Ideally, a prospectively established mechanism agreed to by each individual member of the department of surgery, the chief of surgery, and the hospital administration should be in place to ensure that the surgical procedure is performed as soon as possible after the original delay. Furthermore, the surgeon should not be penalized for postponement of a case due to fatigue.
If a fatigued surgeon, either self-reported or identified by the operating room staff, is asked to perform an emergent procedure, a prospectively established procedure should be in place to rapidly provide a replacement surgeon. The specifics of such an organizational mechanism for surgeon replacement will vary depending upon the needs of each community. However, the details of surgeon replacement should be determined before an actual event and not in the middle of the night (or on a weekend) when a patient is waiting for an emergency procedure. Undoubtedly, such a mechanism will require input from hospital administration, the surgical department, and the individual surgeon.
Medical staff: As part of the medical staff bylaws and the medical staff rules and regulations, each medical staff should establish a limit on surgical work hours commensurate with the surgical needs of that community and hospital, while maintaining patient safety. This should include an acceptable workload for the practicing surgeons and a reasonable amount of night call. Limitations on length of on-call duty should be dictated by the medical staff to protect the health of the surgeon and the patient. Also included in the rules and regulations should be operational standards regarding “hand-off” communication between on-call surgical physicians.
Surgical department: The surgical department, working with the medical staff, should establish the policies and procedures to ensure adequate surgical staffing and reasonable patient caseloads. Further, where possible, guidelines should be in place regarding taking call the night before undertaking an elective surgical schedule. (This expectation has far-reaching implications for the hospital and for the clinicians and must be individualized for each hospital/community.) The surgical department should establish mechanisms for ensuring that additional surgical clinicians can be made available to a sleep-deprived surgeon.
Individual surgeon: “Individual surgeons should be trained in evaluating their own level of sleep deprivation as a component of providing excellent patient care.”15To this end, each attending surgeon should undergo mandatory sleep deprivation training to better understand the insidious and harmful effects upon the neurocognitive and fine motor capabilities of every individual, particularly a surgeon. It is also important that each surgeon have an understanding of fatigue management and strategies to address exhaustion on a personal level (see figure). Furthermore, because all but one of the methods of measuring sleepiness are subjective and the objective measurement tools are not practical for clinical measurement of sleep deprivation effects, each surgeon must be able to evaluate his or her capacity to safely and effectively complete a surgical procedure.
While further study is indicated to evaluate the scope of sleep deprivation among surgeons and potential harm to surgical patients, the surgical community must assume the responsibility for reforming surgical attitudes and surgical work practices “…so that exhaustion is considered as posing an unacceptable risk [to both patient and surgeon] rather than as a sign of dedication.”13 This cultural change in surgical practice will have far-reaching consequences. However, without self-remediation it is foreseeable that additional governmental regulation will be imposed upon the surgical community, just as it has been upon pilots, long-distance truck drivers, and surgical residents.
As mentioned previously, because of situational and geographical differences, the guidelines need to be broad and variable. What may be right for a well-staffed regional hospital may be inapplicable to a small critical access hospital in a rural, remote area during the winter. Situational and geographical circumstances will need to be addressed by each institution. One size doesn’t fit all. But what is applicable to all institutions is that the issue of sleep deprivation needs to be addressed prospectively during the light of day with all parties present at the table, not in the middle of the night on a weekend when a crisis occurs.
- Durmer JS, Dinges DF. Neurocognitive Consequences of Sleep Deprivation. Semin Neurol. 2005;25(1):117-129.
- Williamson AM, Feyer AM. Moderate sleep deprivation produces impairments in cognitive and motor performance equivalent to legally prescribed levels of alcohol intoxication. Occup Environ Med. 2000;57(10):649-655.
- Mitler MM, Carskadon MA, Czeisler CA, Dement WC, Dinges DF, Graeber RC. Catastrophes, sleep, and public policy: Consensus report. Sleep. 1988;11(1):100-109.
- Robins NS. The Girl Who Died Twice: Every Patient’s Nightmare: The Libby Zion Case and the Hidden Hazards of Hospitals. New York: Delacorte Press; 1995.
- Reznick RK, Folse JR. Effect of sleep deprivation on the performance of surgical residents. Am J of Surg. 1987;154(5):520-525.
- Bartle EJ, Sun JH, Thompson L, Light AI, McCool C, Heaton S. The effects of acute sleep deprivation during residency training. Surgery. 1988;104(2):311-316.
- Eastridge B, Hamilton EC, O’Keefe GE, et al. Effect of sleep deprivation on the performance of simulated laparoscopic surgical skill. Am J Surg. 2003;186:169-174.
- Ellman PI, Kron IL, Alvis JS, Tache-Leon C, Maxey TS, Reece TB, Peeler BB, Kern JA, Tribble CG. Acute sleep deprivation in the thoracic surgical resident does not affect operative outcomes. Ann Thorac Surg. 2005;80(1):60-65.
- Ayalon RD, Friedman F. The effect of sleep deprivation on fine motor coordination in obstetrics and gynecology residents. Am J Obstetrics and Gynecology. 2008;199(5):576.
- Philibert I. Sleep loss and performance in residence and non-physicians: Meta-analytic examination. Sleep. 2005; 28(11):1392-1402.
- Ellman PI, Law MG, Tache-Leon C, Reece TB, Maxey TS, Peeler BB, Kern JA, Tribble CG, Kron IL. Sleep deprivation does not affect operative results in cardiac surgery. Ann Thor Surg. 2004;78(3):906-911.
- Glickman RM. House-staff training—the need for careful reform. N Eng J Med. 1988;318(12):780-782.
- Gaba DM, Howard SK. Patient safety: Fatigue among clinicians and the safety of patients. N Eng J Med. 2002;347(16):1249-1255.
- Rothschild, JM, Keohane, CA, Rogers, S, Gardner R, Lipsitz SR, Salzberg CA, Yu T, Yoon CS, Williams DH, Wien MF, Czeisler CA, Bates DW, Landrigan CP. Risks of complications by attending physicians after performing nighttime procedures. JAMA. 2009;302(14):1565-1572.
- Keune JD, Kodner IJ, Healy GB. Disclosing sleep: An ethical challenge. Bull Am Coll Surg. 2011;96(6):20-21.
- Nurok M, Czeisler CA, Lehmann LS. Sleep deprivation, elective surgical procedures, and informed consent. N Eng J Med. 2010;363(27):2577-2579.
- Kahol K, Leyba MJ, Deka M, Deka V, Mayes S, Smith M, Ferrara JJ, Panchanathan S. Effect of fatigue on psychomotor and cognitive skills. Am J Surg. 2008;195(2):195-204.
- Gerdes J, Kahol K, Smith M, Leyba MJ, Ferrara JJ. Jack Barney award: The effect of fatigue on cognitive and psychomotor skills of trauma residents and attending surgeons. Am J Surg. 2008;196(6):813-819.