Exploring the limits of surgeon disclosure: Where are the boundaries? First-place essay—Pro

A 68-year-old woman has just arrived in the preoperative area for her elective sigmoidectomy. Recently diagnosed with adenocarcinoma of the sigmoid colon, she is eager to complete her surgical resection and adjuvant chemotherapy and return to her daily activities of gardening and reading without worry. She has been anxious for weeks about her surgery, given that it will be her first major operation. Although you are a surgeon, you share her apprehension equally because this particular patient is your mother.

Because you are a well-respected surgeon, your mother asked you to review her records, attend her clinic visits, and accompany her to the hospital on the day of her surgery. When you picked her up from your childhood home early this morning, she was understandably nervous. You reassured her that she is in the capable hands of your esteemed surgical colleagues. The nurse and anesthesiologist complete their preoperative duties and checklists, and the operating room is staffed and prepared for the 7:30 am start. The surgical resident introduces himself, and mentions to you that the case will be delayed for 30 minutes. You inquire as to why, since everything seems to be ready. The resident informs you that the attending surgeon was on call overnight and is wrapping up the second emergent case of the evening. As you thank the resident for his assistance in your mother’s care, you privately wonder just how tired your surgical colleague is given the previous evening’s caseload.

Effects of sleep deprivation

Sleep deprivation is one of many variables that may limit a surgeon’s ability to provide optimal care. The profession has historically encouraged each surgeon to make their own determination about their capacity to operate, as advocated for in a 2010 letter to the editor written by College leaders and published in the New England Journal of Medicine.1 Whether the surgeon is incapable of performing the indicated surgery due to ill health, intoxication, unfamiliarity with the surgical technique, or any other reason, the patient should be informed. Respect for the patient’s autonomy, the edict primum non nocere, and the desire to improve the patient’s health implore the surgeon to disclose these personal limitations. The authors of the 2010 letter to the editor noted “…the root of the problem…is a lack of awareness about our human limitations,” though they did not believe mandatory disclosure to be the solution.1 However, without mandatory disclosure, the admirable professional traits of optimism, confidence, and determination will overwhelm the aspiration to fully complete the consent process via voluntary disclosure.

Yet, how easily can a surgeon deal with the repercussions of this disclosure? What options are available for the sleep-deprived surgeon scheduled to perform your mother’s sigmoidectomy? There is no standard, institutionalized process to deal with mandatory or voluntary disclosure of sleep deprivation. To improve outcomes, the surgical profession must recognize that sleep deprivation harms patient care, is an issue that affects informed consent, and requires systemic changes to accommodate the effects of mandatory disclosure.

Sleep deprivation affects surgeon performance as it affects all people—by impairing motor performance and cognitive performance.2 Drivers who slept less than six hours the previous night were 10 times more likely to be involved in a vehicle crash.3 The performance of fighter pilots, who are trained extensively to execute tasks reflexively, suffers from sleep deprivation.4

Though difficult to admit for some, surgeons also are human and suffer from performance deficits secondary to sleep deprivation. Sleep loss leads to a reduction in resident physician performance, and an increase in perioperative complications.5,6 Conflicting evidence from large retrospective reviews show that the science is not settled, and randomized trials are needed.7,8 Nevertheless, in light of recent evidence that medical errors are the third-leading cause of death in the U.S., surgeons can improve quality by reducing errors due to sleep deprivation.9 The stakes are too high to wait until further research confirms these preliminary findings. Recognizing that sleep deprivation affects performance and could affect patient outcomes, even slightly, is the first step.

Informing the patient

After acknowledging that surgeon sleep deprivation could endanger patients, our duty is then to inform patients of this risk factor. The informed consent procedure is a hallowed process, more intricate than a simple contract. It is one aspect of a fluid discussion where the surgeon describes the patient’s disease or injury, the medical and surgical treatments considered, and the potential risks and benefits for that particular patient.

Yet, are we truly informing the patient of all the risks of surgery? Are all the ramifications that affect this sacred opportunity to operate on another person being discussed? A simple categorization of the variables affecting postoperative outcomes could be divided into “patient factors” and “health care factors.” As part of the informed discussion, the patient learns about the risks associated with their comorbidities and the steps taken to reduce those risks. Health care factors are varied and difficult to alter, and they are more challenging to explain as part of an informed consent. Even the definition of sleep deprivation is ethereal and differs from surgeon to surgeon or patient to patient. However, the number of hours that a surgeon has slept in a 24-hour period or the number of sleep interruptions during the night are quantifiable. If it can be calculated, and its effect on patient care can be placed into the proper context, then it must be disclosed.

The precise definitions, mechanisms, and recommendations of disclosure will not be delineated here. Rather, the surgical community needs to conduct an honest and thoughtful critical analysis of how to achieve the goal of informed consent as it pertains to the provision of health care by surgeons. The debate should not center on whether the surgeon should inform the patient, but instead on how to integrate the disclosure into the surgeon’s schedule. Surgical societies have a duty to draft  consensus statements supporting and outlining the details of mandatory disclosure. If we don’t create the process, then the terms will be foisted upon us by a well-meaning but inexperienced populace supported by nonsurgical groups.10

The deliberation over the specific mechanisms surrounding mandatory disclosure of sleep deprivation does not nullify the requirement to disclose this information. Adherence to the principles of beneficence, non-maleficence, and autonomy should not be contingent upon the creation of policies and plans to deal with the consequences of the disclosure.

As your mother waits to speak with the surgeon and sign the consent form, you think about the amount of sleep deprivation your colleague has sustained. Will this fatigue cause even minor complications? You begin to wonder what systemic changes could make this situation more tenable for you, your surgical colleagues, and your patients.


References

  1. Pellegrini CA, Britt LD, Hoyt DB. Sleep deprivation and elective surgery. N Engl J Med. 2010;363:2672-2673.
  2. Van Dongen HP, Maislin G, Mullington JM, Dinges DF. The cumulative cost of additional wakefulness: Dose-response effects on neurobehavioral functions and sleep physiology from chronic sleep restriction and total sleep deprivation. Sleep. 2003;26(2):117-126.
  3. Stutts JC, Wilkins JW, Vaughn BV. Why do people have drowsy driving crashes? Input from drivers who just did. November 1999. Available at: www.aaafoundation.org/sites/default/files/sleep.PDF. Accessed September 12, 2016.
  4. Caldwell JA, Mu Q, Smith JK, et al. Are individual differences in fatigue vulnerability related to baseline differences in cortical activation? Behav Neurosci. 2005;119(3):694-707.
  5. Philibert I. Sleep loss and performance in residents and nonphysicians: A meta-analytic examination. Sleep. 2005; 28(11):1392-1402.
  6. Rothschild JM, Keohane CA, Rogers S, et al. Risks of complications by attending physicians after performing nighttime procedures. JAMA. 2009;302(14):1565-1572.
  7. Vinden C, Nash DM, Rangrej J, et al. Complications of daytime elective laparoscopic cholecystectomies performed by surgeons who operated the night before. JAMA. 2013;310(17):1837-1841.
  8. Govindarajan A, Urbach DR, Kumar M, et al. Outcomes of daytime procedures performed by attending surgeons after night work. N Engl J Med. 2015;373:845-853.
  9. Makary MA, Daniel M. Medical error—the third leading cause of death in the U.S. BMJ. 2016;353:i2139.
  10. Nurok M, Czeisler CA, Lehmann LS. Sleep deprivation, elective surgical procedures, and informed consent. N Engl J Med. 2010;363:2577-2579.

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