“How do you stay awake?” I am often asked from friends outside the medical field upon explaining my schedule and frequent 24 hour call shifts. When asked this question, my replies run the gamut from, “You get used to it” to, “Coffee!” or, “I’m a surgeon, we don’t need sleep!” and finally, “You’re so busy most of the time that it keeps you awake.” My friends then try to console me by stating that at least the schedule will get better once I am an attending surgeon and finished with residency.
Unfortunately, this is not the case. As a resident, I am protected by rules regulated by the Accreditation Council for Graduate Medical Education (ACGME). After working a 24 hour shift, it is required that I go home and sleep with a mandatory 14 hour respite from the hospital. An attending surgeon, on the other hand, is not protected by these rules. He or she may be up all night operating for an emergent case, and then have a full day of clinic or surgery the following day.
Concerns have been raised regarding the safety of allowing surgeons to perform elective operations after being awake all night on call. There have been efforts to either prevent this or require surgeons to disclose this information to patients as part of the informed consent process. In fact, this was the thesis of a Perspective article in the NEJM in 2010 by Drs. Michael Nurok, Charles A. Czeisler, and Lisa Soleymani Lehmann (specialists in anesthesia, sleep medicine, and bioethics, respectively). Predictably, this did not go over well in the surgical community. While in theory, restricting attending surgeons’ ability to operate post-call may reduce complications, there are many financial and logistical ramifications of such a policy. Fortunately for surgeons, a large, multi-institutional study by Govindarajan et al. published in this week’s NEJM found no effect of sleep deprivation on elective daytime operations performed by attending surgeons.
Govindarajan et al. performed a retrospective 1:1 matched cohort study using information from multiple linked health databases in Ontario, Canada of patients undergoing 1 of 12 commonly performed elective operations (ranging from laparoscopic cholecystectomy to coronary artery bypass graft). Patients were placed into the “control group” or the “post-midnight” group (aka the “sleep deprived” group) based on whether their surgeon had a fee code identifying that he or she had had a physician-patient interaction between midnight and 7am the night prior to surgery. Surgical outcomes were compared between the two groups with focus on the primary outcomes of mortality, complications, and readmission within 30 days and secondary outcomes of length of stay and duration of surgery.
Nearly 40,000 patients were included, split evenly between the 2 groups, which were treated by about 1,500 physicians at close to 150 hospitals. In 71% of cases where a physician worked at some point from midnight to 7am, the treatment provided included a billable procedure. The authors found no significant difference in crude or adjusted rates of the primary outcomes (complications, death, or readmission) or secondary outcomes (length of stay or duration of operation). Stratification by hospital academic status, physician age, or procedure type did not affect outcomes. There was, however, a small, but significant, increase in complications in cases where the surgeon had performed 2 or more procedures the night before. No differences were found in the other outcome measures, though.
While this study does shed new light on this issue, there are some limitations inherent to the study. The authors cleverly used billing codes to identify overnight work performed by the surgeons. While this gives some idea of how much a surgeon may have worked overnight, it cannot tell us exactly how many hours a surgeon slept the night prior to surgery, in both groups. Additionally, there was a high level of experience in the physicians studied—a mean of 21 years in practice—which may bias results, although adjusted analysis and stratification did not find any differences.
So what does this mean for surgeons and patients? Deputy Editor, Dr. Mary Beth Hamel says, “Although the authors report reassuring evidence that patients’ surgical outcomes are not compromised when experienced attending physicians work during the night prior to operating, this study does not exclude an adverse effect of sleep loss on attending surgeons’ performance. It is possible that the surgeons compensated by making adjustments in their schedules for days following night work.” While this study surely adds new data to the ongoing discussion on sleep-deprived surgeons, it by no means puts the issue to rest (pun intended). Especially with ongoing review of ACGME resident duty hours, we are sure to see more studies of its kind in the future and with it more controversy.