In an NEJM perspective, the former president of the Sleep Research Society reports an 83% increase in the risk of surgical complications in patients undergoing elective daytime surgery performed by attending surgeons who had a <6-hour opportunity for sleep between procedures during a previous on-call night. He argues that physicians who have been awake for 22 of the previous 24 hours should be required to “inform their patients of the extent and potential safety impact of their sleep deprivation and to obtain consent from such patients prior to providing clinical care or performing any medical or surgical procedures.” The patients should then be given the choice of (1) proceeding with the surgery by the attending surgeon of record, (2) rescheduling it, or (3) proceeding with the surgery by a different surgeon.
No published studies have examined the influence of sleep deprivation on complication rates in interventionalists or electrophysiologists.
Is the effect of sleep deprivation on the quality of PCI or EP study a real (or perceived) problem?
When a patient undergoes elective PCI or EP study, should the cardiologist be required to inform the patient of the amount of sleep that he or she had the previous night?
Should invasive cardiologists be prohibited from performing procedures the day after being awake while on call?
Do you need to take a nap before answering these questions?
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The issues at hand here are complex. In the paper, the discussion circles around an elective procedure, which can be rescheduled or in theory be performed by another surgeon. Is this comparable to a diagnostic cath performed by a fellow and the answer in my view is “yes”. As fellows in the cath lab our skills are relatively transferrable to other fellows. But no one is going to tell a patient that they have been up all night and therefore may be at higher risk of causing a complication.
The issue becomes more complex when it comes to cases that are more subspecialised such as high risk intervention or complex VT ablation, which require a skilled and experienced operator. Are the risks of having a tired proceduralist who is very skilled in her area higher than having a novice with less experience but a good night’s sleep? And should these comparable risks be explained to the patients? But can patients even comprehend these? I think the answer to these questions is no.
acgme/IOM is working really hard to ensure 8 hour protected sleep time for interns-most of them likely of younger age and much better physical condition than their more senior attendings- whose responsibilities at worst are supervised by atleast 2 ‘filters’ of a senior resident and an attending supervising-not to mention hoards of pharmacists/nurses/ancillary and essential staff.But who is the safety net for a sleep deprived interventionalist??!!There are serous regulatory issues at stake here………….
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I think we ignore this data at our peril. It would be ignorant and arrogant of us to assume that our cath lab skills are anything different to a surgeon in the study when sleep deprived. In some countries that may mean more trips to court..
I agree with Saurav. As a non US cardiology fellow this was the first thing I thought when reading about your new hours regulations. You should learn from other country’s experiences +- mistakes.
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I’m a bit skeptical about intellectual bias with this type of research, as it all seems to be performed by experts in sleep medicine, who have much to gain by highlighting the potential issues with sleep deprivation. Having said that, common sense does tell us that procedural performance will suffer without enough rest.
What I am much less convinced about is that cognitive performance suffers enough to be clinically relevant with modest sleep deprivation. I also think the effects vary tremendously from person to person. Specifically I think we are prematurely implementing extreme work hour limitations on interns with the new ACGME rules. I have concerns the net effects of work hour restrictions will be negative rather than positive, particularly in the short term, because of
1) reduced in-hospital physician coverage
2) Interns moving to supervisory roles without sufficient clinical exposure
3) Creation of a physician work force that can’t handle the workload of practice and does not have the same level of professionalism.
In the end, I think it is an issue of professionalism for the individual practitioner. If sleep deprivation (or illness, family problems, or a myriad of other things) may have a negative effect on a procedure, the physician should be mature and professional enough to find a replacement unless it is an emergency.
Where to draw the line? I do not know our vasular surgeons’ perioperative stroke and mortality rate for CEA. I imagine a patient might want to know that. I do think the issue of sleep deprivation is key and warrants wider recognition, but not necessarily mandates. The major reference in the editorial is a retrospective study. I agree with above…its a professionalism issue. And how about caffeine and modafenil (approved for shift workers and used in the military)?
Please !
ON THE ISSUE OF CARDIOLOGISTS AND SLEEP DEPRIVATION:
At some point you HAVE to allow a professional to exercise reasonable judgement. Cardiologists, including interventionalists, are reasonable judges of their own abilities. If truly up “all night” and dog-tired due to a bunch of STEMIs, I have cancelled a case the next AM (or at the very least delayed it a few hours) in order to catch up on rest. What’s next, mandated bedtime for cardiologists? On a daily basis, I sleep at 12-1 am and get up at 6 am – not good enough? What time should I go to bed? 10pm? 11pm? How about mandating trips to the restroom (probably WILL improve procedural outcomes!?) Get my point!
ON THE ISSUE OF RESTRICTING TRAINEE HOURS:
Many years ago the UK moved their training model to bankers hours for their interns and residents (house officers and registrars is what they call them). The result was that patients would be seen in the ED by A, admitted to a sort of ED holding area by B, transferred to the ward and then clerked by C, and eventually discharged by D as “C” would be around only part of the time. As a consequence, trainees in the UK hardly ever see a patient from entry to the hospital (usually via the ED) all the way to discharge (or demise). There is no continuity of care. Patients admitted to the service are presented on rounds often by someone who did NOT do the inital clerking (so they’re reading off someone else’s H&P). Sometimes on rounds in the UK the Consultant (=attending) is the ONLY one who actually knows the patient! This could NEVER happen in the (old) American system. Furthermore, in the UK the introduction of “regulated’ hours has led to a new culture or attitude amongst trainees in which they view their apprenticeship as a job and all they want to do is “get it over with” and bolt. The culture of wanting to work to learn has gone down the drain. Don’t forget that the real strength of the American post graduate medical training was the intense high volume exposure. It is unfortunate to see that the US model is changing now and moving towards the British style. There is NO substitute for experience and trainees of the future are at risk of being undertrained. So far Asia has not adopted this change and hopefully won’t ever.
Disclaimer: I’m an FMG who trained the “old” way with loads of call and long hours. This is not an “in my day …….” rant just an honest opinion
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