Sleep deprivation adversely affects clinical performance and impairs psychomotor skills as severely as intoxication from alcohol. Yet, while the Accreditation Council for Graduate Medical Education revised regulations regarding work hours for residents, no such regulations exist for fully trained physicians.
Long shifts, long workweeks, sleep disorders, personal circumstances: All can contribute to fatigue from sleep deficiency. An article in the December edition of the New England Journal of Medicine, (NEJM) written by Michael Nurok, M.D., Ph.D.; Charles A. Czeisler, Ph.D., M.D.; and Lisa Soleymani Lehmann, M.D., Ph.D., suggests that such factors should be taken into account when an elective surgery is scheduled, to reduce the chance of acute sleep deprivation. For instance, elective surgery should not be scheduled the day after a surgeon has been on emergency overnight call, the authors suggest, particularly when the surgeon practices in a large, busy hospital where patient activity will require him to be awake most of the night.
Having a policy in place to require surgeons to inform their elective surgery patients that they are sleep deprived and giving them the option of rescheduling is important, the NEJM article says, because it takes the burden off of the physician to make the decision of whether or not to go ahead with the surgery. “When no policy exists to facilitate rescheduling or to prohibit sleep-deprived physicians from working,” the authors explain, “the burden of deciding to proceed with the operation or reschedule it largely falls to the treating clinician, who faces competing interests and may choose not to inform patients or engage them in the decision-making process.” Additionally, chronic sleep deprivation impairs one’s ability to recognize incapacitated functions due to sleep loss. Therefore, a surgeon may not be able to accurately recognize his own situation, making an official guideline mandating sleep guidelines and obtaining a patient’s informed consent on elective surgery even more practical.
However, in a letter to the editor in the same edition of NEMJ, Carlos A. Pellegrini, M.D.; L.D. Britt, M.D., M.P.H.; and David B. Hoyt, M.D., American College of Surgeons, Chicago, IL, disagree that a policy is warranted. Rather, the doctors suggest that surgeons should be properly trained to recognize and disclose their own impairments with patients. While they commend the article authors for their attempt to address the problem and generate conversation on the topic, Pellegrini and associates say, “we maintain that a call for mandatory disclosure essentially eliminates the necessary judgmental latitude surgeons should possess to determine their fitness for providing optimal patient care.”
Still, surveys do indicate that patients want to be informed, the article's authors insist. Up to 80% say they would request a different surgeon if they found out that their doctor had been awake for 24 hours.