In a recent New England Journal of Medicine, a perspective piece on what to do with fatigued surgeons is generating debate.
The issue of work-hour restrictions has been a controversial issue when it comes to doctors in training, something that I wrote about earlier in the year in USA Today. But once doctors graduate and practice in the real world, there are no rules.
As summarized in the WSJ’s Health Blog, the perspective piece argues for more regulation for tired surgeons:
… self-regulation is not sufficient. Instead, “we recommend that institutions implement policies to minimize the likelihood of sleep deprivation before a clinician performs elective surgery and to facilitate priority rescheduling of elective procedures when a clinician is sleep-deprived,” they write. For example, elective procedures wouldn’t be scheduled for the day after a physician is due to be on all-night call.
And the authors suggest that patients be “empowered to inquire about the amount of sleep their clinicians have had the night before such procedures.”
It’s a noble goal, and indeed, data does show that fatigued surgeons tend to make more errors. Patients, once confronted with a choice of being operated on by a tired surgeon, may choose to postpone surgery.
The counter-arguments, predictably, from the American College of Surgeons, also raise come compelling points:
… surgeons are smart and professional enough to learn to “have a conversation with yourself” when they are short on sleep and assess their preparedness for surgery. Or, they can consult other members of the surgical team for guidance, he says.
“No one wants an exhausted surgeon to operate,” says Britt. But he says there’s no clear-cut way to define fatigue, and that “mandatory disclosure” based on some arbitrary threshold isn’t appropriate. If doctors are supposed to disclose their sleep patterns, what about other things that might affect performance, such as financial worries or a fight with a spouse?
Whether surgeons can self-police their own tiredness is debatable, but I can see merit in the slippery slope argument. In addition to the concerns raised above regarding a surgeon’s financial and marital stresses, should we also ask critical care physicians or hospitalists to disclose their fatigue? After all, there are studies that also show an increase in medical errors in the intensive care unit when these doctors are fatigued. Should patients be allowed to refuse care from a tired intensivist as well?
And finally, if tired physicians aren’t allowed to operate, who’s going to pick up the slack? Already, there’s a shortage of general surgeons, and the effect of these regulations will only extend wait times.
Of course, everyone wants to reduce medical error. And it’s reasonable to start with combating fatigue. Doing so, however, requires more doctors who can take over for their tired colleagues.
And that’s going to cost more money, which is a fact that’s conveniently excluded from the discussion.