Attending physicians who work too many hours need restrictions too

Dr. Lewis didn’t sleep last night.

All day he stood, heavy in full surgical scrub with a human heart in his hands, replacing damaged valves and calcified arteries until the heart beat on its own again. After he finished, there were a few hours before the transplant to get some dinner, to call home.

The heart came on a helicopter. A young man, a bad accident, a perfect heart. Dr. Lewis pierced the veins and the arteries and connected the sick dying man to the bypass machine that would pump and breathe for him in the time between the cooler arrived and the heart in the cooler started to beat inside the dying man’s chest.

They had to shock it a few times to get it going, but it beat with the vigor of a heart taken out of a young man’s chest. He finished in the morning when the day shift nurses arrived. He did a perfect job.

And then he decided to keep going. The surgical fellow, the scrub nurse, the physician’s assistant and the anesthesiologist all asked him to stop, to reschedule the case. But Dr. Lewis was in charge, and he wanted to keep going.

There are work hours rules for residents. A maximum of eighty hours per week and twenty-four hours at a time, with one day per week completely away from the hospital. When we are finished with residency, we make our own rules.

I thought about walking out, past the nurses’ station and the ladies’ restroom, past the anesthesiology office and the lunch room, out to the preoperative waiting area to Estelle Johnson, whose coronary arteries were going to be bypassed by Dr. Lewis.

“Mrs. Johnson,” I would say, “I’m here to tell you that Dr. Lewis has been awake and operating for twenty-four hours and I’d like you to decide if you would prefer to have this surgery today or if you would prefer to postpone it until Monday. Dr. Lewis will have the whole weekend off and will be well rested on Monday morning.”

“Monday,” she would say. “I’ll have the heart surgery on Monday.”

But I was sitting at a computer in the break room overhearing all of this, and I puzzled again at the ultrasound images of cardiac diastolic dysfunction on my screen. I sipped my coffee.

Dr. Lewis did a perfect job. Estelle Johnson’s coronary arteries run fast and smooth. Tonight he will sleep a deep and perfect sleep.

I imagine the worst things. When the bridge over the river is icy on the drive home I picture wrestling the kids out of their car seats after the car flies over the guardrail and drops into the frozen river. Cars honk at me when I crawl across the bridge, but the boys babble in the back seat and we haven’t gone over the guardrail yet. I imagine what Estelle’s husband dreamed about while she was on the operating room table.

He should have done it on Monday.

All the research has shown one thing: sleep-deprived doctors are bad doctors. Crises happen at all hours, so we will always need to be able to stay awake through the night, however painful. But as residents our hours are diligently recorded and after twenty-four hours we get kicked out of the hospital. Why not, then, for the man in charge?

Felicity Billings is an anesthesiology resident who blogs at One Case at a Time.

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  • http://skepticalscalpel.blogspot.com/ Skeptical Scalpel

    “All the research has shown one thing: sleep-deprived doctors are bad doctors.” This is simply not so.

    Two recent papers in major journals have shown just the opposite. There is no difference in outcomes of cardiac surgery and thoracic transplant surgery regardless of the amount of sleep the surgeon had. Here is the evidence http://is.gd/TBnRRI.

    • YokelRidesAgain

      “All of the research” has not demonstrated the stated result; moreover, virtually none of the research has done so. The majority of assessments of sleep deprivation on physician performance have been performed in resident populations; the most common outcome measures have been physiologic measurements (EEG and/or sleep latency tests), psychometric tests of cogntive performance, or subjective report. None of these outcome measures have been correlated with physician work performance in a clinical setting, much less patient outcomes. The state of research in this field is akin to approving a drug for human consumption based on changes in a laboratory parameter without measuring clinical outcomes.

      I am aware of a single study in which the overall rate of medical errors made by first year resident physicians was found to decrease with implementation of a shift work schedule vs. a traditional 24 hour call model. However, neither the rate of errors in decision making that were actually carried out (“non-intercepted errors”) nor patient adverse events was affected.

      I am aware of no other study showing a clinically meaningful effect of sleep deprivation on physician performance.

  • Dr L. Harvey

    This is what I’ve been fearing with restrictions in resident’s hours. The current generation of health care professionals are being trained to think of patient care as ‘shift work’.
    I’m sorry but patients do not get sick &/or require emergency care on a 12 hr day schedule. It has also been my experience, based on 30+ years of practice, that it’s almost impossible to ‘sign out’ the subtle signs you may be monitoring to make a determination of the appropriate care of the patient.
    While I agree that an impaired (from exhaustion or other reason) health care professional should be prevented from taking care of patients an arbitrary time limit is counterproductive to good patient care.

  • http://www.drdarrellwhite.com drdarrellwhite

    “…he did a perfect case.”

    Once upon a time the medical landscape was populated by Giants. Mostly men, they strode upon the Earth performing miracles, or so it seemed. Patients first and foremost, always. Lifestyle? Not so much. It was all about lives saved.

    We should be very, VERY careful in how we approach the giants (lower case purposeful) who remain, those fragile bridges to a time when doctors did not have jobs, they practiced a profession. We should be very careful not to legislate the best of those who remain out of this professional behavior, for once they are gone Dr. Lewis will be replaced at the table in the middle of the night by a pale substitute, there only because that is his shift.

    The Law of Unintended Consequences seeks not even the middle of the curve, but the lowest acceptable denominator. We, all of us, patient and colleague as well, will miss Dr. Lewis and his brothers (and few sisters) when we legislate them (and their all too few true successors) out of medicine.

    http://blog.skyvisioncenters.com/?p=78

  • http://www.drdoctormd.squarespace.com drdoctormd

    Dr. Lewis has block time on Fridays. He can’t get on the OR schedule Monday. It’d have to be an add-on. And you know how that scrub team hates adding hearts late on Mondays. Plus the hospital needs to send some people home because of CMS cuts and low inpatient volumes. And Mrs. Johnson’s son took a week off work to fly into town and has to be back next Wednesday.

  • http://hightechsurgeon.blogspot.com JF Sucher, MD FACS

    “All the research has shown one thing: sleep-deprived doctors are bad doctors.

    There is no research that shows outcomes for surgeons are different based on number of hours worked. This is significant, as there is a tremendous difference in what a surgeon does and how he/she does it than say, a radiologist. Performing an operation is a constant stimulus to the brain. It is unlike any activity that others do in medicine. Taking research from other medical fields and applying them to surgeons and their work is misleading.

    Apart from the lack of research, there is a more simplistic argument here.

    First, no surgeon wants to stay awake all night and all day. There are people to take care of, and frankly, pushing the work from one day to the next only snowballs to a point where your still working just as many hours trying to keep up with the volume of work that keeps coming.

    Second, there is no one else to do the work if you limit the surgeon. Does this not make sense? If there is X amount of work, and you limit surgeons to X minus Y-hours, then people will simply not get their operation and they will die.

    Third, there are only so many surgeons, and the population is growing. We have not graduated any more people in general surgery than we did in 1970. Couple that with the fact that surgeons are retiring at a faster rate than ever before. We are nearing a crisis in surgery.

    Finally, surgeons do not always get to pick the date and time of the operation. We work in a dynamic environment where emergencies arise on a daily (and nightly) basis. If you want to limit the surgeon’s work hours, be prepared to hear “I’m sorry Mrs. Smith, but the surgeon who can save Johnny’s life is over his work hours, it is too unsafe for him to operate”.

    I often wonder where this work limit idea should end? If you tell me I have to stop and go home because I will be too unsafe, then … won’t I be too unsafe to drive home? Should you get me a professional driver to shuttle me around? Maybe you should put a monitor on me and make sure that I had a good night of sleep. How else will you know if I am not too tired to come into work? (Guess what, a lot of us surgeons have families that keep us awake at night)…

    You will fail to make patients safer by simply limiting surgeon work hours. There aren’t enough surgeons to handle the current load. The gap in surgeon to patient volume is widening. Before limiting the hours, you will need to increase the numbers of surgeons being educated. You can’t put the cart in front of the horse.

  • Internist

    >>Performing an operation is a constant stimulus to the brain.>>

    No, much of surgery is muscle memory, with only occasional decisions, more in some specialties, less in others.

    Spoken like an internist, I know, but I also knew early on I didn’t want to spend my professional life among surgeons…

    • http://skepticalscalpel.blogspot.com/ Skeptical Scalpel

      Indeed spoken like an internist. You are mistaken. Many decisions are made before, during and after surgery. Although your comment is insulting, I am not going to insult you back. I will say that you obviously made the right career choice.

    • http://hightechsurgeon.blogspot.com JF Sucher, MD FACS

      To the anonymous “Internist”. Maybe you posted in jest. But you comment is not taken as such. And it does nothing to enlighten the readers of this post. But I am compelled to reply.

      First, anything that an anonymous individual posts is of no value, as you are unable to stand behind your comments as an individual or professional. Second, you are correct. You spoke, not only like an Internist, but also like one with little understanding. There is a significant difference in being the operating surgeon versus being a spectator. Muscle memory plays a role in maneuvers, but it does not obviate the need to know what to do and when to do it.

      Finally, your last statement stuns me: “I didn’t want to spend my professional life among surgeons…” That comes off as pompous. I can say that I very much enjoy my time and interaction with my medical colleagues.

      • Internist

        Your comment re: the way surgeons work vs. radiologists (and, presumably internists) is arrogant and insulting to those of us who work in the “thinking” specialties. This prevalent attitude informed my professional choices, despite my enjoyment of performing procedures and despite the blatant favoritism in reimbursement you enjoy.

        Fact: your brain isn’t working constantly while you’re performing surgery, much as you’d like to believe this to be true. For this reason – not because you’re Superman – you’re able to perform successful procedures while you’re sleep-deprived.

        • http://www.drdarrellwhite.com drdarrellwhite

          Do you have any research to prove your conjecture?

  • docguy

    Dr. Lewis would love to reschedule, but he has block time, and the next 3 blocks are full because no one wants to do hearts anymore because the ct surgeon is making less than everyone else in the room so when you reschedule it’s gonna be 3 weeks before you get done and then there might be some other emergency again as well.

    This is how you get to Canada where it’s a year to get a knee scope.

  • http://www.expeditingtheinevitable.com Linda Brodsky MD

    Would it be better to have a tired doctor than no doctor? Sometimes, maybe, but with the so-called physician shortage, many patients would be left waiting for that perfectly rested doctor that does not exist and will not exist as long as 50% of our time is spent on non-doctor tasks, ever increasing in our over-regulated medical world.
    As a surgeon of 30 years, I have learned to work well even when I have less sleep. Some people are able to do that, they become surgeons.
    On a final note, there are new specialties emerging which have people who take the night call, laborists, hospitalists, trauma specialists, acute care surgeons, etc. This might help to alleviate some of this problem.

  • http://Www.drdoctorMD.squarespace.com Drdoctormd

    There was a case a couple of years back against one of our surgeons who had a bile leak–a known complication–after a scheduled elective cholecystectomy. The plaintiff won a big award (something like a million) because it was revealed that the surgeon himself underwent a CABG three weeks later. The claim was that the patient had a right to know the physician’s impending medical condition and make an informed decision. Not exactly the same I know, but germaine, ie where do we draw the line? It is a slippery slope.

    I know there was an appeal, but I dont know the outcome.

  • http://www.mdwrites.com md

    Physicians should be restricted as to the number of hours they can work in a day or week. Safety should be a priority. Physicians who are working 80+ hours a week and getting 3 hours of sleep a night, will not only suffer in their decision making abilities, but will also begin to suffer from psychological problems over time. They may not even have insight into their problem. I do not know how this could be enforced, but it will likely reduce the number of mistakes made, and perhaps increase physicians enjoyment of the practice of medicine.