Toronto surgeon Nancy Baxter says the rise of a team-based culture has changed how doctors work since she was in training.Kevin Van Paassen/The Globe and Mail
Patients having elective surgery during the day fare no better or worse if the doctor operating has worked the night before, according to new Canadian research that followed the outcomes in nearly 39,000 cases.
The research, based on billing data from close to 1,500 Ontario doctors over a five-year period, tracked similar patients who had the same procedure conducted by the same attending physician, with and without a night off to rest. It found the risk of adverse outcomes from the daytime surgery was similar, even if the doctor had treated patients between midnight and 7 a.m. the night before.
The findings are in the Aug. 27 issue of the New England Journal of Medicine and is the latest chapter in a decades-long debate over doctor fatigue and the effects that round-the-clock demands have on patient safety.
Nancy Baxter, the chief of general surgery at Toronto's St. Michael's Hospital and a senior researcher on the study, said the findings do not discount the effect that sleep deprivation can have on performance. Instead, she said they show physicians are finding ways – either through scheduling or monitoring their performance – to respond to the need for emergency care without negatively affecting patients.
"This shows that by and large we have gotten the balance right," Dr. Baxter said.
The study is unique, she said, because it compares "apples to apples," matching outcomes of surgeries by the same doctor – the only variable being whether the surgeon had a night off before. It compared results across 147 Ontario hospitals, both academic and non-academic, and found little variation in patient outcomes 30 days after surgery across a range of 12 procedures.
Dr. Baxter argues the results show there is no need to regulate physicians' work hours or compel them to disclose to patients that they have gone without sleep as part of the consent process before an operation.
Charles Czeisler, a leading U.S. sleep researcher who has long called for such measures, says these latest findings do not change his perspective. By looking only at whether a doctor has treated patients during a seven-hour period the night before, Dr. Czeisler said there is no way of knowing how much sleep that physician has managed to get. A surgeon who comes in to operate at 5 a.m., he said, and then moves on to do elective day surgeries is much different than one who has been up for 24 hours before working a day shift.
"The only way to get at this is to find out how much that doctor is sleeping," said Dr. Czeisler, chief of the sleep and circadian disorders division of Boston's Brigham & Women's Hospital.
Dr. Czeisler says the Canadian findings replicate those of a 2009 study that found complication rates were not significantly increased for procedures performed by attending physicians who worked at some point the previous night. But that same study, he noted, found complications did increase in cases where doctors did not have a six-hour break to sleep.
Dr. Baxter said there are limitations to the new study, conducted for the Institute for Clinical Evaluative Sciences, but pointed out the results were only slightly increased for those doctors who performed two or more procedures the night before – a measure the researchers used to indicate what they describe as "more profound sleep loss."
Dr. Baxter – who remembers nodding off while standing in the operating room as a young resident – said much has changed since the early 1990s, when she was in training, to address the issue of chronic doctor fatigue caused by extended periods without breaks for proper rest. And unlike medical students, the attending physicians in this study, she said, are likely to have greater control of their schedule and can minimize the times they work night and day shifts back to back.
In her own case, Dr. Baxter says she schedules elective surgeries on Wednesdays and usually takes her on-call shift Thursdays.
The answer to concerns about doctor fatigue is not regulation, she argues, but a more team-based culture. As a physician, she said, "you should be able to call on colleagues if you are feeling you are at the end of your rope."
Najma Ahmed, a trauma surgeon and director of the residency program at the University of Toronto medical school, says surgeons rarely are alone in the operating room and there are many checks on patient safety.
That said, Dr. Ahmed argues surgeons often are required to do their jobs under duress and their long, arduous training prepares them to function in a professional manner under such circumstances.