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 The odds of having a surgery-related problem were 22.2 percent when
the doctor had been treating patients between midnight and 7 a.m.
and 22.4 percent when the doctor had, presumably, received
sufficient sleep.
The senior author of the study, Dr. Nancy Baxter of the University
of Toronto, told Reuters Health in a telephone interview that the
new results argue against proposals calling for doctors to inform
their patients if they are sleep-deprived.
But the study didn't directly measure how much sleep the doctors
actually received, said Dr. Charles Czeisler, chief of the division
of sleep and circadian disorders at Brigham and Women's Hospital in
Boston. He was not connected with the research.
According a 2009 study that he and his colleagues published in the
Journal of the American Medical Association (JAMA), once the actual
amount of sleep is taken into consideration, the odds of a serious
mistake nearly triple.
"Given the increased risk that we've seen with just one night of
insufficient sleep, patients have the right to know if their doctor
has been awake for one night, two nights, or even three consecutive
nights," he told Reuters Health by phone.
The Baxter study, released Wednesday in The New England Journal of
Medicine, was based on data from 147 hospitals in Ontario. It looked
at nearly 39,000 cases performed by 1,448 experienced surgeons.
The researchers tracked 12 widely-varying types of operations, from
bypass surgery and hip replacement to hysterectomy and angioplasty,
done during a five-year period. A billing code database told them
whether the doctor had worked from midnight to 7 a.m. the night
before the operation.
Thirty days after surgery, the odds of death were 1.1 percent
whether or not the doctor had worked during the early morning hours
before the operation. The readmission rates were 6.6 percent if the
surgeon had been up late and 7.1 percent if he or she had not. The
30-day complication rate was 18.1 percent in the overnight group and
18.2 percent when overnight work was not a factor. In both groups,
half the patients went home in three days or less.
The type of hospital, the doctor's age and the type of operation
made no difference.
Czeisler said he and his colleagues reported similar results in
their 2009 study of 4,471 cases, which is online here: http://bit.ly/1NBkEkv.
But simply looking at whether a doctor did any work overnight
doesn't tell you if the physician was actually sleep deprived, he
said. For example, an hour-long procedure might be done at midnight
and the doctor may not have to be back at work until late the next
morning.
So in their JAMA study, the Czeisler team went further. They
calculated the actual time between the overnight procedure and the
morning procedure.
When the doctor had only six hours or less to sleep, the
complication rate was 170 percent higher than when the doctor had
the opportunity to sleep more than six hours.
He said the Baxter study didn't go far enough because, "If you don't
know if the person is sleep deprived, you can't evaluate it."
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He also faulted the study for assuming that doctors who worked
anytime from midnight to 7 a.m. hadn't received a full night's
sleep. Surgeons often start their day before seven.
"Physicians who have started their procedure at 6:30 in the morning
would be placed in that sleep-deprived group" when they probably
don't belong there, Dr. Czeisler said.
Baxter, in a follow-up email, acknowledged that "we do not know how
much sleep was lost. However we looked at the subgroup of
individuals who performed at least two procedures overnight,
assuming they were up for most of the night, and still did not see a
consistent signal - certainly nothing like the effect found by the
JAMA study."
"The JAMA study was in a single institution and included only a
small number of patients and providers. It is possible that the
findings were due to chance alone," she said. Alternatively, the
doctors in the JAMA study might not have had the flexibility to
changes their schedules to avoid sleep deprivation.
Baxter, who is chief of the division of general surgery at St.
Michael's Hospital in Toronto, said lack of sleep may not have had
an effect because experienced surgeons know how to pace themselves,
their experience lets them do an adequate job even when they're
tired, and "surgeons tend to be people who deal better with lack of
sleep than other physicians" thanks to self-selection.
But the findings should not be considered by doctors to be a license
to work without proper rest, she said. "I don't want people to take
from this the idea that this is open season on being on call and
operating the next day without self-regulation being in place,
without understanding your abilities, and potentially canceling
cases if you're that tired," she said.
As for patients who might be concerned if their surgeon was up the
night before, Baxter said. "It's probably something they don't need
to worry about."
Said Czeisler: "They're talking about sleep deprivation without
having determined if these doctors were sleep deprived."
SOURCES: http://bit.ly/1U6sAZU The New England Journal of Medicine,
online August 26, 2015.
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