Tired surgeons mind their p's and q's

Sleep-deprived surgeons may be no more likely than rested ones to make an error during an operation the next day, a new study suggests.

Canadian researchers found that patients having gallbladder surgery were not at increased risk of complications when their surgeon had handled an emergency operation overnight instead of getting a full night's rest.

The findings, reported in the Journal of the American Medical Association, come at a time when surgeons' work hours are under scrutiny.

There are already limits in the United States and on how many hours surgical residents (surgeons in training) can work.  There's also been calls to curb senior surgeons' hours -- one proposal is to bar them from scheduling an elective surgery on a day after they had been on call overnight.

Lead researcher Dr Christopher Vinden, a general surgeon at the London Health Sciences Centre Victoria Hospital in London, Ontario, said there were no new evidence to support that.

If anything, he said, "it seems like self-regulation is working."

Nothing routine

Vinden said surgeons who were truly too fatigued after an overnight case may cancel their elective surgery for the next day, But that, he pointed out, is only one potential explanation for the findings.

"What we know from the [research] on sleep deprivation is that mundane tasks seem to be the most affected," Vinden said.

"Surgery is not a mundane thing."

Dr Michael Zinner, surgeon-in-chief at Brigham and Women's Hospital in Boston, agreed. "There is nothing routine or monotonous about surgery," he said.

"Every patient is different and each case is unique."

Removals

Based on past studies, sleep deprivation does affect abilities like driving a car, noted Zinner, who co-wrote an editorial published with the study. "But," he said, "surgery is not like driving a car."

For the study, Vinden's team looked at billing records of 331 general surgeons at 102 community hospitals in Ontario. Those surgeons performed just more than 2 000 gallbladder removals on a day after they had operated overnight during a seven year period.

Vinden's team compared each surgeon's results with those of four other gallbladder removals he or she had done after a night off work and overall the researchers found no differences in complication rates.

Complication risks

Around 2% of patients had to be switched from minimally invasive "keyhole" surgery to an invasive, open surgery during the procedure -- whether their surgeon had operated the night before or not.  Less than 1% suffered some kind of injury that could be blamed on surgeon error -- like a puncture or cut in a blood vessel or nearby organ.

Vinden said his team focused on gallbladder removal because in the world of surgery, it's the closest thing to "mundane."

"It's the most common procedure that general surgeons do," Vinden said. If sleep deprivation were to boost patients' complication risks, he said, you would expect to see the effect in gallbladder removals.

Other, smaller studies have found no extra risks to patients when their surgeon worked the night before. "But none have been as well done, or as large, as this one," Zinner said.

He added that the study also focused on the "real rank-and-file" general surgeons who -- in Canada and the United States -- handle the bulk of all surgeries done each year.

Another surgeon

Zinner said he thinks the public "can feel comforted" by the findings of this and other studies. It's not even clear how often surgeons in this study were truly sleep-deprived -- they could've operated after midnight, then gone home and slept before doing a gallbladder removal the next afternoon.

And Zinner agreed with Vinden that there is likely some "self-regulation" going on: Fatigued surgeons do often tell their elective-surgery patient that they'll either have to delay the procedure or have another surgeon do it.

"I've done it," Zinner said. "It's part of the professionalism."

Both he and Vinden said that any laws curbing senior surgeons' hours would end up delaying many operations. In smaller community hospitals especially, Zinner noted, there are simply not enough surgeons.

More information

The US Agency for Healthcare Research and Quality has advice on making sure your surgery is safe.