Dr. Michael Nurok, co-author of the widely discussed editorial 'Going Under the Knife for Elective Surgery: Is your Surgeon well-rested?', written for the New England Journal of Medicine, recommends that more responsibility be in the hands of patients by asking whether a surgeon is sleep-deprived.
Doctors who are on-call and awake all night working should inform daytime elective surgery patients of their sleep-deprived status, an article in a prestigious medical journal says.
These surgeons should have informed, written consent from the patient before proceeding with the operation, argues the perspective piece published in this week's New England Journal of Medicine.
Co-author Dr. Michael Nurok said there's a general assumption that physicians will care for patients in the best possible state.
"That said, working while fatigued has been part of the culture of medicine for a long, long time," said Nurok, an anesthesiologist and intensive care doctor at Hospital for Special Surgery in New York City.
"There has been this idea that training for medicine involves training for working under fatigued conditions, but we now know that fatigued physicians are impaired by their fatigue."
In recent years, regulations have started to limit the working hours of interns and other doctors-in-training, but the same doesn't necessarily apply to fully trained doctors.
Ideally -- and some institutions have done this -- steps should be taken to ensure that a surgeon who's been on call for 24 hours in a busy practice is not allowed to schedule elective surgery the next day, Nurok said.
The lack-of-sleep situation is less likely to arise in a rural practice where a surgeon may be on call for long periods of time and only very rarely has to go in at night to operate, he suggested.
The article cites research showing an 83 per cent increase in the risk of complications in patients who undergo elective daytime surgical procedures by a physician who had less than a six-hour opportunity for sleep between procedures during a previous on-call night.
"I have seen surgeries being performed by surgeons who have been up overnight -- it does concern me," Nurok said, noting several scenarios in which people talked to the surgeon and said, "Are you sure you want to do this?"
"One of the major problems with fatigue is that we know that when people are fatigued, they don't self-assess their degree of impairment. So the response to that is usually, 'I'm fine.' But we know that people often are not fine."
The article suggests providing a different surgeon or a new date for surgery that's not too far down the road.
The implications for patients are not inconsequential.
Sholom Glouberman, president of the Patients' Association of Canada, said a patient has to prepare for elective surgery.
"You take time off work, you make sure that you have transportation to the hospital, you might have to do preparation by fasting and having an enema, all of those things, which is very uncomfortable," he noted.
"If you walk in the hospital on the day of your surgery and you're told that the surgeon hasn't had enough sleep and you've prepared yourself psychologically and physically for the surgery, then it's a tough choice. And it's a choice where, without having enough preparation, you might very well make the wrong choice."
It puts a decision into the patient's lap that should be figured out by the hospital, he said.
In Canada, Glouberman noted, rescheduling an elective surgery as a priority doesn't necessarily occur because these appointments are often made months in advance.
"People who are quite uncomfortable with knee problems or shoulder problems, waiting for orthopedic surgery, might have to wait for another six months for it."
Michael McBane, national co-ordinator of the Canadian Health Coalition, said it makes sense that doctors should disclose their fatigue.
"I do think patients should know if the doctor's been up for 22 hours. They should be informed of that because obviously it affects their performance and their judgment," he said from Ottawa.
"I think people have to be flexible and realize there are circumstances such as this -- if a doctor hasn't had any sleep, you want them postponing it even if it's inconveniencing you. In the long run, it's much safer for everybody."
It's not an ideal solution, he said, because some patients may still choose to go ahead with the surgery.
But the American College of Surgeons disagrees with the notion of mandatory disclosure, calling it unwarranted.
"Rather, we maintain that surgeons should be trained to identify and address this (sleep-deprivation) problem," said a letter signed by three doctors at the college, also published in the journal.
Surgeons who meet the college's standards of professionalism and ethics are likely to view the disclosure recommendation "as oppressive and insidious," they wrote.
"Many other factors -- including marital difficulties, an ill child, financial worries, and so on -- negatively affect performance. Are we going to demand full disclosure of these problems as well?"
Dr. Shaf Keshavjee, surgeon-in-chief at the University Health Network in Toronto, said he agrees with the college -- that it's up to the surgeon to decide whether to perform or reschedule a surgery.
It's important that surgeons be trained to recognize when they're too fatigued to perform surgery, he said.
"If you feel like you're exhausted and you're not going to be able to perform something, then you have to say 'I can't do it,"' he said.
Shift workers like nurses and anesthetists can be scheduled, he said, but there aren't always replacements for workers at the calibre of surgeons.
There are impediments to implementing a system that would give patients a say in cancelling surgeries, he noted.
"If the surgeon cancels his whole list and then has to rebook it in the operating room -- I forget how many thousands of dollars a minute it costs to run an operating room -- it sits there empty with all of the staff but no surgeon to operate, how do you run health care and not run health care into the ground?"
To watch the accompanied CTV news interview with Sholom Glouberman click here. You can also find a CBC audio interview