As an OB/GYN physician who took overnight call for 15 years before leaving the practice of medicine, the CNN article about the latest editorial in the New England Journal of Medicine, which discusses how sleep-deprived surgeons should consider disclosing their sleepy status, caught my attention. As a doctor hard at work on my current book, BROKEN: One Doctor’s Search For the Lost Heart of Medicine, which details the many fractures in our current health care system, this editorial taps right into one of my sincerest concerns about how broken our health care system truly is.
The Truth Will Terrify You
As a full partner in a busy OB/GYN practice with four other doctors, I was expected to work a full day, take call at the hospital all night, and work all the next day — about every fourth night. One weekend a month, I was expected to start work at 8 a.m. Friday morning and finish at 8 a.m. Monday morning. Yup. You heard me right. I was making medical decisions — and operating — for 36 hours and sometimes 72 hours straight without a wink of sleep. Sometimes I got lucky and the pager kept quiet for a few hours a night. But on average, I slept between 2-4 interrupted hours on a good night as a full-fledged doc — and none on a bad night.
Driving Vs. Operating — Which Is Worse? Drunk or Exhausted?
One weekend when I was on call, I finally made it home on Sunday, after 60 hours without one minute of sleep. I curled up in bed, fell into a deep sleep, and minutes later, my pager blared a 911 page. Someone who needed a C-section had just rolled into the ER and was already eight centimeters dilated. As I threw on my green scrubs and dropped Visine in my bloodshot eyes, my mother, who was visiting, said, “Honey, you’re too tired to drive safely. Let me drive you to work.”
Looking at her with bleary eyes, I said, “Mom, I’m going to work to perform surgery. Don’t you see the ridiculousness of what you just said?”
She said, “No. But I do see the ridiculousness of what you’re about to do.”
She was dead right. As the wife of a doctor, Mom knows that I didn’t have a choice. The system is set up to force many docs like me to keep these kinds of schedules. After 15 years of that kind of madness, I finally hung up my white coat. I decided I’d rather not practice medicine than practice it this way. I decided to live more authentically to who I really am — to be ALL ME, ALL THE TIME — and I just couldn’t find a way to retain my integrity in the midst of a system that regularly asked me to put myself and my patients at risk.
Sleepy = Drunk
Studies have linked performing surgery after a sleepless night to driving with a blood alcohol of 0.1% — legally drunk. And general surgeons who performed elective surgery the day after working all night had a rate of complications 171% higher than if they had slept the night before. One study found that when residents worked a 24-hour shift more than once per week, the risk of patient fatalities increased 300%. Another study showed that the risk of mistakes increased 700% in months that interns were working shifts that lasted at least 24 hours. Yowsers.
Many think it gets better when medical training ends, and in some ways it does. But I was never expected to work 72 solid hours as a medical student or resident. But as a full-fledged surgeon? Yup. Crazy, eh?
I Was Lucky — But You Might Not Be
When I was practicing, I had to perform surgery when I was the on-call emergency doctor. I couldn’t avoid it because there was nobody else in the hospital to do it for me. But I refused to perform elective surgery post-call. What if I had hurt someone unnecessarily? What if a baby had died? What if I had injured someone’s colon as a complication from being tired and they required a colostomy? What if someone lost so much blood during a C-section that they had to have their uterus removed and couldn’t have more kids? WHAT IF?
I count my lucky stars that this never happened to me. But it could have. So easily. And it happens to most surgeons, at least the ones who had to work the kind of crazy hours I did before I decided enough was enough. Behind closed doors, most will admit to some fatigue-based mistake. In fact, in one survey, one in five first year residents admitted to making a fatigue-based mistake that hurt someone, and one in twenty admitted to a fatigue-based mistake that killed someone. Yikes.
Should Sleepy Surgeons Operate?
I don’t have all the answers to how we should fix our broken system. But the latest New England Journal Of Medicine editorial suggests that sleep-deprived surgeons should inform patients scheduled for elective surgery if they aren’t well-rested at the time of surgery. Patients would then have a choice of whether or not to reschedule, and 80% of those given the choice say they would ask to reschedule.
Of course, this would wreak havoc with everybody’s schedules. If you were the patient, you’d have to get your IV yanked out, since you’d probably be in your hospital gown, all ready to go, when your doctor confessed to being sleep-deprived. Although the doctor wouldn’t, the hospital might still charge you for your hospital admission, even though you didn’t get surgery. The childcare you’ve arranged, the time off work you’ve scheduled — forget it. You’re likely to wait another six weeks to get a slot on the operating room schedule. Not to mention that most people about to undergo surgery are REALLY ready to get it over with. Putting it on hold would create a lot of stress.
But what if it saved your life? Or helped you avoid a fatigue-based complication? Frankly, I think you deserve to know if your doctor has been up for 72 hours before she takes a knife to you.
What Would I Do?
I’ve got insider knowledge, as do many doctors. We know enough to call long ahead of time if we’re the ones going under the knife electively. We check out when the doctor is on call, and we make sure we’re not on the OR schedule for the next day. In fact, most doctors offer each other that professional courtesy. We wouldn’t even think of operating on a colleague when we’re post-call. So why should we operate on YOU?
I never did. Not when it was elective. And if you want to protect yourself and be an empowered patient, you’ll want to take the same precautions yourself.
How To Protect Yourself If You’re Getting Elective Surgery
1. When you schedule surgery, ask whether your doctor is scheduled to be on call the night before.
2. The day before surgery, double-check. Your doctor’s call schedule could have changed. You never know how much your doctor sleeps at home, but at least make sure your surgeon has had the opportunity to get a good night’s sleep.
3. Ask the day of surgery, even if you checked the night before. Emergencies may come up unexpectedly. It’s your right to ask your doctor how many hours of sleep he got the night before.
4. You can’t know for sure that your doctor will tell you the truth, but if your doctor admits to being sleep deprived (which a study published last year in the Journal of the American Medical Association defined as not having the opportunity to sleep at least six hours between procedures after a previous on-call night), it’s your right to refuse to consent to surgery.
What If You Need Surgery Emergently?
1. If it’s daytime, you can ask whether the surgeon you were assigned slept the night before. If not, you can always ask for one who did (though, depending on your health insurance, you may not get your wish granted).
2. If it’s 3 a.m., you’ll have fewer choices and are likely to get stuck with whoever is on call. You can still ask about sleep deprivation, and if your surgeon is as sleep-deprived as I was on some of my call shifts, you can always ask for a rested surgeon. (If I had ever been asked to find a replacement, I would have called one of my partners and begged them to come in. Would they have done it? I don’t know. I never got asked.)
In Defense of The System
As someone who has been writing a book about how broken our health care system is and why I had to leave it, I find it hard to defend the system, but I can say that strides are being made. Regulations that include caps on the number of hours medical students and residents work are being placed on some medical training programs as the result of recent studies, and things seem to be better than when I was a medical student 15 years ago. Also, HMO’s like Kaiser and many academic hospitals are regulating the hours of surgeons and other doctors, such that they work shorter shifts and have more coverage.
But the same is not true in smaller hospitals or solo or group private practices, where reform is desperately needed.
It’s Up To You To Protect Yourself
I hate to say that doctors don’t always have your best interests at heart. After all, we all pledge the Hippocratic oath and promise to “First, do no harm.” I can honestly say that most doctors mean well. We went to medical school for the right reasons — to help. To heal. To serve. But way too often, we get broken by the system. We get tired. We get busy. We start to accept the system without questioning it. And sometimes, we forget why we’re here.
It’s up to you. When it comes right down to it, it’s YOUR body, your health, your life. You have a right to know, and as doctors, it’s our responsibility to tell you the truth.
What do you think? Have you had surgery? Have you ever asked your doctor how much sleep she got the night before? Would you? Will you?
Wishing you well,
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