Heartfelt with Dr Melissa Walton-ShirleyView all posts »
The impossible dream: Legislation of "enough sleep" for every physician every nightJan 16, 2011 17:07 EST
An editorial in the January 5, 2011 issue of the New England Journal of Medicine suggests the need for legislation of sleep requirements and disclosure for operators who haven't slept for 22 hours out of the past 24. Although it's ideal to have a good night's rest before performing surgery, caths, interventions, or simply writing orders on a complex case, it's not always possible. Furthermore, this ivory-tower recommendation would do a great disservice to rural America, already hurting from physician shortages and grueling schedules. I can imagine how happy Mrs Smith (who has been NPO since midnight and her five family members who took off from work and traveled a hundred miles) would be to hear me say, "Sorry Mrs Smith, I didn't sleep well last night so I'm going to cancel your case." Although I have done that in extreme situations, in the course of a busy physician's day, "less-than-ideal" circumstances are still good enough to get a safe job done. I firmly support structuring training programs to provide optimal conditions for patients and residents, but it's best to let attending physicians decide when they are too sleep-deprived to perform.
Sleep legislation is a slippery slope. It's common knowledge that students perform better on tests if they have breakfast. Should we disclose that we didn't eat the morning of a procedure? Caffeine sharpens recall but it can accentuate a tremor. Should we regulate caffeine intake for physicians? What about the time I learned my father had a Clarks level III–IV melanoma just before my workday? Should I have canceled all my cases the month my mother-in-law lay dying with terminal cancer, sometimes on the next ward? What about the nights we aren't on call yet our mind runs on like a ticker tape? Should I always report it to my patients if I had less than six hours of restful sleep before I round or cath? I've had a long surgery on two occasions in my lifetime, and I did not query my surgeon about his night. If the truth be known, he's probably better after 20 hours of work than some are with a week's vacation. Trust is an integral part of any doctor-patient relationship, and in the private-practice world, it is within this realm of trust that the sleep issue should remain.
Most mistakes in medicine are not due to sleep deprivation. They are due to distraction, too few hours during the workday, too few physicians to handle a heavy workload, and even things like an office worker filing an abnormal lab before we see it and the patient never calling to verify the results. Prevention comes from good planning, systems analysis, and surrounding ourselves with excellent coworkers, not legal constraints. I'd say I've made far more errors of omission from folks interrupting my train of thought with a phone call or a simple question than sleep deprivation. That's why I double-check just about everything, and I find mistakes before they cause an issue.
Residency programs should provide ample opportunity for sleep because those students of medicine and surgery are at the extreme end of deprivation. During my residency, a premier surgeon in training suffered a grand mal seizure while preparing to operate. While the anesthesiology student was trying to intubate the patient, the attending was on the floor trying to stabilize the resident. The young patient with a gunshot wound died after the ET tube was placed in his esophagus. The resident surgeon was not allowed to operate for 12 months, and the entire tragedy very nearly ended a career that took 23 years of training. It also ruined the lives of the family members of that unfortunate patient. Both parties could have been protected if the surgery resident, rumored to have not slept for three days, had been forced to take 12 hours off before returning to the operating room. These extreme cases require consideration, compassion, and a commonsense approach, all of which trump regulation. Program directors should have their finger on the pulse of their residents and the patients whose lives they affect. Sentinel events should be flagged, reported, addressed, and corrected. At the same time, directors must strike a balance between time off and missed opportunities for learning.
Sleep is a precious commodity for any physician but sometimes escapes us due to reasons beyond our control. Whether from emergent disruptions, patient concerns, personal stresses, or reflux from eating lunch at 9:00 pm, a restful night isn't always possible. Whether mature attending physicians are fit to perform a procedure is a personal judgment, but residents in training need just that: training to make that judgment. A good mentor provides enough direction to give them the tools to make decisions about sleep and work when the time comes.
Like many other human attributes, sleep requirements are highly variable. Ben Franklin, Leonardo da Vinci, and Napoleon Bonaparte slept two hours per night and took a 20-minute nap every four to six hours during the day. They weren't acute-care specialists but harbored the same DNA that drives scientists and inventors. These personalities often force sleep to take a back seat to work and creativity, but above all, dedication to acutely ill patients is the greatest motivator for sleep deprivation in those physicians who stand on their feet long hours during a long call night. It was once said that "every closed eye is not sleeping and every open eye is not seeing." In the end, no one can make that judgment for us, and there isn't a single piece of legislation out there that could discern the difference.
Casting call for cardiologists and citizens: Smoke-free ordinance "play" coming to a "theater" near you
Feb 1, 2011 09:45 EST Next post »
Cardiologists' mantra for the New Year: "Bite me, 2010! Bring on 2011! and take back the attention and accolades we deserve"
Jan 8, 2011 09:46 EST