Blog dedicated primarily to randomly selected news items; comments reflecting personal perceptions

Saturday, August 29, 2015

Trusting the Professional Skills of the Rest-Deprived

"Overall, the risks of adverse outcomes of elective daytime procedures were similar whether or not the physician had provided medical services the previous night."
"Attending physicians have greater experience than trainees, which may compensate for decrements in performance so that clinical outcomes are not affected."
"More important, attending physicians may exercise professional judgement and self-regulate their practise the next day by cancelling surgeries or arranging for coverage by colleagues if they feel too fatigued to perform surgery safely."
"However, the effect of profound sleep loss may warrant further study, and it remains important for physicians to critically assess the effects of all sources of fatigue on their individual ability to treat patients and self-regulate their practices appropriately."
Study: Institute for Clinical Evaluative Sciences, Toronto
Jean-Sebastien Evrard/AFP/Getty Images

It would appear that the performance of medical trainees, famously sleep-deprived throughout their medical internships have been the focus of most such studies to evaluate performance levels of sleep-deprived professionals undertaken in the past. Those studies concluded that mood, cognition and "psychomotor function" stood to be impacted through sleep deprivation on the part of medical interns or trainees. This led, logically, to North American residency training programs instituting reasonable duty-hour restrictions.

Now, a new study out of Ontario and published in the New England Journal of Medicine -- where about 39,000 patients who had undergone a dozen surgical procedures, ranging from bypass and spinal surgery to hip and knee replacements at 147 Ontario hospitals between 2007 and 2011, which examined practised surgeons' performances when sleep deprived -- concludes that concern is misplaced when it is skilled practitioners who are involved, not trainees.

The result of the study was that a surgical procedure is perfectly safe and the result predictably so despite being performed by a physician who had not slept between midnight and 7:00 a.m., going on to perform daytime operations following all-night work. Patients are no more likely to die, to suffer complications, or to be readmitted to hospital, than those who experienced their surgery done by a fully-rested doctor, the research held.

The study examined the work-and-sleep-deficits of 1,448 different doctors. Half of the patients had been treated by doctors who had delivered overnight medical care to patients, and then prepared to do the same with daytime patients. An equal number of patients received similar elective procedures from the same number of adequately-rested physicians. The analysis held that the rate of death, readmission or complication was identical between the two groups.

Taken into account was the physicians' age or the type of medical procedure involved, when evaluating the outcomes. On the other hand, a "small but significant" increase in complications was noted among those patients whose doctors had performed two or more procedures the previous night. The differential, however, was considered not sufficient to justify concerns over surgical outcomes performed by sleep-deprived doctors.

While agreeing that sleep deprivation and fatigue could have the potential to affect physician performance, the conclusion seemed to be that adjustments in policy shifts relating to duty hours and the practices of attending surgeons "may not be necessary at this time", according to the researchers. Which does seem strange, when taking into account that "small but significant" increase in complications noted.

And the equivocating statement on the ability of physicians to themselves recognize whether they have been sleep-impaired and accordingly call on others to fill in for them, and the importance placed in physicians critically assessing fatigue effects on their capacity to function professionally. There are so many variables at play here; professional pride, stubbornness of character, failure to recognize just how spent their energy is, that it would simply seem to be common sense to assume that lack of rest equals potential impairment.

Bearing in mind that the patient is at the merciful skill of the surgeon, without being aware that the health professional's skills may have been compromised by lack of adequate rest prior to operating. In full fairness to the patient, there should be hospital rules and regulations pertaining to the dependability of the physician attending to the condition of the patient before surgery is embarked upon.

Much depends upon the professional acuity and capability of the doctor whom the patient trusts is operating under ideal circumstances.

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