David Baxter PhD
Late Founder
Who's up, doc? Journal issues wake-up call to sleep-deprived MDs
By Sharon Kirkey, Ottawa Citizen
May 24, 2011
Physicians need to give up the idea that working long hours on call is something to be proud of, says a new editorial in the Canadian Medical Association Journal.
National standards are needed to protect patients from doctors so sleep starved they might as well be legally impaired, Canada's leading medical journal says.
Studies have found a near doubling in the rate of complications ? including massive hemorrhage or organ injury ? when surgeons operate with fewer than six hours of sleep after a night on call.
The problem of sleep-deprived physicians is poised to only get worse, states an editorial published in this week's issue of the Canadian Medical Association Journal. Medical care is more complex than ever, placing "unprecedented" demands on a doctor's physical and cognitive wherewithal.
Physicians need to give up the idea that long stretches on call should be worn like a badge of honour, the authors state. Instead, a culture shift is needed. Working while sleep deprived is neither "normal nor acceptable," the authors write, adding: "Those of us who remain overconfident that we can continue to perform our duties properly with inadequate sleep should imagine the reaction if we were made to seek informed consent from each of our patients to accept treatment under these conditions."
Limits have been imposed on how long residents and medical students can go without sleep. But, for practising doctors, there are virtually none, the authors of the editorial say ? even though practising doctors are older and probably even more vulnerable to the effects of sleep loss.
What's more, unlike doctors-in-training, fully trained doctors usually have no one looking over their shoulder "to catch their mistakes."
In understaffed community hospitals, doctors can work days in a row with minimal backup and sleep, says Dr. Paul Hebert, the journal's editor-in-chief and a critical-care doctor at The Ottawa Hospital. But even in big city hospitals doctors frequently work "long, long hours, and often on call, and the next day still do clinics," Hebert said.
It's difficult to make hard and fast rules, he says. Several of his colleagues sleep, on average, four hours a night "and they function just fine." Others can become completely dysfunctional.
"The things that go first are executive function and judgment," Hebert said in an interview. "Your co-ordination starts to be impaired after having less than a few hours sleep a night."
But, "a lot of us were trained in a bit of a macho culture, where it's kind of like, 'I can do it.'"
Strategies are needed to restrict how long doctors can work without sleep, the journal says, including strict policies on going home after being on call, not scheduling cases the day following a night on call and shifting resources between hospitals to provide backup to under-serviced communities.
"Ultimately, licensing, accreditation, insurance and government institutions need to establish minimum best-practice standards for maximum work and minimum uninterrupted sleep hours."
A 2009 study published in the Journal of the American Medical Association involving post nighttime procedures found an 83 per cent greater risk of complications when surgeons had less than six hours' sleep.
An editorial published last year in the New England Journal of Medicine argued that sleep-deprived doctors shouldn't be allowed to operate without a patient's written, informed consent.
Says Hebert, "If you had to get consent from every patient, maybe the system would change."
According to the CMAJ, less than six hours of uninterrupted sleep from overnight calls impairs a doctor's judgment and motor performance similar to a blood-alcohol level above 0.05 per cent.
By Sharon Kirkey, Ottawa Citizen
May 24, 2011
Physicians need to give up the idea that working long hours on call is something to be proud of, says a new editorial in the Canadian Medical Association Journal.
National standards are needed to protect patients from doctors so sleep starved they might as well be legally impaired, Canada's leading medical journal says.
Studies have found a near doubling in the rate of complications ? including massive hemorrhage or organ injury ? when surgeons operate with fewer than six hours of sleep after a night on call.
The problem of sleep-deprived physicians is poised to only get worse, states an editorial published in this week's issue of the Canadian Medical Association Journal. Medical care is more complex than ever, placing "unprecedented" demands on a doctor's physical and cognitive wherewithal.
Physicians need to give up the idea that long stretches on call should be worn like a badge of honour, the authors state. Instead, a culture shift is needed. Working while sleep deprived is neither "normal nor acceptable," the authors write, adding: "Those of us who remain overconfident that we can continue to perform our duties properly with inadequate sleep should imagine the reaction if we were made to seek informed consent from each of our patients to accept treatment under these conditions."
Limits have been imposed on how long residents and medical students can go without sleep. But, for practising doctors, there are virtually none, the authors of the editorial say ? even though practising doctors are older and probably even more vulnerable to the effects of sleep loss.
What's more, unlike doctors-in-training, fully trained doctors usually have no one looking over their shoulder "to catch their mistakes."
In understaffed community hospitals, doctors can work days in a row with minimal backup and sleep, says Dr. Paul Hebert, the journal's editor-in-chief and a critical-care doctor at The Ottawa Hospital. But even in big city hospitals doctors frequently work "long, long hours, and often on call, and the next day still do clinics," Hebert said.
It's difficult to make hard and fast rules, he says. Several of his colleagues sleep, on average, four hours a night "and they function just fine." Others can become completely dysfunctional.
"The things that go first are executive function and judgment," Hebert said in an interview. "Your co-ordination starts to be impaired after having less than a few hours sleep a night."
But, "a lot of us were trained in a bit of a macho culture, where it's kind of like, 'I can do it.'"
Strategies are needed to restrict how long doctors can work without sleep, the journal says, including strict policies on going home after being on call, not scheduling cases the day following a night on call and shifting resources between hospitals to provide backup to under-serviced communities.
"Ultimately, licensing, accreditation, insurance and government institutions need to establish minimum best-practice standards for maximum work and minimum uninterrupted sleep hours."
A 2009 study published in the Journal of the American Medical Association involving post nighttime procedures found an 83 per cent greater risk of complications when surgeons had less than six hours' sleep.
An editorial published last year in the New England Journal of Medicine argued that sleep-deprived doctors shouldn't be allowed to operate without a patient's written, informed consent.
Says Hebert, "If you had to get consent from every patient, maybe the system would change."
According to the CMAJ, less than six hours of uninterrupted sleep from overnight calls impairs a doctor's judgment and motor performance similar to a blood-alcohol level above 0.05 per cent.
