Attending neurosurgeons who perform emergency cases the night before don’t seem to provide poorer outcomes for their patients.
Neurosurgeons called in to do an emergency case at night do not see any decline in their performance when treating unruptured cerebral aneurysms the next day, a new study shows. Specifically, there are no increases in inpatient mortality, discharge to a facility versus home, or length of stay based on attendings’ night work.
Public awareness about physicians’ level of rest—or exhaustion—is high, according to lead author Kimon Bekelis, MD (Dartmouth-Hitchcock Medical Center, Lebanon, NH). “When you see a patient in the morning before the surgery, most of the time the patient [asks], ‘Have you had a good nights’ sleep?’ It’s extremely common,” he told Neurovascular Exchange.
Approaches to handling night work vary, he said: “Typically, most providers try to clear their elective schedules when they’re on call, but that’s not necessarily always easy to plan.” Vascular neurosurgery by default involves a lot of emergencies, with events like stroke, aneurysm, and intracranial hemorrhage that are hard to predict. For example, even if not on call, neurosurgeons might get brought in unexpectedly in the middle of the night to treat one of their patients, Bekelis said. “For continuity of care, you would take care of it, and then you’d have elective cases the next day.”
In his experience, Bekelis added, “most physicians are responsible. . . . If they’re tired or overworked, they typically would not take on elective cases but cancel them if they don’t feel they’re up to their best performance.”
The goal of the current study, published online recently in Neurosurgery, was to see if surgeons are effectively managing the strain of night work.
No Apparent Differences
Bekelis and colleagues analyzed data on 4,700 patients in New York’s Statewide Planning and Research Cooperative System database who underwent endovascular coiling or surgical clipping for unruptured cerebral aneurysm between 2009 and 2013.
Slightly more than half (54.1%) were treated by surgeons who had done night work; among these patients, the mortality rate was 1.3% and 17.8% were discharged to rehab. Their average length of stay was 5.5 days.
Using an instrumental variable analysis, the researchers found no statically significant gaps in inpatient mortality (adjusted difference -0.7%), discharge to a facility (adjusted difference -0.1%), or length of stay (adjusted difference -0.58 days) between patients whose surgeons did and did not work the night before (P = NS). The study had 80% power to detect a mortality difference as small as 4.1%.
Whether and Whom to Restrict
Prior studies have “heightened public awareness and ongoing debate about the effects of sleep deprivation and fatigue on physician performance,” the researchers note.
But Bekelis pointed out to NVX that concerns mainly relate to residents, who have less control of their work demands. “Residents are the first line of defense so to speak. They are the people in the hospital. They are the people dealing with the nitty gritty details of care,” he explained.
“My personal opinion is that we don’t have very strong data either way” on whether restricting the work hours of residents is beneficial or harmful, Bekelis said, noting that there are “a lot of strong opinions” on the issue.
But attending surgeons, “thankfully, rarely have to be in the hospital unless they’re operating, because the residents take care of all the work. That really allows them to rest,” he noted, adding that there are “a lot of levels of support underneath them.”
“So even when they’re doing a case in the middle of the night, most of the time that is a short period of time—they come in and do the case,” Bekelis continued. “Also, they have the experience and hopefully the judgment, because they’ve been at it for a long time, to not do an elective case the next day unless they’re comfortable doing it.”
It’s not that attending neurosurgeons are “superhumans,” but rather that they self-regulate, he stressed.
Surgeons Say No to More Rules
In comments accompanying the paper, Robert E. Harbaugh, MD (Penn State Health, Hershey, PA), says that the duty hour restrictions placed on residents 13 years ago have had adverse effects on patients.
Beyond reducing “continuity of care,” the rules “foster a shift-work mentality with its attendant loss of the individual’s commitment to the patients,” he writes. “Duty hour restrictions force our residents to choose between adherence to regulations requiring them to end their shift or their commitment to patients who could still benefit from their care. If they choose the latter, they must lie or put their program at risk. We should not make our residents feel they must lie about doing the right thing.”
Applying restrictions on the work hours of staff neurosurgeons would result in “profound negative consequences,” Harbaugh stresses. “Neurosurgery is a demanding technical specialty, but we do much more than perform procedures. We care for our patients in the clinic, the emergency room, the operating room, the recovery room, the intensive care unit, and on the hospital wards. We are specialists in the care of patients with neurological disease, not technicians who have mastered a motor skill.”
Studies like the one performed by Bekelis et al make the case that fatigue, “a fact of life in a surgical career, . . . can be recognized and managed in a way that best serves our patients and our specialty,” he concludes.
Nathan E. Simmons, MD (Dartmouth-Hitchcock Medical Center), commenting in the journal, agrees: “The authors confirm what many neurosurgeons have suggested for years. Namely, our ability to monitor our personal functional status for safe and effective care of patients is intact.”
Bekelis K, Missios S, MacKenzie TA. Outcomes of elective cerebral aneurysm treatment performed by attending neurosurgeons after night work. Neurosurgery. 2017;Epub ahead of print.
- The study was supported by grants from the National Center for Advancing Translational Sciences of the National Institutes of Health.
- Bekelis reports no relevant conflicts of interest.