continued on next page
staff surgeons, and experimentation with skills at the resident
level. 6, 7 These results, however, are inconsistent with other
studies, which indicate reduced performance, specifically
in laparoscopic skills in sleep-limited residents as demonstrated by Eastridge and colleagues. This study contrasts
with a similar study showing non-inferiority in laparoscopic
ability. 8, 9 When examining patient outcomes, the results are,
again, mixed. Although Rothschild and colleagues noted
an increase in complications in elective cases following call
( 3. 4 percent versus 6. 2 percent), on examination of the data
from all types of procedures and all surgeons, there was no
significant difference in outcomes with or without a prior
night of call. 10 Several investigations of cardiac procedures
have not detected an increase in morbidity of patients of post-call surgeons. 11-13 One item which may be suggested by the
variations in the data is that there are disparities in the operations that are affected by sleep deprivation, whereas others
exist where necessary technical abilities are well-preserved
despite operator fatigue; this may also vary depending on
the surgeon. These considerations still need to be elucidated.
Therefore, any attempt to standardize mandatory disclosures
seems somewhat heavy-handed.
Some of the inconsistencies are affected by confounding factors, and comparisons between studies are limited
by differing definitions of sleep-deprived. A surgeon may
be classified as such if limited sleep opportunities between
call and elective cases are available, or simply if he or she
takes a call shift the preceding evening. However, countless other factors play into the surgeon’s performance, even
if post-call status disclosure is mandated. An off-duty surgeon may not have slept well the previous night in his or
her own bed; the corollary is that a post-call surgeon may
have not been disturbed once during their shift. Additionally, other pressures, personal or professional, arguably may
have an equivalent impact on performance. 14 Further, given
the group dynamics of a successful operation, would the
state of all members of the operative team be expected to
be disclosed in the informed consent? Mandating disclosure
of one aspect of a provider’s mental state opens the gate
to further unwarranted personal investigation. And without conclusive evidence to confirm consistently different
outcomes, these actions pander to public fear, rather than
improve patient safety. 15
1. Abelson J, Saltzman, J, Kowalczyk L, Allen S. Clash
in the name of care. Boston Globe. December 2015.
Available at: apps.bostonglobe.com/spotlight/clash-in-the-name-of-care/story/. Accessed September 12,
2. Roach GD, Dorrian J, Fletcher A, et al. Comparing
the effects of fatigue and alcohol consumption
on locomotive engineers’ performance in a rail
simulator. J Hum Ergol. 2001; 30( 1-2):125-130.
3. Morris TL, Miller JC. Electrooculographic and
performance indices of fatigue during simulated
flight. Biol Psychol. 1996; 42( 3):343-360.
4. Anderson C, Dickinson DL. Bargaining and trust:
The effects of 36-hours total sleep deprivation
on socially interactive decisions. J Sleep Res.
2009; 19( 1): 54-63.
5. Tomasko JM, Pauli EM, Kunselman AR, Haluck
RS. Sleep deprivation increases cognitive workload
during simulated surgical tasks. Am J Surg.
2012;203( 1): 37-43.
6. Uchal M, Tjugum J, Martinsen E, et al. The
impact of sleep deprivation on product quality and
procedure effectiveness in a laparoscopic physical
simulator: A randomized controlled trial. Am J Surg.
7. Jakubowicz DM, Price EM, Glassman HJ, et al.
Effects of a twenty-four hour call period on resident
performance during simulated endoscopic sinus
surgery in an Accreditation Council for Graduate
Medical Education-compliant training program.
Laryngoscope. 2005;115( 1):143-146.
8. Eastridge BJ, Hamilton EC, O’Keefe GE, et al.
Effect of sleep deprivation on the performance of
simulated laparoscopic surgical skill. Am J Surg.
9. Olasky J, Chellali A, Sankaranarayanan G, et al.
Effect of sleep hours and fatigue on performance
in laparoscopic surgery simulators. Surg Endosc.
2014; 28( 9):2564-2568.
10. Rothschild JM, Keohane CA, Rogers S, et al.
Risks of complications by attending physicians
after performing nighttime procedures. JAMA.