How Not to Respond To a NEJM Letters To the Editor:

In todays NEJM, three surgeons from the American College of Surgery (ACS) reply to a commentary on sleep deprivation and elective surgery. The letter is instructive.

Read it, and you will note several things:

1. Given the attention adverse medical events and errors are receiving, and knowing ANY error that is potentially avoidable is an error worth preventing, why would a doc state: “Because this procedure is relatively simple [elective colostomy], many surgeons could successfully complete it with or without a good night’s sleep.” As an internist, am I beyond reproach? If sleep deprived, could I misdiagnose a life threatening problem masquerading as a simple ailment. Yup.

2. If John Q public read this letter, would it pass the sniff test? Knowing the evidence that sleep deprivation affects performance, I dont believe so. It smacks of old school ivory tower parochialism, and these surgeons must take a step back and appraise how a lay person would interpret this stance.

3. Can a physician actually self-police him or herself and recognize fatigue? Is there evidence to support this thinking? If there is, please notate in the comment section below and I will addend this post and partially recant my conclusions.

4. Is presenting a patient with the facts about potential fatigue improper? Again, based on the evidence and potential untoward outcomes, I don’t believe so. This is not a slippery slope, and “marital difficulties, an ill child, financial worries,” are not equivalent. If evidence ever surfaced that pilots, surgeons, and heavy equipment operators are at great risk of causing increased harm while under stress, greater than ambient levels we all experience, than I believe it is time to reconsider. Until then, disclosure is not unreasonable. What is there to hide?

5. Finally, I do not place much stock in the state of current quality measurement (“the cores”). The present set of process measures are a mixed lot and studies correlating outcomes with these metrics are varied. Unless the institution from which these scores hailed was an outlier at the bottom, I would have no compunction undergoing a procedure there. However, if you were to ask me whether I would submit myself to an elective operation from a sleepless or overly fatigued surgeon, the answer is emphatically no. The same goes for a family member. I know better. Enough said.

It will be interesting to see the reaction to above in the coming days. Of course, feel free to comment. Bottom line to me, and I say this respectfully, the ACS has not helped their cause and wont win over any adversaries.

Brad Flansbaum

Bradley Flansbaum, DO, MPH, MHM works for Geisinger Health System in Danville, PA in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996, at the inception of the hospital medicine movement. He is a founding member of the Society of Hospital Medicine and served as a board member and officer. He speaks nationally in promoting hospital medicine and has presented at many statewide meetings and conferences. He is also actively involved in house staff education.

Currently, he serves on the SHM Public Policy Committee and has an interest in payment policy, healthcare market competition, health disparities, cost-effectiveness analysis, and pain and palliative care. He is SHM’s delegate for the AMA House of Delegates.

Dr. Flansbaum received his undergraduate degree from Union College in Schenectady, NY and attended medical school at the New York College of Osteopathic Medicine. He completed his residency and chief residency in Internal Medicine at Long Island Jewish Medical Center in New York. He received his M.P.H. in Health Policy and Management at Columbia University.

He is a political junky, and loves to cook, stay fit, read non-fiction, listen to many genres of music, and is a resident of Danville, PA.

2 Comments

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  2. Rachel Lovins on January 30, 2011 at 8:02 pm

    there are additional problems, other than sleeplessness, that we need to worry about. Physicians are supposed to police themselves in many areas: sleeplessness, substance abuse, mental health, diminishing skills with age. As I read recently pilots are subjected to physical and cognitive tests every 6 months. Us? pretty much never, except for re-taking the boards every 10 years if we’re not grandfathered in. I’m not saying I want someone else to measure my physical and cognitive health ever 6 months, (I don’t) but the level of outside evaluation of our capabilities and health is probably not sufficient.

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