Wake-up call
Imagine that you are lying on an operating table at 8am. Which of the following surgeons would you choose to do your operation: Surgeon A who has consumed four shots of vodka for breakfast, Surgeon B who has narcolepsy, or Surgeon C who has been up all night working a 24-hour shift? The answer is that it doesn't much matter because all three will have similar psychomotor, cognitive and attentional impairment.
The Hospital Authority has proposed new measures to address iniquitous medical workloads and duty hours, one of which is to pay special allowances to compensate doctors for extra overnight shifts. Compelling scientific evidence on the impact of sleep deprivation on the clinical performance of doctors should caution against this proposition.
The practice of medicine demands onerous working hours. Historically founded on duty of care and apprenticeship, the custom morphed into a rite of passage, replete with misplaced bravado. Their professionalism lamentably exploited by employers, doctors are now routinely required to work lengths of time (cumulative and shift) that would never be tolerated in other fatigue-sensitive occupations like road transport or aviation. The uncomfortable truth is that extended duty hours, while tacitly tolerated by government, are dangerous for patients and detrimental to doctors.
People become sleep-deprived in two ways. Chronic loss occurs when continually excessive working hours prevent adequate rest and a sleep deficit accrues. Acute lack of sleep follows continuous wakefulness for 24 hours. Both produce a predictable decline in human performance, which is characteristically underestimated by those affected. Sleep debt can only be repaid by restorative sleep, not by the payment of special cash allowances.
Why should the public be concerned about fatigued doctors? After being awake for 24 hours, there is a measurable impairment in human cerebral and motor function, equivalent to that induced by a blood alcohol level of 0.1 per cent (twice the legal limit for driving in Hong Kong). This translates directly into hazards for patients, and studies show that doctors working shifts of 24 hours or more make substantially more medical errors (in some instances up to seven times greater) than those working for 16 hours. One analysis showed that patients undergoing elective daytime operations were three times more likely to have serious surgical complications if their surgeon had been on call overnight and had less than six hours' sleep. In a subsequent public opinion survey, 80 per cent of Americans polled said they would request a different surgeon to perform their operation in those circumstances.
Excessive working hours are unhealthy for doctors. Their mental well-being suffers, with depression, burnout and marital discord major results. It is emblematic that only half of the surgeons recently surveyed said they would recommend their children pursue a career in medicine. Physical health is also affected. For example, physicians working 24-hour shifts are 60 per cent more likely to have a needle-stick injury. Just like tired truckers, drowsy doctors are a hazard on the road: after 24 hours of duty they have more than double the risk of falling asleep at the wheel (13 per cent report nodding off), and of having a car crash while driving home from work (one accident per 1,000 commutes). In response to the findings, some hospitals in America now offer round-trip taxi vouchers to surgical residents.
Education also suffers and, in one study, 70 per cent of surgeons-in-training admitted to falling asleep during lectures after long shifts (although, with admirable candour, so did half of those working shorter shifts). Falling asleep during teaching rounds (22 per cent), while assisting in operations (7 per cent) and, astonishingly, even while examining patients (5 per cent) are all commonplace.
So why the resistance to reducing doctors' working hours? Vocation, for one. Postgraduate medical training necessitates 10,000 to 20,000 hours of practice to develop expertise. This takes five years to achieve on a typical surgical residency in America, working 80 hours per week, with every third night on call. Professional organisations correctly point out that, if training is not to be compromised, any reduction in working hours must be accompanied by improved, focused and competency-based instruction, augmented with simulation.
Logistics are a problem if the intention is to reduce duty hours but maintain the same staffing level: this requires a transition to a shift system, and requires special safeguards for patient handover.
The elephant in the room, of course, is that more staff is likely to be the only durable solution. But this requires commitment, long-term vision and funding.
Estimates from the United States indicate that around 10 per cent more medical staff will be needed to meet working-hour reduction targets there; by analogy, this would mean an additional 500 medics are needed in the public sector in Hong Kong.
Another way to reduce the impact of fatigue is to use pharmacological performance-enhancing agents. A popular candidate drug, modafinil (itself licensed for the treatment of narcolepsy), has been shown to improve wakefulness in emergency-room physicians, and is likely to attract more widespread use - conceivably also in Hong Kong where the prospect of generous special allowances might induce doctors to work additional night shifts and then counteract the effects with a drug. The government needs to wake up to the dangers of sleep-deprived doctors, before the highly dedicated become highly medicated professionals.
Darren Mann is a general surgeon in Hong Kong
