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Thursday, April 18, 2019

The effects of sleep deprivation on surgeons

Twenty years ago, you probably wouldn’t have been able to name any of the numerous prescription medications available to you, let alone think to ask your doctor for a particular one by name. Today, the average (even perfectly healthy) consumer is barraged by hundreds, if not thousands, of “direct-to-consumer” advertisements for prescription drugs.

In 1997, the FDA created specific guidelines for broadcast advertising related to prescription drugs. Ever since then, drug companies have taken advantage of this opportunity to promote their medicines for a wide range of conditions, from Alzheimer’s disease to low white blood cell counts due to cancer treatment — not to mention the myriad ads for over-the-counter products.

Direct-to-consumer ads must, by law, include information on a drug’s risks and side effects as well as its benefits. Often, this comes in the form of a rapidly recited list of potential problems. But because it is difficult if not impossible to cover all potential risks in a brief television spot, these ads must also point consumers to more complete information listed in a print ad or on a website. This information is usually a lengthy and technical text compiled by the drug companies — often, the very same text they give to doctors and pharmacies.

Consumers have complained that the information on side effects is so unclear and hard to read that they barely bother. In response, the FDA is now calling for a Drug Facts box that summarizes the most important risks of each drug, using plain English, color schemes, and easily readable fonts.

This change is a step toward giving consumers better “informed consent” before they decide to try a new drug. However, critics point out that the FDA has left much of what is included in the Drug Facts box up to the pharmaceutical companies. Aside from any “black box” warnings and “contraindications” (situations in which a person should definitely not take the drug), the only guideline is that the box must list the “most serious and most common” side effects. That could still leave out a lot of valuable information.

Informing consumers about new and potentially useful drugs is not a bad thing. However, a truly informed consumer should not rely solely on direct-to-consumer drug ads before making the decision to try a new one. Buyer beware: a new medication will undoubtedly be more expensive than older medications that can do the job just as well.

If you see an ad for a drug that you think might help you or be an improvement over medication you’re already taking, talk with your doctor. Be sure you understand the potential risks and side effects, both short- and long-term (and be aware that they are not as well understood in brand-new drugs). If your doctor says “no,” be prepared to hear her or him out. No matter how innovative a new drug might be, it may not be the right drug for you. And if you’re still interested after a while, you can always revisit the issue down the road. For the past month, the Boston medical community has been mourning the death of Dr. Anita Kurmann, who was killed in a traffic accident while biking to work on a Friday morning. Dr. Kurmann, an endocrine surgeon, was completing a three-year fellowship at Boston University and Harvard-affiliated Beth Israel Deaconess Medical Center. She had made great progress with coaxing stem cells to grow into thyroid tissue. Her bicycle has been painted white and chained to a post at the site where she died, one of several “ghost bikes” that commemorate other lives lost in a similar fashion.

It’s ironic that Dr. Kurmann lost her life doing one of the things that kept her fit and healthy. But, as a study described in this week’s Journal of the American Medical Association points out, cycling is becoming an increasingly risky activity. For the study, a team of researchers from the University of California, San Francisco examined data regarding hospital admissions for cycling injuries between 1998 and 2013. They found that the rate of people seeking treatment for bicycle injuries had risen 28%, from 96 to 123 per 100,000 — and the rate of injuries that sent people to the hospital had increased by 120%, growing from 5.1 to 11.2 per 100,000. Head injuries accounted for 16% of all injuries; torso injuries accounted for 17%. And the proportion of accidents on city streets had risen from 40% to 65% of all bicycle accidents. Moreover, it was people over 45 — not children or teens — who had the greatest increase in bicycle-related injuries.
Advice for city cyclists

Nicole Freedman is a former Olympic cyclist who has served as bicycle commissioner of Boston and is currently Chief of Active Transportation and Partnerships in Seattle. She says that cycling is still a fairly safe way to get around in the city, as long as riders are alert to potential hazards. Based on the kinds of accidents she’s seen, she has three pieces of advice:

    Stay clear of any trucks. “The last place you want to be is on the right of a truck,” she says. “If you find yourself in this situation, get up on the curb.” The greatest danger arises when a truck, especially an 18-wheeler or a flatbed, makes a right turn. A cyclist on the truck driver’s right may be in his or her blind spot, and it’s often impossible for a cyclist to see the truck’s turn signal flashing from this position. Dr. Kurmann was killed in one of these “right-hook” crashes.
    Be hyper-aware of your surroundings. You want to try to predict what trucks, cars, and pedestrians are going to do next. “Cycling on city streets is very different from a recreational ride on a designated bike path,” Freedman cautions.
    Give parked cars a wide berth. “Dooring,” in which cyclists are smacked by drivers opening car doors or injured trying to avoid a car door, is one of the most common causes of injuries in urban areas.

Everyday safety tips

Even if you’re cycling on a secluded country lane, it’s a good idea to follow these common-sense suggestions from the League of American Bicyclists:

    Protect yourself. Wear a properly fitted helmet and clothing with reflective fabric at night and in cloudy weather.
    Maintain your bike. Make sure your bike fits you and that it is fit for road conditions. Get a good light for night cycling.
    Learn and follow the rules of the road. Most states require bicyclists to follow the same rules as drivers of other vehicles. You can find the rules of the road for most states here.
    Communicate with those who share the road with you. Make eye contact and use hand signals to indicate what you’re about to do. The simplest gestures, like extending your right or left arm to signal a turn, can avert a collision.

For more detailed information on bike safety and all things cycling, check out the League’s website.
If you’d rather let someone else do the driving…

There’s a way to minimize your cycling risks even further — cycle inside a moving vehicle. Entrepreneurs have developed a way for you to get your cycling miles in, enjoy the landscape moving past, and leave the road worries to someone else. Buses equipped with stationary bikes have sprung up on both coasts and may be coming to a place near you sometime soon. If your surgeon was working the night before, would you want him or her to perform your surgery the next day? The answer to whether a sleep-deprived surgeon is a safe surgeon may surprise you, according to a recent study published in The New England Journal of Medicine.

Over the past decade, concerns regarding trainee doctors’ lack of sleep and the potential for medical errors have brought changes in the number of consecutive hours a trainee can remain in the hospital. Although this is safer in theory, it also brings up a concern that limiting hours in the hospital may also limit a trainee’s experience and produce doctors who are not as well prepared as they might be. This concern is particularly important for procedure-based physicians like surgeons, whose skill often improves in proportion to the number of operations they do.

To address the effect of sleep loss on surgical outcomes, Dr. Anand Govindarajan, a cancer surgeon and assistant professor at Mount Sinai Hospital and the Institute for Clinical Evaluative Sciences in Toronto, led a study of hospital billing data involving approximately 40,000 patients in Canada who underwent 12 types of non-emergency procedures. The operations varied in complexity and ranged from gallbladder removal to bypass surgery.

Dr. Govindarajan and his team first examined the data for approximately 20,000 patients who had had surgery performed by a physician who had operated the night before, between the hours of midnight and 7 a.m. (This was known as the night-call group). They then matched each patient with one of another 20,000 patients who had had the same surgery, performed by the same surgeon, when she or he had not operated the night before. (This was dubbed the non–night-call group). The researchers found that both sets of patients fared equally well. When comparing the night-call group with the non–night-call group, there was no significant difference in the rates of death (1.1% in both groups), readmission (6.6% versus 7.1%), or complications (18.1% vs 18.2%) within 30 days of surgery. This conclusion remained unchanged even after the researchers accounted for differences in the patients’ genders, ages, socioeconomic status, and any other health conditions they may have had.

Dr. Govindarajan’s study has implications for both patients and policy makers. Contrary to intuitive thinking, patients did just as well when a surgeon worked the night before surgery as when she or he didn’t. For patients, the study is reassuring and means one less thing to worry about before surgery. The message for policy makers is that placing regulations on night call for surgeons may not improve safety, and may even increase cost.

Of course, although the study suggests that surgeons’ sleep loss may not be as detrimental to patients’ outcomes as one would think, the authors acknowledge that other factors may have also contributed to the results. For example, the surgeons may have canceled morning procedures if they felt that they could not do their job safely, or may have scheduled a lighter day leading up to the night call.  Even so, the study shows that patient safety wasn’t compromised. It is also important to note that in this study, all the surgeons were fully licensed physicians, not trainees, and trainees are the very doctors most likely to be subject to limited hospital hours. Compared with trainees, fully licensed physicians are likely more experienced and may not be as affected by sleep deprivation.

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