Should Surgeons' Work Hours Be Capped Like Pilots'?

Kerry Dooley Young

June 28, 2018

The number of hours worked by surgeons should be capped to reduce harmful mistakes caused by exhaustion and burnout, according to an editorial published online June 25 in the Journal of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (JISAKOS).

The researchers also aim to reduce stress-induced bad habits such as excess drinking.

In the editorial, C. Niek van Dijk, MD, PhD, notes the working hours of airline pilots and train drivers are carefully monitored and that these employees are subject to testing for drugs and alcohol abuse. (The same also applies in the United States to truck drivers.)

"Why aren't we surgeons monitored and similarly prevented from overworking?" van Dijk asks. "Are we assumed to be morally superior because of our Hippocratic Oath? Or is it because we can only damage the occasional patient if we are exhausted, rather than an entire planeload?"

The editorial is part of a growing body of literature documenting concerns about burnout among physicians. Practitioners of general surgery as a group fell on the higher end of the ranking in Medscape's National Physician Burnout and Depression Report for 2018. This group had a 43% burnout rate, with critical care and neurology (48%) and family medicine (47%) holding the top rungs. Lower down in the rankings were orthopedics (34%) and plastic surgery (23%).

In the editorial, the veteran orthopedic surgeon van Dijk says colleagues in his field of sports medicine and orthopedics "seem happier and less strained than our comrades in emergency surgery or even general surgery."

"It is simply because, I would suggest, we do not deal as much with life and death issues. In fact, we rarely need to think about death. We are closer to artisans — to sculptors and restorers," van Dijk writes. "In short, we don't need to anaesthetize ourselves as well as our patients."

Still, even van Dijk's relatively happy specialty is subject to many of the same pressures and problems shared by other surgeons. In the editorial, van Dijk recalls an incident from the early days of his career in the 1980s. He said he was invited to perform a live surgical demonstration "far away from home."

"In talking with the anesthesiologist, I noticed a heavy smell of alcohol. It was 2PM. What was I to do? I took my host aside, but he reassured me that he 'works better after a few beers, it's normal,' " van Dijk wrote. "I accepted and performed my demo. My public was happy and the surgery successful."

In the editorial, van Dijk said he know thinks he should have refused to perform the surgery.

In an interview with Medscape Medical News, van Dijk said there can be financial reasons for surgeons to put in long hours, including pressure from employers and layering private practice on top of work for national health services. These demands plus on-call duty can routinely have surgeons working from morning into evening. Surgeons respond as well to the needs of those who require their skills, he said.

"You want to be there for your patients. You don't want to have waiting lists," van Dijk told Medscape Medical News. "You are stimulated to always work."

van Dijk also said the administrative work associated with his job has swelled from occupying about 6% of his time at the start of his career to about 40% now.

"It's increased dramatically over the years. And that's not what we are on Earth for, to do administration," he said in an interview. "We're on Earth, as surgeons, to do our work, to see our patients."

American College of Surgeons Report

The American College of Surgeons (ACS) has been wrestling for years with the issues that van Dijk explores in his editorial.

Its "Being well and staying competent: Challenges for the Surgeon" report, created in 2012, notes that healthcare systems and hospitals don't have an incentive to limit surgeons' working hours. Instead, that decision often is left to the surgeons, who may be "conflicted and unable to make a rational evaluation" of their level of sleep deprivation, the report said. There have been calls to have patients weigh in on whether tired surgeons should perform an elective scheduled procedure.

"Some leaders of the [ACS] rightfully question whether each and every patient scheduled for surgery can make an informed decision on the day of surgery as to whether to proceed with the proposed procedure or to reschedule, if the proposed surgeon has been up all night caring for other patients," the report said.

The ACS instead argues for "a coordinated and systematic approach to the issue of surgical sleep deprivation."

Krista Kaups, MD, a past chair of the ACS' Governor's Committee on Physician Competency and Health, told Medscape Medical News a reason why van Dijk's idea of using the limits on pilots' hours as a model would not translate well to surgery.

One surgeon may have specialized knowledge of certain procedures or know the patient particularly well. "Pilots often have a copilot who can take over, or they trade off duties, or on long flights somebody will go and take a nap," Kaups said. "The trouble is you can't very well, in the middle of an operation, have the time clock go off and the surgeon say, `Well, tag. You're it.' "

Still, she agrees with van Dijk on the need to address burnout. In many cases, surgeons face the same issues seen in other fields of medicine, such as a loss of autonomy because of greater hospital ownership of physician practices. Administration, in the form of electronic medical records, also contributes to surgeons' feelings of dissatisfaction, she said.

"It's the frustration of dealing with a system that wasn't exactly designed by clinicians," Kaups said. "At times, EPIC is a four-letter word."

Kaups noted that van Dijk's editorial cited a study published in 1991 as the reference for this claim, making it a bit dated: "It has been shown that there are more heavy drinkers among physicians than among the general population." The ACS report said that data suggests that the prevalence of alcohol and drug abuse among physicians likely is similar to that of the general population

Still, Kaups and others within the ACS acknowledge concerns about problem drinking in the profession.

"We know that for surgeons the substance of abuse tends to be alcohol," she said. "That gets tied in with burnout and depression."

In the report, ACS said that physicians may have a sense of "invulnerability" that may lead them to underestimate their risk for abuse of alcohol.

"Personality traits such as obsessive-compulsive disorder may lead to success in medicine but may also predispose physicians to impairment," the report said. "Indeed it has been shown that substance abuse has early roots, and a healthcare professional's underlying personality or behavior disorder may be unmasked by the stress of his or her chosen occupation."

The editorialist has disclosed no relevant financial relationships.

JISAKOS. Published online June 25, 2018. Extract

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