Importance. The association between physician fatigue and patient outcomes is important to understand but has been difficult to examine given methodological and data limitations. Surgeons frequently perform urgent procedures overnight and perform additional procedures the following day, which could adversely affect outcomes for those daytime operations. Objective. To examine the association between an attending surgeon operating overnight and outcomes for operations performed by that surgeon the next day. Design, setting, and participants. In this cross-sectional study, a retrospective analysis of a large multicenter registry of surgical procedures was done using a within-surgeon analysis to address confounding, with data from 20 high-volume US institutions. This study included 498 234 patients who underwent a surgical procedure during the day (between 7 AM and 5 PM) between January 1, 2010, and August 30, 2020. Exposures. Whether the attending surgeon for the current day’s procedures operated between 11 PM and 7 AM the previous night. Two exposure measures were examined: whether the surgeon operated at all the previous night and the number of hours spent operating the previous night (including having performed no work at all). Main outcomes and measures. The primary composite outcome was in-hospital death or major complication (sepsis, pneumonia, myocardial infarction, thromboembolic event, or stroke). Secondary outcomes included operation length and individual outcomes of death, major complications, and minor complications (surgical site infection or urinary tract infection). Results. Among 498 234 daytime operations performed by 1 131 surgeons, 13 098 (2.6%) involved an attending surgeon who operated the night before. The mean (SD) age of the patients who underwent an operation was 55.3 (16.4) years, and 264 740 (53.1%) were female. After adjusting for operation type, surgeon fixed effects, and observable patient characteristics (ie, age and comorbidities), the adjusted incidence of in-hospital death or major complications was 5.89% (95% CI, 5.41%-6.36%) among daytime operations when the attending surgeon operated the night before compared with 5.87% (95%CI, 5.85%-5.89%) among daytime operations when the same surgeon did not (absolute adjusted difference, 0.02%; 95% CI, −0.47%to 0.51%; P=.93). No significant associations were found between overnight work and secondary outcomes except for operation length. Operating the previous night was associated with a statistically significant decrease in length of daytime operations (adjusted length, 112.7 vs 117.4 minutes; adjusted difference, −4.7 minutes; 95% CI, −8.7 to −0.8, P=.02), although this difference is unlikely to be meaningful. Conclusions and relevance. The findings of this cross-sectional study suggest that operating overnight was not associated with worse outcomes for operations performed by surgeons the subsequent day. These results provide reassurance concerning the practice of having attending surgeons take overnight call and still perform operations the following morning.
Commentaire du Dr Marius Laurent (PAQS)
- Voilà un sujet controversé, abordé ici rétrospectivement à partir de données d’un registre regroupant les interventions de 20 hôpitaux aux USA pendant un peu plus de dix ans, soit près de 500 000 interventions effectuées par 1 131 chirurgiens. Pour 13 098 de ces interventions, le chirurgien avait opéré la nuit précédente (entre 23 heures et 7 heures). L’étude ne décèle pas de différence de mortalité, de complications majeures ou mineures. Une pierre de plus au monument qui fait du chirurgien un héros, qui contrairement au conducteur de poids lourd ou au pilote d’avion de ligne semble insensible à la fatigue. On aimerait tellement ne pas en douter… Bien sûr, l’étude est vaste et bien faite, mais elle reste une étude observationnelle rétrospective. Elle se déroule dans de grandes institutions : nous n’avons pas d’information sur la taille des équipes au travail ni sur leur niveau de qualification, mais nous pouvons supposer que cet encadrement est optimal, voire généreux. Nous ne savons rien quant à la liberté du chirurgien de choisir son intervention du lendemain, éventuellement en en choisissant une plus légère (on sait que cette intervention dure marginalement moins longtemps que celles qui ne sont pas précédées d’une chirurgie nocturne : travail plus rapide ou intervention plus simple ?). Quoi qu’il en soit, l’éditorial qui accompagne l’article souligne que l’article est rassurant pour le patient, mais que l’on ne peut pas faire l’impasse sur le nombre croissant de burn-out et de désordres psychologiques chez des praticiens fatigués et privés de sommeil, l’effet de la pandémie de Covid-19 l’a bien illustré [1].
Sun EC, Mello MM, Vaughn MT, et al. Assessment of perioperative outcomes among surgeons who operated the night before. JAMA Intern Med 2022;182(7):720-728. Doi : 10.1001/jamainternmed.2022.1563.
Note :
1- Leya GA, Feldman ZM, Chang DC. Are surgeons really more resilient than athletes?: the trade-off between surgeon outcomes and surgeon well-being. JAMA Intern Med 2022;182(7):728-729.