Perspective
Sleep Deprivation, Elective Surgical Procedures, and Informed Consent
N Engl J Med 2010; 363:2577-2579December 30, 2010
Comments
open through January 4, 2011
- Article
A surgeon on overnight call responds to an 11 p.m. call from the hospital, where a patient has presented with an acute abdomen. After working up the patient for several hours, the surgeon decides to call in an anesthesiologist and perform a bowel resection. By the time the procedure is completed and the operative note has been dictated, it is time for morning rounds. The surgeon has not slept all night and is scheduled to perform an elective colostomy at 9 a.m. Does the surgeon have an obligation to disclose to the patient the lack of sleep during the past 24 hours and obtain new informed consent? Should the surgeon give the patient the option of postponing the operation or requesting a different surgeon? Should the hospital have allowed the surgeon to schedule an elective procedure following a night he was scheduled to be on call? Should it allow a surgeon to perform elective surgery after having been awake for more than 24 hours? What potential unintended consequences of disclosing a clinician's sleep deprivation should be considered?
Sleep deprivation adversely affects clinical performance and impairs psychomotor performance as severely as alcohol intoxication.1 Ensuring that physicians are not fatigued from sleep deprivation is a challenge for medical systems, given competing needs for continuity of care and 24/7 coverage of clinical services. In response to this problem, the Accreditation Council for Graduate Medical Education has revised its regulations regarding residents' work hours to restrict trainees who are in their first postgraduate year to a maximum of 16 hours of continuous work followed by a minimum of 8 hours off duty.2 No such regulations exist for fully trained physicians.
Performance of elective surgery in a new patient despite sleep deprivation from work with other patients cannot be rationalized on the basis of a continuity-of-care argument. Moreover, this is an area of clinical practice that may be amenable to policies aimed at improving patient safety by reducing the adverse effects of sleep deprivation.
Fatigue from sleep deficiency may be due to the loss of one night's sleep, chronic insufficient sleep, repeated interruptions of sleep, or misalignment of the circadian phase — which may be attributable to long work shifts, long workweeks, a sleep disorder, or personal circumstances. Researchers have documented the adverse effects of sleep deprivation and sleep disorders on individual performance.1 In surgery, there is an 83% increase in the risk of complications (e.g., massive hemorrhage, organ injury, or wound failure) in patients who undergo elective daytime surgical procedures performed by attending surgeons who had less than a 6-hour opportunity for sleep between procedures during a previous on-call night.3
Policies should take into account the circumstances that may lead to acute sleep deprivation before scheduled elective surgery. For example, a surgeon who is intermittently scheduled for overnight emergency call for a busy group practice or hospital will probably be awake much of the night. Alternatively, a surgeon who practices in a rural area and always carries a pager may only occasionally have to perform surgery in an emergency, such as a motor vehicle crash. Some institutions already have policies prohibiting physicians who cover busy practices from scheduling elective procedures on post-call days, thereby avoiding the first scenario. Such prohibitions should be standard practice. Policies that facilitate timely rescheduling of elective procedures or at least require that informed consent be obtained again under such circumstances may address the second scenario.
Unlike other practice areas, elective surgery is potentially amenable to rescheduling, although many competing interests influence that possibility, even when all parties stand to gain by avoiding errors and complications and improving outcomes (see table
Forces That Oppose the Rescheduling of Elective Surgery.). When no policy exists to facilitate rescheduling or to prohibit sleep-deprived physicians from working, the burden of deciding to proceed with the operation or reschedule it largely falls to the treating clinician, who faces competing interests and may choose not to inform patients or engage them in the decision-making process.Surveys indicate that most patients would be concerned about their safety if they knew that their doctor had been awake for 24 hours and would want to be informed of sleep deprivation; 80% say they would request a different provider in such circumstances.4 Given the data on sleep deprivation, the associated risk of surgical complications, and patient preferences, we believe that hospitals should prohibit the performance of elective surgical procedures when an attending surgeon or anesthesiologist is acutely sleep-deprived — and should ensure priority rescheduling of the canceled surgery.
As a first step, we recommend that institutions implement policies to minimize the likelihood of sleep deprivation before a clinician performs elective surgery and to facilitate priority rescheduling of elective procedures when a clinician is sleep-deprived. In addition, patients should be empowered to inquire about the amount of sleep their clinicians have had the night before such procedures.
The Sleep Research Society (SRS) has endorsed model legislation that would require physicians who have been awake for 22 of the previous 24 hours to “inform their patients of the extent and potential safety impact of their sleep deprivation and to obtain consent from such patients prior to providing clinical care or performing any medical or surgical procedures.” The American Academy of Sleep Medicine and the SRS have also endorsed model drowsy-driving legislation stipulating that the functioning of a person who has been awake for more than 22 of the previous 24 hours is impaired by sleep deprivation (www.sleepresearchsociety.org/GovernmentAffairs.aspx).
Chronic sleep deprivation degrades one's ability to recognize the impairments induced by sleep loss.5 Sleep-deprived clinicians are therefore not likely to assess accurately the risks posed when they perform procedures in such a state, and they should not be permitted to decide whether or not to proceed with elective surgery without obtaining the patient's informed consent. In keeping with the ethical and legal standards of informed consent, patients awaiting a scheduled elective surgery should be explicitly informed about possible impairments induced by sleep deprivation and the increased risk of complications. They should then be given the choice of proceeding with the surgery, rescheduling it, or proceeding with a different physician. If patients decide to proceed, they should explicitly consent to do so — in writing, on the day of the procedure, in front of a witness, and ideally on a standardized form designed for this purpose.
This approach would represent a fundamental shift in the responsibility patients are asked to assume in making decisions about their own care and might prove burdensome to patients and physicians and damaging to the patient–physician relationship. Yet this shift may be necessary until institutions take responsibility for ensuring that patients rarely face such dilemmas. Although it may be challenging to assess sleep deprivation, estimate the risk of resulting harm, and enforce a formal sleep policy that necessitates the disclosure of clinicians' personal information, we believe that the benefit of creating such a policy outweighs the burden. To implement such policies, institutions will need to absorb the financial and administrative consequences of canceling and rescheduling elective surgeries in a timely manner. But these steps might ultimately reduce institutional costs if outcomes are improved and complications reduced.
The problem of sleep deprivation vexes medical practice. Public debate and creative solutions are needed to ensure that patients' interests are protected. We believe that elective surgeries provide an opportunity to create and evaluate a policy designed to avert the adverse effects of sleep deprivation on patient outcomes. Strategies learned from applying such policies can then inform other areas of practice.
Editor's note: A related letter to the Editor from the American College of Surgeons appears in this issue (pages 2672–2673).
Dr. Czeisler is a former president of the Sleep Research Society (SRS) and a member of both the American Academy of Sleep Medicine and the SRS.
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
Source Information
From the Department of Anesthesiology, Hospital for Special Surgery, New York (M.N.); the Department of Anesthesiology (M.N.), the Divisions of Sleep Medicine (C.A.C.) and General Internal Medicine (L.S.L.), Department of Medicine, and the Center for Bioethics (L.S.L.), Brigham and Women's Hospital; and the Department of Global Health and Social Medicine (M.N., L.S.L.) and Divisions of Sleep Medicine (C.A.C.) and Medical Ethics (L.S.L.), Harvard Medical School — both in Boston.
- References
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Ulmer C, Wolman DM, Johns MME, eds. Resident duty hours: enhancing sleep, supervision, and safety. Washington, DC: National Academies Press, 2008.
2
Nasca TJ ,Day SH ,Amis ES Jr . The new recommendations on duty hours from the ACGME task force. N Engl J Med 2010;363:e3-e3
Full Text | Web of Science | Medline3
Rothschild JM ,Keohane CA ,Rogers S , et al. Risks of complications by attending physicians after performing nighttime procedures. JAMA 2009;302:1565-1572
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Blum AB ,Raiszadeh F ,Shea S , et al. U.S. public opinion regarding proposed limits on resident physician work hours. BMC Med 2010;8:33-33
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Van Dongen HPA ,Maislin G ,Mullington JM ,Dinges DF . The cumulative cost of additional wakefulness: dose-response effects on neurobehavioral functions and sleep physiology from chronic sleep restriction and total sleep deprivation. Sleep 2003;26:117-126
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Citing Articles
1
Lars Peter Holst Andersen, Mads Klein, Ismail Gögenur, Jacob Rosenberg. (2012) Psychological and Physical Stress Among Experienced and Inexperienced Surgeons During Laparoscopic Cholecystectomy. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques 22:1, 73-78
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Jason Y. Lee, Phillip Mucksavage, David C. Kerbl, Kathryn E. Osann, Howard N. Winfield, Kanav Kahol, Elspeth M. McDougall. (2012) Laparoscopic Warm-up Exercises Improve Performance of Senior-Level Trainees During Laparoscopic Renal Surgery. Journal of Endourology120104063043001
CrossRef3
Jonathan M. Tomasko, Eric M. Pauli, Allen R. Kunselman, Randy S. Haluck. (2012) Sleep deprivation increases cognitive workload during simulated surgical tasks. The American Journal of Surgery 203:1, 37-43
CrossRef4
Eric W. Schaefer, Mark V. Williams, Phyllis C. Zee. (2012) Sleep and circadian misalignment for the hospitalist: A review. Journal of Hospital Medicinen/a-n/a
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Vitalie Crudu, Jennifer Sartorius, Peter Berger, Thomas Scott, Kimberly Skelding, James Blankenship. (2012) Middle-of-the-night PCI does not affect subsequent day PCI success and complication rates by the same operator. Catheterization and Cardiovascular Interventionsn/a-n/a
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Maria Veronica Hegar, Michael S. Truitt, Alicia J. Mangram, Ernest L. Dunn. (2011) Resident fatigue in 2010: Where is the beef?. The American Journal of Surgery 202:6, 727-732
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Vincent D. Pellegrini. (2011) Perspective: Ten Thousand Hours to Patient Safety, Sooner or Later. Academic Medicine1
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James E. Coverdill, James G. Bittner, Mary Anne Park, Walter L. Pipkin, John D. Mellinger. (2011) Fatigue as Impairment or Educational Necessity? Insights Into Surgical Culture. Academic Medicine 86, S69-S72
CrossRef9
William Lineaweaver. (2011) Sleepy Surgeons and Patient Safety. Annals of Plastic Surgery 67:3, 203-204
CrossRef10
Benedict C. Nwomeh, Donna A. Caniano. (2011) Emerging ethical issues in pediatric surgery. Pediatric Surgery International 27:6, 555-562
CrossRef11
Geoffrey G. Hallock. (2011) Fatigue, Work Hours, Dinosaurs, and Other Fossils. Annals of Plastic Surgery 66:4, 323
CrossRef12
Pellegrini, Carlos A., Britt, L.D., Hoyt, David B., . (2010) Sleep Deprivation and Elective Surgery. New England Journal of Medicine 363:27, 2672-2673
Full Text
- Comments (21)
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21 Reader's Comments
GREGORIO MALDINI | Resident | Disclosure: NoneBAL HARBOUR FLJanuary 04, 2011sleep deprivation is bad, inexperience is much worse
The ideal situation is to have a very experienced and well rested surgeon. This is not always possible. The new breed of residents are very well rested but they lack the large experience of the past and worse, the commitment to patient care. Surgery used to attract the brightest people. In the last 10 years the smartest people did not even go to medical school. Now rest and family time are more important than ever. I trained in Italy and in the USA (thanks God during the 120 hours workweek). To have a good night sleep you should not worry about the case done in the afternoon (and this comes only with large experience). USA surgical care is dangerously shifting toward the european model that i know to well. Very rested doctors that are often incompetent as well. I wonder if the authors would like to have major surgery performed by a young rested surgeon vs a more experienced with a little less sleep.
ANNE MARCOUX, MD | Physician | Disclosure: NoneLANGHORNE PAJanuary 03, 2011Reality check
I recently received a silly and unnecessary call from a patient at 3AM that vexed me so much that I really didn't go back to sleep that night. There were 14 colonoscopies scheduled for me starting at 7:30AM. All these patients had had bowel preps and had taken off from work. Would anyone care to calculate the economics if I had simply cancelled my day's work, apart from the cost to my practice and to the surgery center? I can't cancel away the overhead!
Hospitals can't find enough specialists willing to take ER call already. This would be the final nail in their coffin.PAUL VAITKUS, MD | Physician | Disclosure: NoneJanuary 03, 2011It's the staff, too
The issue of sleep deprivation does not begin or end with the physician. If the interventional cardiologist is called in for an acute MI, so too are the "on call" cath lab staff who, at every institution I've worked in, are not excused from the next day's workload. Implementing the proposed changes, especially if they apply to staff as well as MD's (as rightly they should) will be a very costly endeavor for the hospitals.
HEATHER SANKEY, MD | Physician | Disclosure: NoneSPRINGFIELD MAJanuary 02, 2011This is a critical area where more research is needed
Thank you for this article. As previous commanders have pointed out, there is a lack of information in this area. I, too, trained during the years of every other night call (as an obstetrician). Now, after 18 years in practice, I can tell the difference between how I make decisions when I'm not chronically fatigued and when it's 5 in the morning after a very long week and little sleep. The adrenaline rush from an emergency helps, but also gives you a false sense of competence. It's not that your motor skills fall way off when you're a little tired, but sleep deprivation affects your decision-making. This is a very difficult thing to study AND there are differences between physicians. All of us know some who just can't handle long nights, but also some who can cat nap throughout the night and do well.
Importantly, many of us had a lot of time in medical school and residency to learn how our bodies handled fatigue. Medical students now take little, if any, overnight call. Residents are limited to working 24 hours. They are not going to be able or willing to work 36 hours, in part because they are trained to believe that they shouldn't. It's the reality of our future.STEVEN BROWN, MD | Physician | Disclosure: NoneGLENDALE WIJanuary 01, 2011Yes, Sleep Deprivation Affects Performance
Those who feel that they perform better while sleep-deprived are delusional. The evidence is overwhelming. Not to mention the risk to the physician and others on the road when the sleep-deprived doctor attempts to drive home.
Fortunately, those like myself, who were born on Krypton before it exploded, need not worry about sleep deprivation. But the rest of you should take heed.VERONICA LERNER, MD | Resident | Disclosure: NoneNY NYJanuary 01, 2011This article totally missed the point
I am a practicing obgyn and am quite familiar with issues at stake. I think this article raises a very important issue but totally missed the point of how to fix the problem. I am curious to know if authors are practicing surgeons because to me that seems highly unlikely based on what they write.
I work in a large practice in NYC and take overnight in house call only once a month. We are all salaired, work for the hospital and go home after 24 hour call with no clinical responsibilities scheduled the next day. A few years ago, when our administration changed, they tried to take the post call day off away in order to maximize the profits by making us work the next day. Because of the outcry it caused on our part, they had to give that idea. Similarly, obgyns in private practice are forced to work the next day because they cannot afford a post call day off. In the modern era of decreasing profits and increasing costs, it all comes down to money! I think this is really unfair to PUT THE BURDEN on the surgeon by MAKING them inform their patients they were up all night! The government, the hospital, the society--should give surgeons a day off and pay them for it!Hélcio Giffhorn | Physician | Disclosure: NoneBrazilDecember 31, 2010SLEEP DEPRIVATION, ELECTIVE SURGICAL PROCEDURES,AND INFORMED CONSENT.
Restriction in working hours for surgeons is an appropriate decision. Working in extreme circumstances is a talent of few surgeons. Sleep deprivation adversely affects performance and the same occurs in aviation. I agree with the comments published in: Ann Thorac Surg 2005;80:2419-23 by Totaro 's. The fact is not increasing a scenario of dilemmas but an understanding and reponsability that failure could happen and, that performance could be considered if a complication occurs. Cardiac Surgery is stressful sometimes and we cannot have faster decisions with sleep deprivation.
Peter Ekeh | Physician | Disclosure: NoneDecember 31, 2010Beware of mandates not supported by data
While the authors have good intentions and their assertions seem to "make sense", I think it is dangerous to impose mandates on physicians that are unsupported by clear data.
As a surgeon, I have personally postponed cases when I felt I was unable to perform optimally - due to fatigue or rarely illness. I can use my judgement to decide appropriately not to start 6 hr difficult case after being up all night on call. I do not need a "hospital rule"
Is there evidence that this is an ongoing serious problem? Should I also disclose to my patients that I was up all night because of an newborn or a "sick child"?George Linhardt | Physician | Disclosure: NoneDecember 31, 2010Ego over common sense
Having been in practice for almost 30 years,I thought, I could operate regardless of sleep when i was younger. . Now I know that I am neither better nor equal with less sleep. I have seen surgeons across the table be barely able to function while operating due to fatigue. I remember one surgeon who fell asleep performing surgery and had to wake them up. They were not chemically impaired, but tired, exhausted. When faced with litigation, skilled plaintiff attorneys will review one's prior activities to an event. Pilots on long missions have relief or chemical stimulants to finish the mission. A truly good athlete or soldier will take themselves out of a planned mission if it will harm his team. The problem with cognitive errors is that you do not know you are making a mistake. How many of us went out the night before we were to take the MCATs when applying to medical school? We are not robots, or machines. We have an ethical obligation to do no harm, and to be our best. We are not as tough as we think. Unfortunately, hospitals are reluctant to embrace this thought as it will increase their cost of providing service for emergency services.
In response to Dr. Pelligrini's comments:
Yes, a liver transplantation is a more complex surgery than a colostomy. Lap choles are routine operations. Both are very major and complex if one is the patient. Both should be routine for the surgeon of record. Routine, usually straightforward procedures, can become suddenly difficult. The argument is not that disclosure is bad but it should be encouraged and surgeons should step away if possible if they cannot provide their sworn best effort. It should not be a financially decision for the surgeon or hospital. What is the harm if you step away, other than inconvenience. A rescheduled surgery is better than an untoward result. What would the patient prefer?Skeptical Scalpel | Physician | Disclosure: NoneDecember 30, 2010Sleep Deprivation
1. Surgeons are not pilots and patients are not airplanes.
2. I wonder if the authors have ever spoken to anyone who works in the real world.
3. There are numerous reasons that their proposal will not work. Read a few if them here http://tiny.cc/h2l4t.R. BRENT NEW, MD | Physician | Disclosure: NoneAUSTIN TXDecember 30, 2010Who will decide for me next?
I would applaud the article by Nurok, et al, were it intended to inform and stimulate a debate... but it has done no such thing. Instead, I am appalled by this authoritative proclamation of academic sleep specialists instructing changes of our surgical practices via proposed legislation and explaining how "institutions will need to absorb the financial and administrative consequences of canceling and rescheduling elective surgeries in a timely manner." Astounding. Who will drive the next wedge into the doctor-patient relationship? The line is getting longer and longer. The ACGME rules regarding work hour limitations of residents in training (starting in 2003) have not been shown to reduce medical errors or produce better/safer doctors. Because of the lack of continuity of care, quite the opposite may be true. Sleep deprivation has not been shown to affect results in cardiac surgery. Shall we continue to remove common sense from the solution equation, even if we haven't defined the "problem"? I felt like I was reading the Op Ed page of the NY Times. Troubling to see this article published in NEJM. Will it become another JAMA?
Howard Krauss | Physician | Disclosure: NoneDecember 30, 2010Regulating Physician Behavior
Undoubtedly, there is no end to our desire and ability to regulate the behavior of our colleagues. The sleep-deprived physician, however, will soon be a relic of the past. In the US there are ever-mounting regulatory and economic pressures that ultimately will create an environment wherein every practicing physician will be a salaried employee, and then ultimately, a shift-worker, such that all concerns of overwork will be gone. A few other things may be discarded along the way, perhaps leading to a more impersonal and less "giving" relationship between physicians and patients, but physicians will no longer need to be concerned or burdended about their patients' well-being when their shifts are done. ... "Good afternoon Ms. Smith - I'm Dr. Larry - I'll be starting your colostomy today - a surgeon from the registry will come in at 3 o'clock to finish." So it goes. The wonks and tablet-holders will be satisfied.
BRIAN SHAPIRO, MD | Physician | Disclosure: NoneGRAND BLANC MIDecember 30, 2010I operate better with less sleep
I operate better with less sleep. Sluggish with to much sleep. This comes from 23 years of training with every other night call for my busy General Surgery practice. The evidence of adverse outcomes from sleep deprivations is laughable. Mostly study's that look at how often an Intern yawns after being up all night.
neil feinglass | Physician | Disclosure: NoneDecember 30, 2010This is an important article that references fatigue and sleep deprivation
This is an important article that references fatigue and sleep deprivation among surgeons and those who work under medical systems that have not adapted to minimize this issue. The dialogue up to now only addresses sleep deprivation in medical education, not the aged surgeon, anesthesiologist, or critical care physician who often has difficulty functioning after long hours of extended high intensity performance or complex care situations. The JCAHO should add these parameters into their National Patient Safety Goals in the future.
ELISE GIGNAC, MD | Physician | Disclosure: NoneSASKATOON SK CanadaDecember 30, 2010Sleep deprivation
As an anesthesiologist I would not anesthetize an elective patient after working 22 hours straight. A simple solution would be to have a call schedule where the surgeon would not be operating or performing other procedures the day after call. Could not an office be booked days post-call?
Kithsiri Senanayake, MBBS | Physician - Surgery, General | Disclosure: NoneKANDY Sri LankaDecember 30, 2010Sleep Deprivation and Surgeons from Developing Country
Sleep deprivation due to over work load is a major problem to surgeons in developing countries. In Sri Lanka the surgeons performed substantial contribution to upgrade the health. We work round the clock and the days that I had no sleep during last year is many. The surgeon who did emergency surgeries in last night should be given the day off. However the inability to do so in a developing country is due multiple reasons. The trained surgeons are appointed mainly to 'popular' stations and the number of patients is very high. Limited subspecialisation has lead to the over work load to general surgeons. The training institutes of surgeons should aim at training the ‘General surgeons with special interest’ in various fields. Eg General surgeons with especial interest in vascular surgery. Policy maker should upgrade the peripheral hospitals which are correctly happening now in Sri Lanka. There is no doubt about the fact that the patients right to inquire about the fitness of his surgeon hence about the sleep deprivation.
YVETTE BUNCH, BS EMT | Other | Disclosure: NoneSPARTANBURG SCDecember 29, 2010Informed Consent
I applaud your article. Sully Sullenberger captain of "Miracle on the Hudson" appeared before US Congress and FAA requesting stricter rest times for pilots. He argued the time down on the ground must take into consideration the time it takes to get from the gate, to the shuttle, to a hotel. Ensuring that all pilots receive adequate rest is key to maintaining a safe aviation system. FAA Administrator Randy Babbitt has made the creation of new flight, duty, and rest rules based on fatigue science a high priority. The FAA is working on an aggressive timeline and a system not updated since the 1940's is being overhauled. We must learn from aviation standards.
JOEL CLEARY, MD | Physician | Disclosure: NoneHAVRE MTDecember 29, 2010better hire some more surgeons!
The issue of sleep deprivation and a surgeon's compromised skills is far from new. I remember deciding not to select a particular residency program because the intern year you were on call every other night with no sleep, and went home in the late evening on the night you were "off call." During my orthopaedic surgery residency, both Surgery and Medicine residents endured 36-48 hour shifts with little sleep, as many of us "older" doctors remember.
But be careful if someone passes another rule. It is estimated that by 2015 there will be only enough orthopaedic surgeons to provide total knee surgery to 1/3 of the patients that need the procedure. There is an evolving doctor shortage, and who will take care of all these patients if there are further mandates against doctors trying to do their job?
Better find more surgeons, or fewer patients!
Joel Cleary, MD, MHAJAMES GAMMIE, MD | Physician | Disclosure: NoneSTEVENSON MDDecember 29, 2010not supported by the data
The authors state with authority that sleep deprivation increases the risk of error during surgery. There exists strong evidence that this is not the case in cardiac surgery (Ann Thorac Surg. 2004 Sep;78(3):906-11)
Sleep deprivation does not affect operative results in cardiac surgery.
Ellman PI, et al.
Nurok's strong but unsupported assertions are another attempt to deprofessionalize medicine. Our most important task as physicians is to hold the interests of the patient first. I agree with the ACS that the decision to proceed with an elective operation should lie with the surgeon. This seems to be a weak attempt to create a new way for plaintiff lawyers to sue physicians.GARY WELCH, MD | Physician | Disclosure: NoneDecember 29, 2010Sleep deprivation and performance
I have personally observed the effects of sleep deprivation in a team up all night doing a transplant and then performing an elective case. I have also experienced colleagues making little sense in their responses when sleep deprived. I think this is a move in the right direction. Truck drivers and pilots are supposed to get appropriate breaks. One of the potential causes of the commuter airline crash in Buffalo a few years ago was pilot fatigue. Physicians are human and subject to the same effects of sleep deprivation. Sixteen continuous duty hours is equivalent to a blood alcohol of .08. Tell the patient that when getting informed consent.
- Letters
? Superman syndrome
Let's be honest physicians work the next day with minimal sleep for pure financial reasons. It may be unavoidable in small groups but it is still a financial decision. There is no way on earth a physcian with two hours of sleep will deliver quality work. Would we really subject ourselves or family members to providers who have been up all night (for elective cases the next day)? Why is it good enough for non family members?