Laparoscopic performance after one night on call in a surgical department: prospective study
BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7323.1222 (Published 24 November 2001) Cite this as: BMJ 2001;323:1222All rapid responses
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Dear Sir,
We read with interest the paper by Grantcharov et al 1 and commend
them for study of the important area of operative performance when sleep
deprived. We do however have some reservations.
All 14 subjects had limited experience in laparoscopic surgery,
having performed a median of 0 laparoscopic cholecystectomies; exposure to
other laparoscopic procedures was not mentioned. Such novices would be
likely to perform such a procedure only under close supervision and would
still be learning basic laparoscopic techniques. Therefore, the validity
of extrapolation of these data to experienced laparoscopists is difficult
to support. There would be merit in repeating the same protocol with
experienced laparoscopists.
Previous studies have suggested that the effects of sleep deprivation
are magnified by monotonous tasks while more interesting or novel tasks
may show no such effects2. We feel that MIST-VR tasks fall into the former
category when compared to actual surgical practice.
Most importantly, correlation of MIST-VR performance with objectively
-measured real-world laparoscopic skill has not been clearly established.
Indeed work from this unit found that MIST-VR performance did not
correlate with actual operating ability and was not able to discriminate
between surgically naïve and experienced groups. Trainee improvement after
a period of surgical training was also seen in controls that had received
no training3. The introduction of MIST-VR as a means of assessing
abilities in real-world surgical practice, be it in relation to sleep
deprivation or (ultimately) surgical competence, must not be considered
until validation against actual operative performance has been obtained.
Yours faithfully,
Peter J. Driscoll, Research Fellow,
Anna M. Paisley, Specialist Registrar,
Simon Paterson-Brown, Consultant.
Department of Surgery, Royal Infirmary of Edinburgh.
Reference List
1. Grantcharov TP, Bardram L, Funch-Jensen P, Rosenberg J.
Laparoscopic performance after one night on call in a surgical department:
prospective study. British Medical Journal 2001;323:1222-1223.
2. Kjellberg A. Sleep deprivation and some aspects of performance
III:Motivation, comment and conclusions. Waking and Sleeping 1977;1:149-
153.
3. Paisley AM, Baldwin PJ, Paterson-Brown S. Surgical simulation for
the assessment of surgical skill. British Journal of Surgery 2001;88:1525-
1532.
NO COMPETING INTERESTS.
Competing interests: No competing interests
All right. All surgeons are heroes. With a kick of adrenaline we will
make every patients sane and happy again. Did you ever hear something
about risk management, about human physiology? Do you really think, your
patients are eager to be treated by a half-wrecked doctor?
Competing interests: No competing interests
This paper, which has received much media attention in the United
States, has some flaws. The differences of a few seconds in time to
perform certain activities, while statistically significant, may not be
clinically significant. Virtual surgery is not the same as real surgery.
Most importantly, performing tasks at a simulator does not evoke the same
kind of adrenaline rush and level of concentration or intenstity as the
act of operating on a living, breathing patient. Pseudo-scientific papers
like this only serve to confound the already muddled debate on resident
trainee working hours in the US.
Competing interests: No competing interests
Grantcharov et.al.'s article was concerning but not surprising. They
report a shift system where the trainees were expected to sleep on duty
and this sleep disturbance will have undoubtedly contributed. A measurable
decrease in performance would have also, I'm sure, been more obviously
detectable for activities other than elective laparoscopy particularly
those requiring quick decisions in a life-threatening situation.
I disagree fundamentally with their final paragraph. Results such as these
should not lead us develop and evaluate countermeasures that can maximise
alertness and reduce fatigue but, rather, should galvanise us into
ensuring that those providing care do so without the need to consider
sleeping i.e. a proper shift system.
Competing interests: No competing interests
unsafe working practices: a wake-up call
In a recent high-profile court case, a motorist who fell asleep at
his wheel was jailed for five years. A judge condemned as "arrogant" his
claims that he could drive safely after a night without sleep.
Surely this is a wake-up call for Doctors all over the UK who still
allow their work to put them in the same position week-in, week-out?
A busy night on call impairs performance the following day (ref 1).
And despite the changes of recent years, many doctors still regularly
potentially work all day, all night, and then through the next day.
Reading the recent headlines I hope that another nail has been
hammered in the coffin of our unsafe working practices.
In 2002 it is simply no longer acceptable - in the eyes of the
public, the media, or the courts- for doctors junior or senior to treat
patients after prolonged periods without sleep. Doctors in this position
should act immediately to change the way they work, or risk being held
accountable.
1. Grantcharov et al. Laparoscopic performance after one night on
call in a surgical department: prospective study. BMJ 2001;323:1222-1223
Competing interests: No competing interests