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Dec 2020

Surgeon Life Events, Stress, Fatigue Create Risk for Patients

There was a good amount of attention paid a few years ago to what is now known as the “weekend effect.”  This refers to a finding that death rates of patients admitted to hospitals over the weekend tend to be higher than for those admitted during the week. Whether this is due to only the sickest patients being admitted during the weekends or to the fact hospitals tend to have reduced and/or more junior staff on call during this time (or a combination of both) remains open to interpretation.  

And if this phenomenon wasn’t enough for providers to contend with, it now seems they also need to worry about the recently discovered “birthday effect.”  

According to a recent study published in the British Medical Journal, patients who undergo surgery on a surgeon’s birthday experience a higher mortality when compared to patients who undergo surgery on other days of the year.  

How much higher?  

According to the study, the patients who underwent a surgical procedure on a surgeon’s birthday had a mortality rate of 6.9 percent compared to 5.6 percent (within 30 days after surgery) for those performed on other days.  Interestingly, the researchers found that the “birthday effect” did not impact the mortality rates of elective surgeries.

To arrive at this conclusion, researchers analyzed the outcomes of almost one million surgeries performed by some 47,000 surgeons on patients aged 65 to 99-years-old.  Patients underwent one of 17 major medical procedures covering four of the most common cardiovascular procedures and 13 of the most common non-cardiovascular surgeries among this patient demographic.  The latter included such procedures as hip and femur fracture, appendectomy, spinal fusion and splenectomy. Given that an estimated 11 – 30 percent of diseases globally require some sort of surgical intervention, the total number of patients potentially impacted by the “birthday effect” is not insignificant.

What is concerning to note is that this increase in mortality is fairly similar to the difference in mortality rates between other special events/holidays, such as Christmas and New Year’s Eve, and non special events/holidays.  It also is comparable to what data show for weekend surgeries.  Researchers suggest that on holidays and other days celebrating life events, such as birthdays and anniversaries, surgeons may have distractions beyond the usual ones, such as noise, conversations and equipment problems, that routinely occur in the OR suite. These may include additional telephone text messages and conversations with the surgical team about the special event.  

Another theory is that on their birthdays (or other celebration days), surgeons may feel pressed for time and therefore to try complete their rounds and scheduled surgeries as quickly as possible to meet outside commitments.  There is research suggesting that this type of time pressure might impact an individual surgeon’s ability to avoid errors in decision making, which could affect a procedure’s outcome.  It also may increase the risk of what is known as “confirmation bias,” which is a tendency to see what will confirm expectations and failing to see what may contradict those expectations.  With this bias, for example, if a surgeon is looking for evidence that the surgery is successfully completed, he or she will tend to see that evidence rather than indications that there are potential problems.  Another possible result of feeling time pressure is that the surgeon may allow junior surgeons to do more of the procedure, which could also result in a poorer outcome.  They also may be less prone to return to the hospital in the evening to personally check on patient status. 

Independent of the “birthday effect” itself, the role of other OR distractions on surgical outcomes can neither be minimized nor ignored since these also have been linked to medical error.  According to research, the most common of these – many of which can be mitigated to a large degree – are movement, conversation that is not related to the surgery taking place, and equipment and procedural distractions.  There is also evidence that auditory and mental distractions have a more deleterious effect on surgical performance than do visual distractions.  They also show that more inexperienced surgeons reduce their speed when distracted while more seasoned surgeons usually do not.  

Another surgeon-related factor that can negatively impact the outcome of surgical procedures is an individual surgeon’s temperament and interpersonal communications skills. One study found that patients of surgeons who behaved unprofessionally around their colleagues tended to have more complications after surgery. The supposition is this type of behavior can negatively impact the surgical team’s performance which, in turn, can threaten patient safety. To give an idea of how much of an impact negative behavior can have, the researchers found that when surgeons had at least one report of unprofessional behavior in the previous three years, their patients were 12 – 14 percent more likely to experience complications in the 30 days after their surgery.  

An overview of factors that can impact a surgeon’s performance needs to include the roles of stress and mental fatigue.  While in the OR, a surgeon uses both technical and nontechnical abilities, both of which can be negatively impacted by stress which, understandably, can threaten patient safety. It also is worth noting that two nontechnical abilities that can be affected by stress are communication and decision making.

There are several steps providers can take to minimize and mitigate factors that can negatively impact a surgeon’s performance.  

  • One of the easiest, of course, is to reduce the amount of both elective and non-elective surgeries taking place on a surgeon’s birthday or other special occasion.   It seems that surgeons themselves may see the benefits of not performing surgical procedures on these days as evidenced by the fact that a number of surgeons chose not to operate on their birthdays.  Another is to monitor surgical team feedback about a surgeon’s interpersonal and leadership skills to determine if any training may be indicated.  This may be very helpful since awareness can often improve surgeon behavior. 
  • Another step is to ensure that surgeons have the ability to listen to their preferred music in the OR (should they want to listen to music) as a way of lowering stress levels.  Supporting this idea is a study that showed that when plastic surgeons listened to the music they wanted, their surgical technique and efficiency when closing was improved.  
  • Other things providers can do is work with surgical residency programs to help better train residents to have their technical and interpersonal skills be less affected by distractions in the OR.  They also can develop fatigue-management programs to minimize the risks of mental fatigue on surgical outcomes. To this end, the American College of Surgeons and The Joint Commission have developed statements on fatigue and offered strategies for recognizing and managing its effects.

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