The Right Choice?

How was your night, Doc? The limits of disclosure in preop


 

This morning I had the usual 7:30 a.m. elective surgical case scheduled. As I usually do, I went to see my patient at around 7 a.m. to review the procedure, answer any new questions that may have come up, and mark the incision site. My patient greeted me very cheerfully with the following questions, "How was your night? Did you sleep OK? Are you feeling good this morning? No arguments at home, I hope?" I readily answered, as I almost always do, when discussing things with patients in the preop area, that I am feeling good and ready for things to go well with the case.

I have been asked such questions many times over the years. However, for some reason the interchange with my patient this morning raised additional questions for me: Is it really acceptable for patients to ask such questions? Do I have an obligation to disclose such things? Do patients really want to know the answers or are they simply making nervous conversation?

In recent years, there have been a number of articles questioning whether surgeons should be required to disclose a lack of sleep to their elective surgical patients so that the patient can make a "truly informed" decision about what the risks of their surgery are. Thus far, there have been no such requirements at any hospital in the United States that I know of. But my patient’s questions raised a number of practical issues for me with such disclosure. We had already had a conversation in my office when I originally obtained consent for the procedure. I had carefully reviewed risks, benefits, and alternatives to the operation, and I had answered a list of the patient’s questions. Since I was actually the patient’s third opinion, it was clear that the patient already had significant background knowledge about the operation. The patient had signed the consent form before leaving my office.

At some point, before, during, or after my conversation with the patient, he had decided to trust me enough to allow me to do the operation. Subsequently, while home in the days prior to the surgery date, the patient had the opportunity to change his mind, but he actually came to the hospital on the morning of surgery. He had thus actively expressed his confidence in me by showing up for surgery. In this context, I believe that the patient’s questions were really a friendly way of expressing some degree of anxiety about the operation rather than an actual second guessing of my capacity to optimally perform the surgery. In this context, I believe that it is more important that I try to alleviate the patient’s concerns than that I give an expansive discourse on whatever stressful issues may be going on in my personal life.

Of particular importance is the issue of how much I have slept. I do not believe that I should discuss any concerns I may have with lack of sleep with my patient unless I have decided that I am not the best person to perform the surgery. I do not think that I would be doing my patient a service by, for example, saying that I didn’t sleep well and studies show that I might have altered judgment and asking the patient to sign a document that I have disclosed this fact. Such a disclosure seems to be designed to protect the surgeon and the institution rather than the patient.

However, if I believe that my lack of sleep, my personal stressors, or any other distraction will significantly hinder my ability to perform the operation safely, then I should not simply disclose these issues to the patient. Rather, I should explain why I should NOT be doing the surgery and either postpone the case or find someone else to do it if the patient requests this and if it is possible. Although some commentators have suggested that a sleep-deprived surgeon is the worst person to be able to assess his or her abilities to optimally perform an operation, I am convinced that we need to depend on the surgeon to make this assessment. Three central required components of professionalism are the exercise of self-regulation, the capacity to make decisions that are altruistic, and the discipline to abide by ethical standards. The issue of self-regulation is absolutely critical to the professionalism of any surgeon. The professionalism of the surgeon is the basis for patients trusting us to operate on them and make decisions in the operating room on their behalf. To mandate a separate disclosure to the patient about the amount of sleep the surgeon got the night before, or any other distracting issue, would be to cast doubt on the professionalism of the surgeon at the very time that patients most need to trust their surgeons.

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