Sleepless Surgeons: Insights From a Study on Consultant On‐Call Interruptions

Unsafe working hours are reported by up to one in two doctors in any given week [1]. Much data relates to junior doctors [1-3] with limited information regarding sleep interruptions during on-call periods, particularly among consultants. Surgeons are renowned for carrying significant ‘on-site’ workloads, but are also frequently on-call for periods of at least 24 h, with responsibility for patients admitted emergently, regardless of the time of day [4]. The effect of these shifts, and in particular overnight sleep disruptions, has largely been ‘off-site’ and ‘out of mind’. Sleep deprivation, both acute and chronic, is known to induce stress, inflammation and negatively impact cognitive performance and behaviour [5-7]. In addition, there are strong links between chronic, repeated sleep interruptions and surgeon burnout [8-10]. After completing a narrative review of the available literature, a mixed-methods, cross-sectional study investigating night-time interruptions for on-call surgeons was conducted in four public hospitals in the lower Hunter region, NSW, Australia (non-capital city but classified as metropolitan) [11]. Over 14 consecutive days from 1 April 2024, consultant surgeons were contacted by phone at 7:00–8:00 AM the morning following their on-call shift and asked to complete a verbal survey. In the event of an unanswered call, a repeated attempt was made 10 min and, if needed, 2 h later. All on-call surgical subspecialties were surveyed at John Hunter Hospital Newcastle (tertiary hospital with 796 beds); and general surgery services at Belmont District (140 beds), Maitland (339 beds) and Calvary Mater Newcastle (215 beds) Hospitals. A 10-item survey (piloted in December 2023, Supporting Information 1) assessed on-call interruptions (OCCs, defined as voice-call or text message) for the 12 h between 20:00 and 08:00. The emphasis was on sleep disturbance, recording the frequency, timing and duration of OCCs, with timing divided into three time periods: Evening: 20:00–21:59; sleep-time: 22:00–05:59 and morning: 06:00 until survey phone-call. Other causes of sleep disruption, cumulative nights of sleep disruption and self-reported perceptions of being well rested were also reported. Additionally, open, unstructured responses were encouraged. A waiver of ethical review was obtained from the Hunter New England Health Human Research Ethics Committee (AU292309-04). The survey response rate was 70% (168/238 surgeon respondents), recording 277 OCCs, average 1.65 OCCs/surgeon/night surveyed. Evening-time OCCs accounted for 45.5% and sleep-time OCCs accounted for 46.2% (Figure 1). Work-related sleep disruptions were reported by 34% of surgeons, with seven (4%) surgeons being woken by OCCs five times in a single on-call night. Neurosurgery (21.1%), General Surgery John Hunter (17.2%) and Paediatric Surgery (8.6%) reported the most sleep-time OCCs (Figure 2). The most common reported OCC duration was 2–5 min (48%), with 13% being < 1 min, 14% 1–2 min, 16% 5–10 min and 10% > 10 min (Figure 3). The majority of OCCs required discussion of information only (71.5%). However, 20.2% OCCs required surgeons to log in remotely to review clinical or radiology results, 2% to attend the hospital to review a patient and 6.5% to attend the hospital to operate. Many surgeons (35.5%) reported being able to fall back asleep within 30 min, but 11.1% reported that it took > 1 h to fall back to sleep, and 16.1% could not get back to sleep after the OCC. Sleep disruptions for non-work related reasons were reported by 25%, mostly due to children (16.7%). In a 7-day week, the median number of nights of sleep disruption was 2, with 23 surgeons (12%) reporting sleep disruption every night, 81% due to work commitments. When asked ‘How rested due you feel this morning’, the median response was 7 (range 1–10 where 10 is ‘perfectly rested’). Unstructured responses were grouped thematically with exemplar quotes presented in Table 1. Does have negative impacts, my mind is constantly thinking Mentally exhausted, physically fine Went to bed late due to operation Leaving the hospital at 12.30 am and waking up for work at 5.30 am means there is not much time to be disturbed Due to hospital on-call hours, normal sleeping patterns and hours are already disrupted There were several differences in the number of sleep interruptions across the participating specialties and hospitals. This may be influenced by the varying seniority and experience of registrars within specialties, and their capacity to handle different clinical scenarios without consultant input. A 2021 study on junior doctors identified that the confidence to escalate cases to senior staff is influenced by hospital policies, the presence of a lack of standardised protocols and the implied attitudes of different specialties [12]. This may also explain the variability of results across the same specialty of General Surgery within different hospitals. The results of this study should also be interpreted within the context of the NSW Health state award that provides no additional remuneration for on-call duties for staff specialists [13]. For visiting medical officers, there is no specific remuneration for OCCs, even those akin to telehealth (where surgeons login, review patient notes, results and provide advice) [14, 15]. The data in this study adds weight to current moves to modernise surgical awards, in line with current medical practice patterns. There are a number of limitations to this study, including the lack of prior comparative literature, the lack of a previously validated survey, lack of detailed information regarding the nature and appropriateness of OCCs, lack of surgeon demographics (as this may have been identifying) and differences in the timing of the ‘start of on-call overnight shift’ between specialties. Nevertheless, this study has several strengths, including a mixed-methods design with a large sample size across hospitals, and a wide range of surgical specialties. On-call consultant surgeons in this study experienced frequent and significant sleep interruptions, often over multiple nights within a week. This is one of the first studies to document sleep disturbance in consultants, unmasking a potential serious issue for workforce retention and patient safety. Repeated sleep disturbances may have a negative impact on surgical performance and wellbeing with the accumulation of physical and mental fatigue a likely contributor to burnout, health decline and workforce attrition. On a policy level, there is a need for system-level recognition, better call triage and incorporation of consultant fatigue into workforce planning. Future research should continue to explore consultant fatigue throughout the various specialties within different hospitals and health districts, providing a broader scope in which to further examine the important issues of surgeon sleep deprivation, chronic exhaustion and burnout. This research acts as a foundation for the creation of policies to reduce burnout rates and facilitate better patient-centred care. Colin Chong: methodology, data curation, investigation, formal analysis, writing – original draft, writing – review and editing. Nick Bui: methodology, data curation, investigation, writing – original draft. Elly Henner-Cwirn: methodology, data curation, investigation, formal analysis, writing – original draft. Jonathan Gani: conceptualization, methodology, investigation, validation, formal analysis, supervision, visualization, project administration, resources, writing – review and editing. Mersidon Fernandez: methodology, data curation, investigation, formal analysis, writing – original draft. Kavesha Sarangadasa: methodology, data curation, investigation, formal analysis, writing – original draft. Christine J. O'Neill: conceptualization, methodology, software, investigation, validation, formal analysis, supervision, visualization, project administration, resources, writing – review and editing. Open access publishing facilitated by The University of Newcastle, as part of the Wiley - The University of Newcastle agreement via the Council of Australasian University Librarians. The authors have nothing to report. The authors declare that they have not used generative AI for the writing of this research. The protocols of the study have met the requirement for a waiver of ethical review and have been approved by the HNELHD Human Research Ethics Committee (authorisation number AU292309-04). A/Professor Christine J. O'Neill is an Editorial Board member of ANZ Journal of Surgeons and a co-author of this article. To minimise bias, she was excluded from all editorial decision-making related to the acceptance of this article for publication. The other authors declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request. Supporting Information: 1. Study survey. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.