A few years ago during a visit home, my mother interrupted me as I was recounting the details of a transplant operation I'd done a week earlier. For as long as I've been a doctor, my mother, who owns a small business, has queried me about my long work hours, usually punctuating her questions with sympathetic clucks and gentle exhortations to eat more of the Taiwanese food she has prepared.
This time, however, there was no softness to her voice. She wanted to know exactly when I had begun the operation. When I finally told her that the start time had been well past midnight after a full day's work, she pushed away the vegetables she had been chopping and put her hands on her hips.
"Why do you surgeons start operations at those kinds of hours?" she asked. "How can that be good for patients?"
For well over a decade now, patient safety has dominated many of the national discussions regarding health care. While research has shown that most errors and complications are rooted in multiple factors, only one — fatigue stemming from work performed at night — has inspired the kind of widespread debate that results in policy changes. Since 2003, for example, doctors-in-training in the United States have not been allowed to work more than 80 hours each week; and more and more hospitals, practices and individual doctors have shifted away from a culture of long hours and overriding devotion to work, instead emphasizing moderation and concern for lifestyle.
But one specialty has held out. Transplant surgeons continue to work at all hours, the timing of their operations determined by the time of death of the donor and the viability of the organs to be transplanted. Two recent small studies have raised serious concerns about what had been accepted as simply the "distinctive nature" of the specialty. The studies — one on kidney transplants and the other on liver transplants — revealed that patients tended to fare worse if their operations took place in the middle of the night.
This week, The Journal of the American Medical Association published a third study on the topic. Unlike the other two studies, which examined the outcomes of abdominal transplants, this one focused on transplant operations performed in the chest. And rather than reviewing the results of a single institution, as the previous investigators did, this most recent study took into account all of the almost 30,000 heart and lung transplants performed in the United States over 10 years.
The results surprised the researchers. Patients fared essentially the same whether the transplants were performed during the day or at night. Contrary to conventional wisdom, patient outcomes had little to do with the time of the operation or the fatigue of the surgeon. Rather, they seemed to hinge on the reliability of the surgical team.
"We all think the risks are higher at night," said Dr. Ashish S. Shah, assistant professor of surgery at the Johns Hopkins University School of Medicine. "But across the country, it appears that we have figured how to do heart and lung transplants safely."
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