In this episode, Tom Varghese, MD, FACS is joined by Jamie Coleman, MD, FACS, from the University of Louisville. They discuss Dr Coleman’s recent article, “Home Is Not Always Where the Sleep Is: The Effect of Home Call on Sleep, Burnout, and Surgeon Well-Being”, which quantifies sleep loss and burnout associated with home call in acute care surgeons, emphasizing that there are both physical and emotional contributors to burnout.
Disclosure Information: Drs Varghese and Coleman have nothing to disclose.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:03):
You are listening to The Operative Word,
a podcast brought to you by the Journalof the American College of Surgeons.
I'm Dr Tom Varghese,and throughout the series, Dr Lillian
Erdahl and I will speak with recently
published authors about the motivationbehind their latest research
and the clinical implicationsit has for the practicing surgeon.
The opinions expressed in this podcastare those of the participants,
(00:26):
and not necessarily that of the AmericanCollege of Surgeons.
Hello, loyal listeners,
welcome to another podcastepisode of The Operative Word,
the podcast for the Journalof the American College of Surgeons, where
we deep dive into fantastic articles,in the latest issue of JACS.
(00:47):
Today, I have the honor and privilegeof being joined
by the ever effervescent and spectacularDr Jamie Coleman.
Dr Jamie Coleman is an associate professorof surgery and Vice Chair of Wellness
in the Department of Surgery
at the University of Louisville. She's an acute care surgeon specializing
in trauma, emergency general surgery,and surgical critical care.
(01:09):
And more specifically, her research focusis on the physiological impact
of sleep deprivation, stress, and burnoutamongst physicians and surgeons.
Dr Coleman,welcome to the show. Oh.
Thank you.
Thank you for the wonderful welcome.
It's good to be back.
In a sense, it's an honor. Yeah.
(01:30):
For the listeners, as everybody knows,I am following in the giant
footsteps of Dr Colemanas serving as host of this podcast.
So hopefully we'll do her justice in terms
of doing a great job on this podcastinterview. So it's been great.
It's been great.
I was happy to, have such big
(01:50):
feet to, hand, hand it off to.
So it's all good.
Well, yeah.
Very excited for the podcast.
It's been really great and I can't waitto see all the new episodes
coming out. Yeah, that was so great to hear that Dr Coleman.
So today we're going to be focusingon your most recent article,
where you were the first authorof the recently published
(02:12):
"Home is not always where the sleepis: The effect of home call on sleep,
burnout, and surgeon well-being.”Let's get to it.
Tell us thewhy of why you embarked on this project
in the first place. That was interesting, you know,
really kind of my interest in
wellness really did start actuallyby about eight years ago or so.
(02:35):
I was coming back from my maternityleave after my second child.
It's just a lot.
There's a lot going on about burnoutand a lot in the literature.
And so I'm just kind of readingsome papers and started seeing that
I was ticking every
single risk factor box. I was female, early career,
young children at home.
(02:57):
I have a spouse who worksfull time outside the home,
but he's not a physician.
And then on top of that,even from a work standpoint,
learning and figuring out that, yes,working at night, nights of call,
nights of in-house call put me at riskfor burnout as well as just being a trauma surgeon.
And so that reallyjust started the question of
(03:19):
why and really then
kind of taking apart what we do as traumasurgeons, trauma acute care surgeons
and how that looks differentand why that might be.
And really what stuck out to me is call.
You know,
for most surgeons in housecall ends when training ends.
(03:40):
But for trauma surgeons, particularlywho are at American College of Surgeons
verified LevelI centers, in-house call is a bit of our
daily,part of our weekly lives.
But at the same time, what we found when I didthe original study, really primarily
focusing on in-house call was the reality,though, is burnout is still very high
(04:03):
in all surgeons and all acrossall specialties within surgeons.
And home-call is what is
part of most surgeons’ lives.
So I really wanted to look at that.
Whereas it was interestingbecause in-house call is so concrete,
that in a sense it was a little bit easierto study vs home call,
(04:24):
as you know, Tom, I mean, there'sa huge difference, a huge variation
in how it's practice acrossa large variety of specialties, practices,
workloads. I mean, all tons of variability in it.
And so the unique thing with this study
is that I was able to actuallylook at the impact of home call
(04:44):
in the same group of surgeonswho also take in-house call.
So kind of takes outa little bit of that variability.
And so taking a step back,I mean, you were saying
that you were going throughthis active reflection process
and that led you to be, to develop theand you call this the SuPer trial, right?
The surgeon performance trial.
Love the acronym, by the way. Thank you. Thank you.
(05:07):
and then your first studywas on in-house call.
And then this study is kindof a continuation, like a part two almost
of the where it was really focusing on in,I mean, sorry, home call.
In contrast, as you correctlypointed out, in contrast to
in-house call, I guess
the the natural question is
(05:30):
from that, like,how challenging was it to do this study
because you're right in-house call. Like even in your article, you put,
you know, you know, in-house call resultsin a defined number of work hours
for the surgeon.
And as a result, it's commonly taken intoconsideration when schedules are made.
But you don't do the same thing with homecall.
(05:51):
So, like, how challenging was it to takeon this project? It's challenging.
It was challenging.
And the topic continuesto be challenging in terms
of how we then move this work forward.
You know, this study was really,
kind of the culminationof actually doing some smaller studies,
really just proof of concept.
In other words,if I give a surgeon a fitness tracker,
(06:11):
can they keep track of it? Can they keep it on?
Can they keep it charged?
You know,like what's the proof of concept?
And the great thing is, is that
proof-of-concept went well.
And the sense ofI think most of us are used
to different devices,whether it's an Apple Watch or an or ring
or a Fitbit or...sothe concept wasn't, you know, it,
(06:35):
was a concept that people were familiarwith or were already wearing,
people already kind of participatingin that sort of activity.
The real challenge with homecall is exactly
what you said in that
we're moving the needle on in-house call.
we're not, you know, 100% there yet.
You know, the data from that priorstudy is the average or the mean
(06:56):
length of home of,excuse me, in house call was 18 hours
with, a range of number of hours. that got reported post-call
anywhere from 1 to over 14 hours,still being in the hospital post-call.
But at the same time,when you know that the surgeon
is going to be in the hospital, like yousaid, you can schedule it.
(07:16):
Like when are you,when you're making a schedule,
you have a better senseof what that means vs when you're doing a
home-call schedule,
What does that mean?
Does that mean you're going to get called?
Does that meanyou're even going to be woken up?
Or does that mean you're 100%going to be back in the hospital?
And so that's where what we had to do withthis was we had to pair,
not only the physiologic data that we'regetting from the fitness tracker,
(07:39):
but daily surveys to say, were you on calllast night? Yes/No.
Do you have to go into the hospital?
Did you get called,all those sorts of things.
And it's hard to really drilldown on the details.
for this study,
I will say
one of the things is that whether asurgeon got called or not was binary.
It was yes or no.
In other words, we didn't keep asking,well, how many calls did you get
(08:02):
and who did the call? You know, I mean, I think we can all appreciate,
depending on who's calling you also can impact,
your take on it and the sense of it'sa chief resident
who's picking up the phone and saying,hey, Dr Coleman, need you to come in.
We got this person to the hospital.
Or is it the transfer centerthat then is putting you on hold
and then patching youthrough to talk to somebody else?
(08:24):
Then you get put on hold again,and then you have to go back
and talk to the transfer centeragain. Hypothetically. Right?
I can see you laughing because,you know, it's it's true.
Like that is obviously a different feel.
There's different levels of frustration. Yeah, I hear you.
And so yeah,I appreciate what you were saying.
So that a little bit of the differencewas the survey aspect.
(08:46):
I think, reading from the paperand from your manuscript, it said that,
daily surveys were deliveredelectronically to participants’ phones.
The daily survey included questionsregarding their feelings of burnout
and restedness not just didthey get the phone call or not?
And then I thought, the fascinating thingis, after 6 months of participating
in the study,you also did 121 item exit survey.
(09:09):
Where you also then quantified thethe level of burnout
and questions regarding changesin their work or home life.
So it wasn't just a pure,retrospective recall.
You were trying to actively do it in time,plus the exit survey.
And that was part of it,you know, is because recall,
I remember when I first startedwith this line of research, now, you know,
(09:33):
6, 7, or 8 years ago now.
And, you know, the response was, oh,so you're going to tell us,
all we're tired.
Okay. But
which I mean, that's fair,
but I think it gets to the pointof objective data
usually results in subjective responsesin the sense of...right?
(09:53):
People that weigh themselves every day,weigh less.
There is value in tracking databecause we respond to it,
even if we don't havea planned intervention.
And so, similarly with this,it was a matter of sure.
I can retrospectively ask people, well,about how many times do you get called
when you're on call?
Or about how many timesdo you take home call?
(10:16):
But there's so much subconscious
bias that goes into thatthat it just wasn't real.
So yes, every participant, 10:00 in the morning,bless them for doing this.
We had over an 85% compliance rate,believe it or not,
tons of branch logic builtin, so they only got certain
questions asked if they answeredprevious questions a certain way.
(10:37):
But it asked, like,were you on call last night.
Yes/no.
If you were on home calldid you get called?
Did you have to go into the hospital?
Did you have to operate?
So, we just, we didn't want to rely
on a weekly survey
or a monthly surveyor just a general survey of
how much do you get called because it justit wasn't real.
(10:57):
And then that way that let usthen pair those nights knowing
what happened to those surgeons,those activities that they reported.
We could then pair thatto their feelings of burnout
and to their sleep patternson those nights.
So, it really allowed us
a great level of detail that just hasn'tbeen done before. That's amazing.
(11:21):
And and let's go.
Let's dive right into the data.
As you said, the data is incredible.
So, for the listeners,and really pay attention to this
when you read this article, so 224 acutecare surgeons volunteered for the study.
That’s just mind boggling in itself.
and that,who reported at least 1 night of home call
(11:41):
and you had a total of 30,507 daysof continuous
24/7 biometric monitoring. That was done with the WHOOP device.
And then you also had an additional 27,964
daily surveysthat were completed by the surgeons.
(12:02):
During the study period,there were 3313 nights of home call
with a mean duration of 18.4 hours.
What you said,
similar to the prior study conducted. Similar to the in-house.
As compared to the in-house call.
It's amazing.
I think that that's where the first thingthat leapt out to the page to me
(12:23):
was that,is that you have this phenomenally robust
data set that that you're trying toI mean, I get it,
people are going to poke holesat any type of study, but, I mean,
they can't questionthe fact that you got a ton of data
from which you can really deep dive into. Correct? Yes.
I mean, this was the nice thing
about when you're one of the firstto do a certain type of study,
(12:44):
you know, I've done these smaller studieswith like 17 surgeons, 3 months,
no additional survey.
Just like I said, proof of concept.Can they wear it?
So then for this one,I had that experience to then
really say, okay, if I had my druthers,like, what do I want to know?
And how are we going to do this?
And coming up with the logistics of it?
And so, yes, and actually the datathat you just quoted, you know,
(13:08):
we had 224 surgeons who participated,the numbers you quoted, actually,
even from just the 171 surgeonswho did home call.
So not all of the acute caresurgeons in the study did home call.
So yes, it was a blessing.
And a little bit of, oh,
there's a lot of data. There's a lot of data here.
That data. But, well, a couple things really struck me.
(13:33):
The first sentence in one of your paragraphs,
you said acute care surgeons,even when they're not on call,
the average amount of sleep is 6 hoursand 45 minutes of sleep.
And I sat there and holy cow. So,
I would argue that most peopleoutside of our field would say that
we're already a little bit sleep deprivedgoing into this.,
(13:56):
Yes, I mean, that's the thing.
And it highlights actually 2 things.
So, 100%.
I mean, the bottom line is the acute caresurgeons in this study
over a 6 month perioddidn't even get the minimum
recommended amount of sleepwhen they're not on call.
Okay. So we know that that's bad.
But what makes that value worse isyou start to add up
(14:17):
all the sleep that they're losing on call. Correct.
That home call resultedin 21 minutes of sleep loss,
4.4% decrease in feelings of restedness,
and a 4.2% increase in burnout.
Just the home call itself. And that's averaged out.
So, you know what I really tried to do
(14:38):
was kind of like, okay,well let's walk through this.
And so, I went back and I'm like,okay, well,
we had 3313 nights of home call.
They were called,
the surgeons were called over halfthe time, as around 53% of the nights.
Okay.
Then out of those 1739 nightsin which the surgeons were called,
(15:00):
then if you got called, then it was justunder 40% of the time that you went
back to the hospital. So, I mean, it's almost a flip of the coin.
If you get called, right, that you'regoing to go back to the hospital.
If you go back to the hospital,so that another flip the coin is about
53% of the surgeons that operated,and on top of that of the surgeons
who went back to the hospital,which happened on 670 nights total,
(15:25):
186, almost
just under 30% reportedhaving a stressful case,
a bad outcome or a death. And so, what happens is, as you can imagine,
as these interruptions occur,there's this degradation of sleep.
So, you know, when I was presenting thisoriginally it was like 21 minutes.
Well, I mean, granted, we're alreadynot getting what we need,
(15:48):
so we actually do need those 21 minutes.
But really what's happening is that it'sactually smoothing out the data
in the sense of if you are on calland you don't even get called,
you don't get called at all. It's 3 minutes loss of sleep.
Just for being on call.
But if you look at the other datathat we have,
(16:11):
there's some great,there was a workforce study that came out,
actually through the Collegethat looked at, you know,
what's the average number of callsthat a surgeon takes at night?
So, we start applying some of the datathat we have and say, okay, a surgeon
is going to take about 7
calls, 7 home calls per month. Right.
(16:32):
You are adding in. Okay.
Well 50% of the time I'm going tohave them go in, another 50% of the time
I'm going to have them operate.
You start adding up the sleep loss
that occurs over the course of a month.
Yeah.
You're looking at basicallyat least an entire night of sleep.
I mean, that adds up. Yeah. So then what happens
(16:57):
is to get back to your original pointabout the fact that
we're not sleeping as much as we shouldwhen we're not on call.
What you realize is we're not recovering.
In other words,we're having this sleep loss
that is then becoming cumulative.
Because for every night of home call,
we're not
turning around the next night,let's say we lose an hour and a half
(17:20):
because we go into the hospital, right? We got called.
We go in.
That's at least an hourand a half of sleep loss.
But I'm not seeing any marked,
or significant, or continuous...I
don't see any evidence that we areregaining or recovering that sleep.
And so yeah, so if you're like, well, I'mnot that busy,
(17:43):
I get called,but I don't go in that much. Yeah.
If you're averaging, you know,at least 1 to 3 hours of sleep
loss every month for your life,
it still adds up and it still interruptsyour circadian rhythm
and all of the things that we knowfrom a physiologic standpoint that happen
from that disruption. And I think with,
(18:05):
the amount of time we have left,I want to really deep dive into that
because I love how you beganyour discussion.
I'll just read these two sentences first,and then we'll ask about
where do we go next?
I mean you articulate it clearly.
You said the care of surgical patients
will always includethose who are critically ill,
and as such, will always require surgeonsto be available around the clock.
(18:29):
While the 24/7 nature of surgeryis inherent to the field,
its potential impactshould not be ignored.
And, you put it front and center.
I mean, that's really the call to action.
Like,
you're not going to be able to changea lot about the nature of the work we do.
It's needed work.
It's really more about how do we navigate,this is the known terrain,
(18:52):
how do we navigate this?
But I guess the question iswhere does this lead to next?
I mean, my mind is already spinningand I'm hoping we can volunteer.
You know,
as a thoracic surgeon, I'd love to be ableto volunteer to figure out what to do.
It's really about, what are you thinkingabout, or at least your gut instincts
about, is itdo we need to replicate this study
(19:12):
in other specialties first? Do you start designing interventions?
Is it differential interventionsdepending on the specialty.
What where is your thoughtsgoing forward? Yeah.
No, you know I think it's a it's an important caveat
because there's the who we are as people.
The type of personality,
the type of person that goes into thisfield.
There's the what we do, right?
And what we do
(19:34):
is inherently stressful.
We know that that surgery in itselfis stressful.
It inherently alters our sleep patterns. We're a purpose-driven people.
This is why we do what we do.
In other words, and I've always saidthere's no greater privilege for me
than having the ability to help somebodyat their most vulnerable moment.
(19:58):
And all the training that we do
all the nights,you know, at home that we missed
or the other sacrificesthat we make on a personal level,
it's for a purpose. And so I always have to give this,
you know, caveat,I always called my pulse check slide
was like,I love my job and I love what I do.
And really what this research is about,exactly what you said, it is,
(20:20):
how do we maintain physician and surgeonwell-being in a system that is inherently,
inherently
containing sleep deprivationand stress?
And the short version is we can,we've been doing it.
But the question really, for me becomes,can we do it better?
And I think moving forward, you know,my first piece of advice for everyone
(20:43):
is, you gotta step on the scale,
you know, is, yeah, I mean, really, it'swhat I tell every department
chair, division chief, you know,when I'm fortunate enough to get invited,
you know,to give grand rounds or something,
it's well, what can we dois first is, you gotta ask the questions.
I mean, I can show you data,
(21:03):
but I can't show youhow your surgeons work.
But you can figure that out.
In other words, I do think every divisionchief, I think every chair should know,
on average,how often their surgeons are taking call
and what that call looks like,because that can vary differently
even in a specialty. You know, pick one specialty, but you go across,
(21:23):
you know, a thousand different hospitalsystems, departments, staffing models.
You know,
APPs, residents, what’s the support system
around the call, all these things.
So I think the very first thing isyou gotta step on the scale.
What are your surgeons doing?
And I,I continue to be surprised that a lot of,
(21:45):
places can't answer that right now.
They can like, well,I can pull out a schedule.
Okay. Well, this is this an average month?
Is this how it looks every month?
How often do the surgeons come in?
How many operations are they doing?
You know, those sorts of things.
So I think really that's where to start.
I mean, interventionreally is at multiple levels.
There's an individual levelwhich we're going to come back to,
(22:06):
but the system level is a little bitof what I'm talking about.
It’s number 1, figuring out what's happeningin your shop and your location.
And then secondly, being mindful about it,thinking about it, being introspective.
Is this where I want to be?
You know, if I've got surgeonsthat are taking 10 nights of
call a month and they're getting calledevery single time and they're coming in
50% of the time,
(22:28):
do I need more surgeons?
Do I need a different call system?
How am I structuring this call?
Are we doing a week of nights at a time?
Can I then offload the surgeonsa little bit the following week?
There's a lot of ways to skin the cat,but I think in order to start coming up
with solutions, you need to figure outwhat your pressure points are
on an individual level,
there's a lot,
(22:50):
you know, I mean, there's a lot
that we can talk about, but,you know, overall sleep hygiene
and all the things I can talk about sleephygiene, limiting alcohol, meditation,
I mean, there's great functional MRIresults, looking at how we can actually
change our neural pathways,making us more resilient to stress, make
us, actually enhance our abilityto process things emotionally.
(23:15):
in our amygdala,you know, the things that we can do.
But I'll tell you, Tom,I think a lot of where we are
still is, in order to change what we do,
we need to acknowledge that what we do is hard. Yeah.
And it's if we don't acknowledgethat what we do is hard,
then why would anyone spend timetrying to recover from something
(23:37):
if they don't think there's anythingfrom which to recover?
So that's what I'm hopinga lot of the work,
we're going to try and move the needlefrom that standpoint.
And then, yes,there's a whole host of individual-level
interventionsthat again, go back to this concept of
how do we strengthen and supportand enhance physician well-being
(23:58):
in a system in which is inherent,
with stress? Well, I think that,
as we wrap this podcast episode up,I am grateful
for the fact that, at least in my career,
this is the first timewe're talking about these type of issues.
It's not,
(24:19):
oh, hey, surgeons need their sleepand it's a sign of weakness or something.
It's really about we...let'stalk about how hard our profession is,
but how to best thrivein this environment.
and, really appreciate you, Dr Coleman,for doing this study.
I agree with you.
(24:40):
there's a lot of work ahead.
I mean, I think that there is just
that we're talking about it, butI think you need to get to that nirvana.
We need to be able to come upwith some positive interventions.
and I'm hoping your workand your blazing a path of,
meaningful difference going forward. I'm hoping your work is
(25:00):
the first signs towards
us improving our culture for the better. That’s definitely the plan.
And that's definitely, the path that I seemoving forward as well.
and I think that is the paththat we're on, truly.
And it's just as excitingto be a part of it.
And it's exciting to do thispodcast as well and just help
share the work that we're doing.
(25:21):
Thank you. Well, on behalf of all of our amazing listeners to this podcast,
from the bottom of our
hearts, Dr Coleman,thank you for being you.
Thank you for leading this work.
And thank you for this incredible article.
that's recently published in the Journalof the American College of Surgeons.
Thanks so much for joining us today. Thank you for having me.
(25:44):
Thank you for listening
to the Journal of the American Collegeof Surgeons Operative Word Podcast.
If you enjoyed today's episode,spread the word on social media
by using the hashtag #JACSOperativeWord.
Subscribe to The Operative Wordwherever podcasts are available,
or listen on the American Collegeof Surgeons website at facs.org/podcast.
You are listening to The Operative Word,
a podcast brought to you by the Journalof the American College of Surgeons.
I'm Dr Tom Varghese,and throughout the series, Dr Lillian
Erdahl and I will speak with recently
published authors about the motivationbehind their latest research
and the clinical implicationsit has for the practicing surgeon.
The opinions expressed in this podcastare those of the participants,
(00:26):
and not necessarily that of the AmericanCollege of Surgeons.
Hello, loyal listeners,
welcome to another podcastepisode of The Operative Word,
the podcast for the Journalof the American College of Surgeons, where
we deep dive into fantastic articles,in the latest issue of JACS.
(00:47):
Today, I have the honor and privilegeof being joined
by the ever effervescent and spectacularDr Jamie Coleman.
Dr Jamie Coleman is an associate professorof surgery and Vice Chair of Wellness
in the Department of Surgery
at the University of Louisville. She's an acute care surgeon specializing
in trauma, emergency general surgery,and surgical critical care.
(01:09):
And more specifically, her research focusis on the physiological impact
of sleep deprivation, stress, and burnoutamongst physicians and surgeons.
Dr Coleman,welcome to the show. Oh.
Thank you.
Thank you for the wonderful welcome.
It's good to be back.
In a sense, it's an honor. Yeah.
(01:30):
For the listeners, as everybody knows,I am following in the giant
footsteps of Dr Colemanas serving as host of this podcast.
So hopefully we'll do her justice in terms
of doing a great job on this podcastinterview. So it's been great.
It's been great.
I was happy to, have such big
(01:50):
feet to, hand, hand it off to.
So it's all good.
Well, yeah.
Very excited for the podcast.
It's been really great and I can't waitto see all the new episodes
coming out. Yeah, that was so great to hear that Dr Coleman.
So today we're going to be focusingon your most recent article,
where you were the first authorof the recently published
(02:12):
"Home is not always where the sleepis: The effect of home call on sleep,
burnout, and surgeon well-being.”Let's get to it.
Tell us thewhy of why you embarked on this project
in the first place. That was interesting, you know,
really kind of my interest in
wellness really did start actuallyby about eight years ago or so.
(02:35):
I was coming back from my maternityleave after my second child.
It's just a lot.
There's a lot going on about burnoutand a lot in the literature.
And so I'm just kind of readingsome papers and started seeing that
I was ticking every
single risk factor box. I was female, early career,
young children at home.
(02:57):
I have a spouse who worksfull time outside the home,
but he's not a physician.
And then on top of that,even from a work standpoint,
learning and figuring out that, yes,working at night, nights of call,
nights of in-house call put me at riskfor burnout as well as just being a trauma surgeon.
And so that reallyjust started the question of
(03:19):
why and really then
kind of taking apart what we do as traumasurgeons, trauma acute care surgeons
and how that looks differentand why that might be.
And really what stuck out to me is call.
You know,
for most surgeons in housecall ends when training ends.
(03:40):
But for trauma surgeons, particularlywho are at American College of Surgeons
verified LevelI centers, in-house call is a bit of our
daily,part of our weekly lives.
But at the same time, what we found when I didthe original study, really primarily
focusing on in-house call was the reality,though, is burnout is still very high
(04:03):
in all surgeons and all acrossall specialties within surgeons.
And home-call is what is
part of most surgeons’ lives.
So I really wanted to look at that.
Whereas it was interestingbecause in-house call is so concrete,
that in a sense it was a little bit easierto study vs home call,
(04:24):
as you know, Tom, I mean, there'sa huge difference, a huge variation
in how it's practice acrossa large variety of specialties, practices,
workloads. I mean, all tons of variability in it.
And so the unique thing with this study
is that I was able to actuallylook at the impact of home call
(04:44):
in the same group of surgeonswho also take in-house call.
So kind of takes outa little bit of that variability.
And so taking a step back,I mean, you were saying
that you were going throughthis active reflection process
and that led you to be, to develop theand you call this the SuPer trial, right?
The surgeon performance trial.
Love the acronym, by the way. Thank you. Thank you.
(05:07):
and then your first studywas on in-house call.
And then this study is kindof a continuation, like a part two almost
of the where it was really focusing on in,I mean, sorry, home call.
In contrast, as you correctlypointed out, in contrast to
in-house call, I guess
the the natural question is
(05:30):
from that, like,how challenging was it to do this study
because you're right in-house call. Like even in your article, you put,
you know, you know, in-house call resultsin a defined number of work hours
for the surgeon.
And as a result, it's commonly taken intoconsideration when schedules are made.
But you don't do the same thing with homecall.
(05:51):
So, like, how challenging was it to takeon this project? It's challenging.
It was challenging.
And the topic continuesto be challenging in terms
of how we then move this work forward.
You know, this study was really,
kind of the culminationof actually doing some smaller studies,
really just proof of concept.
In other words,if I give a surgeon a fitness tracker,
(06:11):
can they keep track of it? Can they keep it on?
Can they keep it charged?
You know,like what's the proof of concept?
And the great thing is, is that
proof-of-concept went well.
And the sense ofI think most of us are used
to different devices,whether it's an Apple Watch or an or ring
or a Fitbit or...sothe concept wasn't, you know, it,
(06:35):
was a concept that people were familiarwith or were already wearing,
people already kind of participatingin that sort of activity.
The real challenge with homecall is exactly
what you said in that
we're moving the needle on in-house call.
we're not, you know, 100% there yet.
You know, the data from that priorstudy is the average or the mean
(06:56):
length of home of,excuse me, in house call was 18 hours
with, a range of number of hours. that got reported post-call
anywhere from 1 to over 14 hours,still being in the hospital post-call.
But at the same time,when you know that the surgeon
is going to be in the hospital, like yousaid, you can schedule it.
(07:16):
Like when are you,when you're making a schedule,
you have a better senseof what that means vs when you're doing a
home-call schedule,
What does that mean?
Does that mean you're going to get called?
Does that meanyou're even going to be woken up?
Or does that mean you're 100%going to be back in the hospital?
And so that's where what we had to do withthis was we had to pair,
not only the physiologic data that we'regetting from the fitness tracker,
(07:39):
but daily surveys to say, were you on calllast night? Yes/No.
Do you have to go into the hospital?
Did you get called,all those sorts of things.
And it's hard to really drilldown on the details.
for this study,
I will say
one of the things is that whether asurgeon got called or not was binary.
It was yes or no.
In other words, we didn't keep asking,well, how many calls did you get
(08:02):
and who did the call? You know, I mean, I think we can all appreciate,
depending on who's calling you also can impact,
your take on it and the sense of it'sa chief resident
who's picking up the phone and saying,hey, Dr Coleman, need you to come in.
We got this person to the hospital.
Or is it the transfer centerthat then is putting you on hold
and then patching youthrough to talk to somebody else?
(08:24):
Then you get put on hold again,and then you have to go back
and talk to the transfer centeragain. Hypothetically. Right?
I can see you laughing because,you know, it's it's true.
Like that is obviously a different feel.
There's different levels of frustration. Yeah, I hear you.
And so yeah,I appreciate what you were saying.
So that a little bit of the differencewas the survey aspect.
(08:46):
I think, reading from the paperand from your manuscript, it said that,
daily surveys were deliveredelectronically to participants’ phones.
The daily survey included questionsregarding their feelings of burnout
and restedness not just didthey get the phone call or not?
And then I thought, the fascinating thingis, after 6 months of participating
in the study,you also did 121 item exit survey.
(09:09):
Where you also then quantified thethe level of burnout
and questions regarding changesin their work or home life.
So it wasn't just a pure,retrospective recall.
You were trying to actively do it in time,plus the exit survey.
And that was part of it,you know, is because recall,
I remember when I first startedwith this line of research, now, you know,
(09:33):
6, 7, or 8 years ago now.
And, you know, the response was, oh,so you're going to tell us,
all we're tired.
Okay. But
which I mean, that's fair,
but I think it gets to the pointof objective data
usually results in subjective responsesin the sense of...right?
(09:53):
People that weigh themselves every day,weigh less.
There is value in tracking databecause we respond to it,
even if we don't havea planned intervention.
And so, similarly with this,it was a matter of sure.
I can retrospectively ask people, well,about how many times do you get called
when you're on call?
Or about how many timesdo you take home call?
(10:16):
But there's so much subconscious
bias that goes into thatthat it just wasn't real.
So yes, every participant, 10:00 in the morning,bless them for doing this.
We had over an 85% compliance rate,believe it or not,
tons of branch logic builtin, so they only got certain
questions asked if they answeredprevious questions a certain way.
(10:37):
But it asked, like,were you on call last night.
Yes/no.
If you were on home calldid you get called?
Did you have to go into the hospital?
Did you have to operate?
So, we just, we didn't want to rely
on a weekly survey
or a monthly surveyor just a general survey of
how much do you get called because it justit wasn't real.
(10:57):
And then that way that let usthen pair those nights knowing
what happened to those surgeons,those activities that they reported.
We could then pair thatto their feelings of burnout
and to their sleep patternson those nights.
So, it really allowed us
a great level of detail that just hasn'tbeen done before. That's amazing.
(11:21):
And and let's go.
Let's dive right into the data.
As you said, the data is incredible.
So, for the listeners,and really pay attention to this
when you read this article, so 224 acutecare surgeons volunteered for the study.
That’s just mind boggling in itself.
and that,who reported at least 1 night of home call
(11:41):
and you had a total of 30,507 daysof continuous
24/7 biometric monitoring. That was done with the WHOOP device.
And then you also had an additional 27,964
daily surveysthat were completed by the surgeons.
(12:02):
During the study period,there were 3313 nights of home call
with a mean duration of 18.4 hours.
What you said,
similar to the prior study conducted. Similar to the in-house.
As compared to the in-house call.
It's amazing.
I think that that's where the first thingthat leapt out to the page to me
(12:23):
was that,is that you have this phenomenally robust
data set that that you're trying toI mean, I get it,
people are going to poke holesat any type of study, but, I mean,
they can't questionthe fact that you got a ton of data
from which you can really deep dive into. Correct? Yes.
I mean, this was the nice thing
about when you're one of the firstto do a certain type of study,
(12:44):
you know, I've done these smaller studieswith like 17 surgeons, 3 months,
no additional survey.
Just like I said, proof of concept.Can they wear it?
So then for this one,I had that experience to then
really say, okay, if I had my druthers,like, what do I want to know?
And how are we going to do this?
And coming up with the logistics of it?
And so, yes, and actually the datathat you just quoted, you know,
(13:08):
we had 224 surgeons who participated,the numbers you quoted, actually,
even from just the 171 surgeonswho did home call.
So not all of the acute caresurgeons in the study did home call.
So yes, it was a blessing.
And a little bit of, oh,
there's a lot of data. There's a lot of data here.
That data. But, well, a couple things really struck me.
(13:33):
The first sentence in one of your paragraphs,
you said acute care surgeons,even when they're not on call,
the average amount of sleep is 6 hoursand 45 minutes of sleep.
And I sat there and holy cow. So,
I would argue that most peopleoutside of our field would say that
we're already a little bit sleep deprivedgoing into this.,
(13:56):
Yes, I mean, that's the thing.
And it highlights actually 2 things.
So, 100%.
I mean, the bottom line is the acute caresurgeons in this study
over a 6 month perioddidn't even get the minimum
recommended amount of sleepwhen they're not on call.
Okay. So we know that that's bad.
But what makes that value worse isyou start to add up
(14:17):
all the sleep that they're losing on call. Correct.
That home call resultedin 21 minutes of sleep loss,
4.4% decrease in feelings of restedness,
and a 4.2% increase in burnout.
Just the home call itself. And that's averaged out.
So, you know what I really tried to do
(14:38):
was kind of like, okay,well let's walk through this.
And so, I went back and I'm like,okay, well,
we had 3313 nights of home call.
They were called,
the surgeons were called over halfthe time, as around 53% of the nights.
Okay.
Then out of those 1739 nightsin which the surgeons were called,
(15:00):
then if you got called, then it was justunder 40% of the time that you went
back to the hospital. So, I mean, it's almost a flip of the coin.
If you get called, right, that you'regoing to go back to the hospital.
If you go back to the hospital,so that another flip the coin is about
53% of the surgeons that operated,and on top of that of the surgeons
who went back to the hospital,which happened on 670 nights total,
(15:25):
186, almost
just under 30% reportedhaving a stressful case,
a bad outcome or a death. And so, what happens is, as you can imagine,
as these interruptions occur,there's this degradation of sleep.
So, you know, when I was presenting thisoriginally it was like 21 minutes.
Well, I mean, granted, we're alreadynot getting what we need,
(15:48):
so we actually do need those 21 minutes.
But really what's happening is that it'sactually smoothing out the data
in the sense of if you are on calland you don't even get called,
you don't get called at all. It's 3 minutes loss of sleep.
Just for being on call.
But if you look at the other datathat we have,
(16:11):
there's some great,there was a workforce study that came out,
actually through the Collegethat looked at, you know,
what's the average number of callsthat a surgeon takes at night?
So, we start applying some of the datathat we have and say, okay, a surgeon
is going to take about 7
calls, 7 home calls per month. Right.
(16:32):
You are adding in. Okay.
Well 50% of the time I'm going tohave them go in, another 50% of the time
I'm going to have them operate.
You start adding up the sleep loss
that occurs over the course of a month.
Yeah.
You're looking at basicallyat least an entire night of sleep.
I mean, that adds up. Yeah. So then what happens
(16:57):
is to get back to your original pointabout the fact that
we're not sleeping as much as we shouldwhen we're not on call.
What you realize is we're not recovering.
In other words,we're having this sleep loss
that is then becoming cumulative.
Because for every night of home call,
we're not
turning around the next night,let's say we lose an hour and a half
(17:20):
because we go into the hospital, right? We got called.
We go in.
That's at least an hourand a half of sleep loss.
But I'm not seeing any marked,
or significant, or continuous...I
don't see any evidence that we areregaining or recovering that sleep.
And so yeah, so if you're like, well, I'mnot that busy,
(17:43):
I get called,but I don't go in that much. Yeah.
If you're averaging, you know,at least 1 to 3 hours of sleep
loss every month for your life,
it still adds up and it still interruptsyour circadian rhythm
and all of the things that we knowfrom a physiologic standpoint that happen
from that disruption. And I think with,
(18:05):
the amount of time we have left,I want to really deep dive into that
because I love how you beganyour discussion.
I'll just read these two sentences first,and then we'll ask about
where do we go next?
I mean you articulate it clearly.
You said the care of surgical patients
will always includethose who are critically ill,
and as such, will always require surgeonsto be available around the clock.
(18:29):
While the 24/7 nature of surgeryis inherent to the field,
its potential impactshould not be ignored.
And, you put it front and center.
I mean, that's really the call to action.
Like,
you're not going to be able to changea lot about the nature of the work we do.
It's needed work.
It's really more about how do we navigate,this is the known terrain,
(18:52):
how do we navigate this?
But I guess the question iswhere does this lead to next?
I mean, my mind is already spinningand I'm hoping we can volunteer.
You know,
as a thoracic surgeon, I'd love to be ableto volunteer to figure out what to do.
It's really about, what are you thinkingabout, or at least your gut instincts
about, is itdo we need to replicate this study
(19:12):
in other specialties first? Do you start designing interventions?
Is it differential interventionsdepending on the specialty.
What where is your thoughtsgoing forward? Yeah.
No, you know I think it's a it's an important caveat
because there's the who we are as people.
The type of personality,
the type of person that goes into thisfield.
There's the what we do, right?
And what we do
(19:34):
is inherently stressful.
We know that that surgery in itselfis stressful.
It inherently alters our sleep patterns. We're a purpose-driven people.
This is why we do what we do.
In other words, and I've always saidthere's no greater privilege for me
than having the ability to help somebodyat their most vulnerable moment.
(19:58):
And all the training that we do
all the nights,you know, at home that we missed
or the other sacrificesthat we make on a personal level,
it's for a purpose. And so I always have to give this,
you know, caveat,I always called my pulse check slide
was like,I love my job and I love what I do.
And really what this research is about,exactly what you said, it is,
(20:20):
how do we maintain physician and surgeonwell-being in a system that is inherently,
inherently
containing sleep deprivationand stress?
And the short version is we can,we've been doing it.
But the question really, for me becomes,can we do it better?
And I think moving forward, you know,my first piece of advice for everyone
(20:43):
is, you gotta step on the scale,
you know, is, yeah, I mean, really, it'swhat I tell every department
chair, division chief, you know,when I'm fortunate enough to get invited,
you know,to give grand rounds or something,
it's well, what can we dois first is, you gotta ask the questions.
I mean, I can show you data,
(21:03):
but I can't show youhow your surgeons work.
But you can figure that out.
In other words, I do think every divisionchief, I think every chair should know,
on average,how often their surgeons are taking call
and what that call looks like,because that can vary differently
even in a specialty. You know, pick one specialty, but you go across,
(21:23):
you know, a thousand different hospitalsystems, departments, staffing models.
You know,
APPs, residents, what’s the support system
around the call, all these things.
So I think the very first thing isyou gotta step on the scale.
What are your surgeons doing?
And I,I continue to be surprised that a lot of,
(21:45):
places can't answer that right now.
They can like, well,I can pull out a schedule.
Okay. Well, this is this an average month?
Is this how it looks every month?
How often do the surgeons come in?
How many operations are they doing?
You know, those sorts of things.
So I think really that's where to start.
I mean, interventionreally is at multiple levels.
There's an individual levelwhich we're going to come back to,
(22:06):
but the system level is a little bitof what I'm talking about.
It’s number 1, figuring out what's happeningin your shop and your location.
And then secondly, being mindful about it,thinking about it, being introspective.
Is this where I want to be?
You know, if I've got surgeonsthat are taking 10 nights of
call a month and they're getting calledevery single time and they're coming in
50% of the time,
(22:28):
do I need more surgeons?
Do I need a different call system?
How am I structuring this call?
Are we doing a week of nights at a time?
Can I then offload the surgeonsa little bit the following week?
There's a lot of ways to skin the cat,but I think in order to start coming up
with solutions, you need to figure outwhat your pressure points are
on an individual level,
there's a lot,
(22:50):
you know, I mean, there's a lot
that we can talk about, but,you know, overall sleep hygiene
and all the things I can talk about sleephygiene, limiting alcohol, meditation,
I mean, there's great functional MRIresults, looking at how we can actually
change our neural pathways,making us more resilient to stress, make
us, actually enhance our abilityto process things emotionally.
(23:15):
in our amygdala,you know, the things that we can do.
But I'll tell you, Tom,I think a lot of where we are
still is, in order to change what we do,
we need to acknowledge that what we do is hard. Yeah.
And it's if we don't acknowledgethat what we do is hard,
then why would anyone spend timetrying to recover from something
(23:37):
if they don't think there's anythingfrom which to recover?
So that's what I'm hopinga lot of the work,
we're going to try and move the needlefrom that standpoint.
And then, yes,there's a whole host of individual-level
interventionsthat again, go back to this concept of
how do we strengthen and supportand enhance physician well-being
(23:58):
in a system in which is inherent,
with stress? Well, I think that,
as we wrap this podcast episode up,I am grateful
for the fact that, at least in my career,
this is the first timewe're talking about these type of issues.
It's not,
(24:19):
oh, hey, surgeons need their sleepand it's a sign of weakness or something.
It's really about we...let'stalk about how hard our profession is,
but how to best thrivein this environment.
and, really appreciate you, Dr Coleman,for doing this study.
I agree with you.
(24:40):
there's a lot of work ahead.
I mean, I think that there is just
that we're talking about it, butI think you need to get to that nirvana.
We need to be able to come upwith some positive interventions.
and I'm hoping your workand your blazing a path of,
meaningful difference going forward. I'm hoping your work is
(25:00):
the first signs towards
us improving our culture for the better. That’s definitely the plan.
And that's definitely, the path that I seemoving forward as well.
and I think that is the paththat we're on, truly.
And it's just as excitingto be a part of it.
And it's exciting to do thispodcast as well and just help
share the work that we're doing.
(25:21):
Thank you. Well, on behalf of all of our amazing listeners to this podcast,
from the bottom of our
hearts, Dr Coleman,thank you for being you.
Thank you for leading this work.
And thank you for this incredible article.
that's recently published in the Journalof the American College of Surgeons.
Thanks so much for joining us today. Thank you for having me.
(25:44):
Thank you for listening
to the Journal of the American Collegeof Surgeons Operative Word Podcast.
If you enjoyed today's episode,spread the word on social media
by using the hashtag #JACSOperativeWord.
Subscribe to The Operative Wordwherever podcasts are available,
or listen on the American Collegeof Surgeons website at facs.org/podcast.
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