Patient Deaths Higher on Surgeons’ Birthdays

Patients were more likely to die when surgeons work on their birthdays, researchers found, perhaps because of the attendant distraction.

In an analysis of Medicare data published in the annual tongue-in-cheek Christmas edition* of The BMJ, 30-day mortality rates were significantly higher for those who had a procedure on a surgeon’s birthday compared with surgeries performed on other days, after adjusting for patient and surgeon characteristics (6.9% vs 5.6%, P=0.03), according to Yusuke Tsugawa, MD, MPH, PhD, of the University of California Los Angeles, and colleagues.

“These findings suggest that a surgeon’s performance might be affected by life events that are not directly related to work, a hypothesis that while intuitive has been otherwise difficult to assess owing to lack of detailed information on events that are potentially distracting to an individual surgeon,” the researchers wrote.

Tsugawa told MedPage Today that further work on understanding why performance declines on surgeons’ birthdays is warranted before implementing any solutions: “If noise and irrelevant conversations in the operating room are the underlying reasons, hospitals can introduce policies to make sure the OR is quiet and less distractive,” he said. “On the other hand, if the time pressure is the underlying reason, hospitals can introduce a policy that allows surgeons not to operate on emergency surgical patients in the late afternoon and leave on time on their birthday.”

Distractions are common in the operating room: there’s noise from calls from the ward, beeper pages, problems with equipment, and conversations about things other than the procedures. While lab experiments have shown that distractions can impair performance, it’s hard to empirically investigate their impact on outcomes.

That’s why Tsugawa and colleagues used surgeon birthdays as a surrogate to measure distraction. Surgeons may be more distracted or feel rushed to finish procedures on their birthdays, they said.

They also looked at Medicare data on deaths within 30 days of surgery for 17 common procedures performed in hospitals from 2011 to 2014. They limited these to emergency procedures done within three days of admission; these spanned cardiovascular, gastrointestinal, and orthopedic surgeries. Medicare also furnished surgeons’ birth dates, which are recorded in the agency’s MD-PPAS file, linked from national provider identifier numbers.

Overall, the group’s analysis included 980,876 procedures and 47,489 surgeons. Just 2,064 procedures were performed on a surgeon’s birthday, which amounted to 0.2% of all procedures.

The 1.3 percentage-point difference in 30-day mortality they found (95% CI 0.1% to 2.5%, P=0.03) in analyses controlled for both patient and surgeon characteristics is “substantial,” they said. It’s a relative 23% increase in mortality, and is comparable to the impact of other events, including holidays and weekends.

Tsugawa and colleagues posited several explanations for the difference. It could be that surgeons feel rushed to complete procedures because they have plans in the evening to celebrate, they said. Research has shown that time pressure may impair the ability to avoid errors of intuitive judgment and may cause heuristic decisions during and after operations. It could also increase the risk of confirmation bias, which is the tendency to gather evidence that confirms expectations while dismissing contradictory evidence.

Birthday conversations with team members could be distracting, as can texts or other birthday messages, potentially leading to medical errors, they wrote.

Surgeons may also allow trainees to do more work on their birthdays, and surgeons may be less likely to return to the hospital to check on patients.

The researchers also found that point estimates showed higher patient mortality when surgeons operated on their birthdays for all but two procedures: carotid endarterectomy and cholecystectomy and common duct procedures. However, the differences weren’t significant owing the small sample sizes, the researchers noted.

Some surgeons evidently opted not to work on their birthdays, with 1,805 working on their birthdays compared with 2,144 working one day before their birthday and 2,027 working one day after.

“This does suggest that birthdays are an important enough factor for some surgeons to choose not to operate on that day, which supports the credibility of our assumption that a birthday could be a distracting factor for those surgeons who choose to operate on that day,” they wrote.

The study was limited by its observational nature, and by the fact that the researchers couldn’t exclude unmeasured confounders, nor could they identify the mechanisms through which patients had worse outcomes.

*BMJ Christmas edition articles are completely factual and based in genuine research, though the topics may be risible.