Issue 28 / 29 July 2013

MANY professions have their rites of passage and initiations that leave their survivors bloodied and bruised but confident of their admission to the tribe — perhaps none more so than medicine.

The trials of hospital residency — the 120-hour weeks, the procedures performed at the end of a 36-hour shift with little fuel other than a cup of instant coffee — provided war stories for generations of doctors.

In recent decades, much of that has changed, though many junior doctors still work shifts that would not be allowed for nearly every other profession or trade.

The focus on reducing long working hours has been driven by concern for both doctors’ wellbeing and patient safety.

A classic Australian study from the 1990s found performance impairment after 17 hours’ sustained wakefulness was equivalent to having a blood alcohol level above the legal driving limit of 0.05.

If we wouldn’t be happy to have a tipsy surgeon operating on us, why would we accept one who was equally impaired by fatigue?

But perhaps it isn’t that simple.

Brisbane liver surgeon Kellee Slater questions whether reductions in working hours could be compromising the training of junior surgeons.

“There was no such thing as ‘safe working hours’ for doctors during my training, and being awake for two consecutive days was worn like a badge of honour”, she writes in a new book.

“The sleeplessness was a difficult but vital part of my training, because the more hours I worked, the more cases I saw and the better I became … I really worry now that junior surgeons’ work hours have been severely restricted by well intentioned laws, as it will be difficult for them ever to get the experience they need to become really good.”

Dr Slater is not the only one to raise such concerns.

A US study in JAMA Surgery this month, and reported in MJA InSight, found the introduction of a 16-hour shift limit for general surgery interns was associated with a significant decrease in operative experience.

Broader implementation of such rules might mean junior surgeons needed additional years of training to ensure they acquired adequate experience, the authors suggested.

I doubt that would be a popular option for many young doctors.

Australia has generally been more active than the US in addressing excessive working hours. The AMA’s most recent Safe Hours Audit found hospital doctors worked 55 hours on average over the 2011 audit week, which doesn’t sound too bad.

However, the audit found 53% of hospital-based doctors were still working hours that could impair their performance, down from 78% a decade earlier.

Surgeons were by far the highest risk group at 77%, compared with just 33% for emergency physicians and 38% for anaesthetists.

The audit also found 21% of doctors did not have a day off during the audit week and the longest shift recorded was 43 hours.

“In any other industry or profession, these statistics would be cause for deep concern and immediate action”, the report said.

We don’t really know whether the gruelling regimes of the past did actually produce better doctors, although those who survived them often seem to believe that to be the case.

Nor do we have accurate data on the toll they exacted, in terms of either doctors’ health or the safety of patients.

The one thing we do know is that balancing the push for safer working hours with the need to provide junior doctors with adequate training and experience is never going to be easy.

 

Jane McCredie is a Sydney-based science and medicine writer.

COI: Jane McCredie commissioned Kellee Slater’s book in her former role as a publisher at NewSouth.
 

12 thoughts on “Jane McCredie: Working rites

  1. Wilson Lim says:

    Studies and audits are all well and good.  It should be obvious that shorter working hours will reduce clinical exposure and experience.  Whether this fact makes a difference remains to be seen.  The newly qualified surgeons have tended to take themselves off for post-fellowship years to gain more experience.  This has been a practice for a long time.  I suspect that the original intent was to have an overseas “holiday” as well as gain some experience but it appears that the holiday has been discarded and gaining exposure and experience is the main aim of an overseas fellowship.  It looks like the trainees themselves do not feel totally confident with their skills and knowledge.  

    In addition, the throughput of cases in tertiary teaching hospitals continue to decrease so the shorten time is further exacerbated with fewer cases.

    If we think that doing more of something makes us better, then doing less may not be so good.  The question is how many of something do we need to do to make us good enough.   That is the question which needs answering and I suspect that it would be different for each procedure and individual.

    I cannot see any option other that increase training time.  

  2. Tilmann Rust says:

    Unquestionably this is a real concern. I have always found that doctors who are exposed to a lot of clinical experience would be much better trained than those with outstanding academic knowledge. Both are essential but in the end practical experience is what matters. South African Surgeons are much better trained than British Surgeons who again are much better trained than Australian Surgeons who are better trained than German Surgeons. These are the countries I have had experience with and am able to compare. The clinical workload, hours worked and the practical experience obtained when doing operations yourself rather than assisting in are all contributing to become ‘luckier’. It is amazing how much luckier you get the more you practice! In Australia with the massive increase in medical students the clinical exposure will dwindle even more and it will reach levels of those experienced in Germany in the 1990’s, with the result that it will become impossible to obtain the necessary experience within Australia and doctors will have to travel like the Germans did in the 1990’s to get their appropriate training.

    I am one of those who worked those hours, interestingly the most I worked was in Sydney being on call for 2 years in a row, with only occasional days off in 2003 and 2004, and although it was hard I don’t think it damaged me. Bullying was much more of a concern especially early in my career.

  3. M.J.Bennett says:

    Dr Slater is in my view unquestionably correct especially in respect of the procedural activities. Not only are todays trainees much less well trained and essentially inexperienced when they have completed their training, they are frighteningly poor at correct decision making. The shorter hours worked results in them seldom seeing a patient through the process from history taking and physical examination, through special investigations to appropriate diagnosis and subsequent treatment even for simple conditions such as acute appendicitis or an ectopic pregnancy. Like Dr Rust, I was lucky to be able to practice a lot (48 hr week-ends on duty etc.) and agree wholeheartedly with his “league” for the reasons he outlined. I’d question the relevance of measurement of “performance” in the studies that compared those with and without alcohol – I never encountered any surgical errors by colleagues due to tiredness in over 40 yrs of specialty practice. Give me a proceduralist who gained his experience in the years before ‘safe working hours’ every day (and night) of the week.

  4. Elizabeth Dodd says:

    There is a confusion here between quality and quantity..

    Our other commenters have only mentioned surgical training, and assumed that procedural skills were only gained by practising often. Every generation has claimed that the next generation gets less training or experience, but our overall standard of health has been shown to improve in a measurable way over the last 30 years. So it can’t be all doom and gloom.

    On another aspect, we see the Federal government pushing for primary care doctors to do more after hours work, to save the hospital doctors from having to do it. Can we discuss the effects of asking those already working over 55 hours a week to do even more hours, rather than spread the load onto the shift working hospital doctors?

  5. Jim Rogers says:

    There may well be truth in the notion that limiting working hours to proved-to-be-safe duration leads indirectly to less experience over a training period.

    It may also mean that the number of fatigue-related, inadvertent adverse patient outcomes, both morbidity and mortality, is currently much lower.

    I doubt anyone can remember or quantify how many or which bad mistakes they made or almost made during training which were purely or partly due to fatigue from overwork and dangerous shift lengths. (“sulely this doesn’t apply to ME!” I expect many will assume, probably wrongly.)

    Can anyone justify killing or harming patients during training to benefit other patients down the track during specialist careers?  I don’t think so.

  6. Frank New says:

    It will be very disappointing, and a concern, if the response to these issues is only a polarised approach of either right or wrong, consideration of one change or none at all, or considering the problem is limited to hours rather than the many aspects of our current system that depend on the status quo.

    It will also be very dissappointing if the ‘solution’ to the secondary problems from changing to safer hours (changes to usual training) was to deny a primary primary problem, despite the abundant good quality information to support cognitive and procedural impairment from fatigue.

    The importance of sufficient good quality experience in developing competence and confidence with procedural and patient management  skills is not in doubt. However I do not understand why working hours that involve high risk of fatigue, impaired and poor quality learning is the only option. If more experience is required, it should be provided, though it seems the option of a longer period of training is not allowed to be mentioned.

    I have treated too many patients with complications from elective operations at late hours consistent with the suboptimal habits, and practice management skills. I have also seen too many practitioners whose lives have been damaged in these circumstances. 

    The option of longer training has many other ramifications within the health system, especially expense to the system, though the past habit of exploiting those who are in a subservient position, who are not allowed to complain, and who have considerable peer pressure to conform to unwise work practices, should not be seen as a good thing only because the full costs of these practices were not previously revealed.

     

  7. Simon Hendel says:

    Fatigue management vs  exposure is a vexing issue in clinical medicine. There is no definitive evidence showing that reduced working hours results in reduced clinical ability. Likewise there is no clear evidence that the ‘bad old days’ resulted in worse patient outcomes.

    Not sleeping does makes you tired though. The only cure for fatigue is sleep – a lesson learned by many other high-risk professions long ago. Working in aeromedical retrieval I see how seriously aviators take fatigue management. Their buy-in is much greater than ours, however, as they’re in the nose of the machine when it crashes. The study of error and fatigue is not new and it is certainly too big to explore in this post. Though, as a crewmember strapped in the back of the aircraft, I’m certainly very pleased that the pilot is rested. There’s enough to worry about without adding fatigue.

    Being tired also makes acquiring new skills and forming new memories harder, so I wonder how much valuable, memorable experience was being had by the surgeons of yesteryear at hour 47 of 48 or even hour 18 of 48? Being tired also makes people irritable, and communicating with fatigued and irritable people is not only annoying but potentially dangerous. What about the tired doctor who crashes their car on the way home? Was it really worth doing that extra case?

    The belief that this hardship made them stronger is not surprising, but it isn’t necessarily true. Shared hardship had by some and not by others is an age-old way of segretating newcomers from veterans.

    The counter to ‘safe hours’ is that some intensity of experience is necessary for building expert skills. So perhaps a robust fatigue management system is needed rather than a tired old surgeon?

  8. Leigh Grant says:

    What has happened to the role of the unaccredited or service registrar? In Emergency Departments today there is a career medical officer training pathway, recognised as a career option. I work in Obs/Gynae where training needs to be balanced against 24 hour service provision. Much of my job involves attending to low risk women in clinic situations, doing paperwork and audits and attending meetings. Having a “service registrar” to fill the clinic role after my busy night shift would allow me to have reduced hours while still obtaining some critical experience. Service registrars will not compete with trainees for sometimes scarce surgical cases, and might enable doctors to gain experience in a different area. 

  9. Genevieve Freer says:

    Impairment after 17 hours of wakefulness on one day has been studied, but what about impairment after working more than ?12 hours every day? We all need 8 hours sleep, plus time to eat, shower, toilet daily, not to mention study ;doctors are no longer provided with serviced accomodation nor meals,nor parking, so we need to cook, shop, wash clothes , park the car, then walk to and from the hospital. So the bad old days are irrelevant..

    I agree that it is not that simple.

    The  JAMA study of 16 hour shift limit  for surgical interns studied does not apply  in this country, where surgical interns are not operating on patients.

    Another issue not mentioned is the training of medical students, who no longer are required to study the Anatomy of the human body. Instead PBL is the order of the day, so medical students have no way of knowing what and where the appendix is. i guess if they have studied statistics, they could diagnose acute appendicitis on the basis of probability as the cause of acute abdominal pain. Medical students on-line skills will not help them in the antiquated public hospital system, where computerised medical records elude medical administration.Perhaps Dr. Who’s time machine may help?

    The analogy of airline pilots is most relevant -when a plane crashes, it makes news headlines, but when a fatigued doctor makes a mistake, it does not.

    I agree with rural doctor- perhaps Jane McCredie could do a few rural GP locum placements , work 12 hours per day, then be on call after-hours, indefinitely.

     

  10. Graham Row says:

    Simon H’s comment struck a chord with me. The absence of clear evidence notwithstanding, expertise in clinical medicine in all its forms does demand hands on experience.  This is a fact from which no practitioner or trainee can escape. For me, the most important adverse effect of fatigue management is its tendency to impair the continuity of care.  Reviewing one’s post op patients at the now long discarded ten o’clock night round was an invaluable learning experience for me as a junior resident..  Safe hours must be much more than mandating limits on hours of duty.  Who accounts for the sleepless night studying or with a sick child or the late night revels the evening before.  Yes indeed, bring in aviation standards of fatigue management; no drinking within twenty metres of an aircraft and no smoking in the twelve hours before flying; (or something like that)!

  11. Abu says:

    It is interesting to read in the time of acountability, professional outcomes, patient outcomes and professionalism, and understanding of the affects of fatigue on error, driving accident returning home, learning, retention, performance, accuracy , health and emotional state that there is any argument to working reasonable hours.

    The belief that poor quality reptition while fatigued is good is astonising to see.

    I am astonished to see medical practitioners would have differing opinions on this.

  12. Sue Ieraci says:

    There is definitely a middle ground to be found. Emergency medicine has had to evolve shift work to provide a 24 hour service and because of the intensity of the work, long shifts are very difficult to endure. Not all specialties lend themselves to shift work, but hospital-based ones with no clinics or rooms (like ICU, for example) could do so. I think many people are deluding themselves that working weekdays for 5 out of 7 days provides ”continuity of care” – particularly at registrar/trainee level. Getting experience might mean working more efficiently rather than longer hours – we need to streamline medical work to more cognitive and skilled-procedures and less clerical/documentation work. Trainees might also benefit from running their own clinics, with oversight. Not everything done ”the old way” is better – many aspects of traditional work practices were counter-productive and almost punitive. As far as I know, nobody has found a good substititue for seeing lots of patients, however.

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