Issue 8 / 11 March 2013

THE negative effects of unsafe working hours in medicine cannot be disputed. A large body of evidence attests to the risks of fatigue for patient safety and the health and wellbeing of doctors.

Health care systems have responded in various ways. In certain regions, strict regulatory frameworks have been introduced to limit working hours, such as the European Working Time Directive and the US Accreditation Council of Graduate Medical Education’s duty-hour requirements.

Australia has adopted a less rigid and more iterative approach. Attitudinal shift, workforce expansion, improved rostering, dedicated clinical handover and industrial requirements have all enabled progress. Although unsafe practices persist, the overall working hours of Australian doctors are decreasing.

Much of the debate has now shifted to focus on the impact of restricted working hours on training. A systematic review published in the BMJ failed to determine an overall negative effect, but there is marked variation in the outcomes of individual studies.

Perspective articles recently published in JAMA and NEJM highlight ongoing concern that various fatigue management strategies might have a detrimental impact on the quality of clinical training. The JAMA article also contends that the development of a shiftwork mentality may undermine the one-on-one patient-doctor relationship and the culture of professional responsibility and accountability. It argues against further tightening of US restrictions to the extent of those imposed in Europe.

It is difficult to discern if the fears are well founded. Clearly, limiting working hours and introducing shift rostering can impact on training by reducing the amount of time trainees spend in the hospital. It can also affect continuity of care and access to supervisors.

However, this assumes that traditional training arrangements remain entrenched and do not evolve in concert with the shift to safe working hours. Innovative models of education and service delivery are clearly required to deliver the parallel objectives of high quality training and fatigue minimisation.

This was a key finding of a UK report by Professor Sir John Temple, which reviewed the impact of the European Working Time Directive on the quality of training of doctors and other health professional.

The one-size-fits-all approach is certainly unlikely to work and individualised solutions must be sought. Arrangements that function effectively in the emergency department may not work on the medical or surgical wards.

The perception that meaningful training can only occur Monday to Friday between the hours of 8 am and 5 pm is no longer valid. However, poor supervision and extensive out-of-hours service requirements compromise quality.

It is for this reason that the Temple report recommended widespread adoption of consultant-delivered service models. For example, senior clinicians might work extended hours and, as a consequence, provide valuable clinical training beyond “office hours”. It also suggested that hospital processes must be explicitly configured to support high-quality medical education. Outpatient clinics, for example, might be optimised to ensure sufficient time and space for teaching and learning. Differing levels of supervision could be provided for junior doctors, based on their stage of training.

Regardless of the concerns expressed in the recent JAMA and NEJM articles, safer working hours are here to stay. Fatigue impacts on both patients and doctors and the safety of both should not be compromised by inappropriate rostering and service arrangements.

Medical training must adapt and take advantage of this new paradigm.

Dr Rob Mitchell is an emergency registrar at Townsville Hospital and immediate past chair of the AMA Council of Doctors-in-Training. Dr Will Milford is a senior obstetrics and gynaecology registrar at the Mater Mothers Hospital in Brisbane and chair of the Council of Doctors-in-Training.

Posted 11 March 2013

12 thoughts on “Rob Mitchell

  1. Peter Schlesinger says:

    As one who trained by long hours I would say that I fear for my children given how medical teaching and training has ‘developed’.

    Yes I worked an average 104 hours in my first year but I only looked after my patients on call, usually numbering 40 who were in hospital longer than today. When I worked first in Obstetrics and Gynaecology we looked after 56 patients on a 1:2, as did our surgical colleagues. We readily contacted our registrars for advice.

    When hours were first made an issue, well before the EU factory-based directives, the hours were reduced from 1:2 to 1:5 but the patient load went from 56 to 150.

    Then hot bedding came in and soon no body, neither nurses not junior doctors had a clue who had what. That is when real mistakes were made, caring for people you hardly knew.

    Today I train people who don’t know their anatomy or physiology and have no knowledge of why we do what we do because they are not interested in anything more than 10-15 years old. Thus they often try to reinvent the wheel.

    We denigrate generalists yet the generalists of the past were not too far removed from early sub spec trainees, today’s generalists in O&G can barely do open surgery and if there is a complication they have to call a surgeon. In 1929 surgeons formed the RCOG and trained in surgery and then O&G, today we are producing gynaecologists who need surgeons to bail them out. I doubt the RCOG will survive much more than 100 years before O & G go their separate ways.

    We worked long hours and had no idea when or whether we would make it. Today people know they will make it almost regardless of ability, but they work too few hours to be confident in instrumental deliveries, breeches, hysterectomy etc. It wasn’t the hours it was the years that were the problem and now we have poorer direct patient care where note making had taken the place of knowing your patients.

    In the UK today even with the EU factory directive being used in healthcare trainees work 17 472 hours of speciality training in 7 years, in the US it is 16 640 in 4 years but in Australia it can be as little as 12 480 in 6 years.

    We need a compromise between hours and years of training. Long hours with a smaller patient work load per trainee for a set number of years is better than shorter hours, smaller patient numbers AND fewer years training.

    The ills of the past were not hours but years of uncertainty. We changed it to unworkable patient numbers which is when the mistakes started, we then added hot bedding and stopped controlling visiting allowing infections which I’m fairly certain come as much from this lack of control as doctors’ ties and white coats. After all, in the US they have low infection rates and still use both. They do however have fewer patients, more hours and less years.

    I will now get down from my soap box, other than to say that like with the direction of politics I foresee medicine moving more to a centre ground than the crazy extremes seen in my career. Only then will patient care and training work for all concerned.

  2. Jules Black says:

    This is a problem that has always vexed me. On the one hand there are the strictly rostered working hours, (+ payment for overtime which I’ve always opposed), and not seeing a case through to its reasonably imminent conclusion, an essential part of the teaching and learning process. Examples from my experience include an anæsthetic registrar handing the bag over to the boss as he went from theatre to theatre saying that it was 5PM and he was now off duty; the acute hæmatemesis in ER the doctor was resuscitating and handed over at 5PM before the patient’s signs were stable; and so on. Leaving a mother in advanced labour whom the Dr had been managing all day, and handing over to a stranger (to the mother) for the closing stages, without managing the outcome personally. Midwives do it, so should the doctors.

  3. C says:

    expecting senior clinicians to provide extensive after hours service is unrealistic. if junior doctors find night duty tiring, imagine trying to do it at age 55 – 60

  4. Peter Schlesinger says:

    We were talking about trainees and directives regarding time worked. The EU directive does NOT apply to consultants! When I worked long hours it was not shift work and a week-end was 72 hours plus Monday normal activity for MY patients. Today it is all shift work but includes people you don’t know at all. However consultant staff are still on call, and often called in by trainees, over a 72 hour week-end.

    I’m 62 and whilst I work a week-end of 72 hours plus Monday morning, there are often no less than 5 different trainees covering that time. Yes I’m second on to them but I’m where the buck stops and I’m the one fielding the calls at 3am and doing a round at 8am.

    Get the patient numbers right and the hours are not an issue if the whole training time is a limited number of years. Experience comes from being there and seeing and doing. If the hours of training are a real issue them we are picking the wrong people.

    Work hard and long at 25-35 and the rest will come easily thereafter. Take short cuts and the confidence will never be there. It is a choice between one years experience 20 times over versus 20 years experience.

    I wish my daughter (and sons) looked after by a confident and competent OB/GYN or doctor and the more we reduce hours and exposure the fewer of this there will be and never, never play the age card. I’m perfectly competent and able to work long hours, even at 62.

  5. Ian Hargreaves says:

    Neuropsychological research suggests it takes about 10,000 hours to gain competence in a psychomotor field, from playing chess to playing a musical instrument.
    This cannot be fast-tracked, and funnily enough, works out at about 4 years of 60-hr clinical weeks, much like an old-school training programme. Time spent in areas like ever-increasing administrative or clerical tasks is not likely to improve one’s ability to elicit clinical signs or read imaging films.

    The good trauma comes in at unsociable hours (after pub closing time), and the rare diagnostic/therapeutic challenges are rare – you won’t get to see acute meningitis or tension pneumothorax on the average ED day. Nor should you expect your first fracture reduction/ lumbar puncture/ chest tube insertion to be perfect and effortless.

    It is perhaps no coincidence that several writers are obstetricians, the most unpredictable of specialties for hours and emergencies. I remember the cheerful midwife saying: “Now I see you’ve had forceps with your other 3 babies, how about trying to have this one naturally?” She had all the carefully documented facts in her university trained hands, 4kg babies with head circumferences above the 97th centile, all posterior lies, all failed to progress, low rotation/liftout forceps. What she lacked was the ‘horse-sense’ that comes with thousands of hours of experience, and my old-school obstetric colleague pulled out a 4th healthy baby, born just like her siblings, all on weekends or public holidays.

    Although the authors assert:”The negative effects of unsafe working hours in medicine cannot be disputed. A large body of evidence attests to the risks of fatigue for patient safety and the health and wellbeing of doctors”, I recall many reported cases of patients sent home by inexperienced doctors, only to die of their meningitis/pulmonary embolism/acute psychosis. I am sure Mark Webber would be driving both faster and safer at the end of the Le Mans 24-hr race than I am after 1 hour in Sydney traffic. Johnny Wilkinson won a Rugby World Cup because he practised kicking even when exhausted, so when he had to under pressure, he had the skill. How can you be certain from a computerized medical record whether the patient is a little more tender/obtunded/suicidal than when the last shift of doctors assessed him? It is easier if you have assessed him yourself previously.

    The “consultant-delivered service models” referred to would seem an acknowledgement that those of us who have done the 100-hour weeks are better at doctoring than the less experienced. How the next generation of consultants will acquire such experience (within one lifetime) is not well elucidated.

  6. BC says:

    I do not pretend to have the answers on this one. As a respiratory and sleep physician I’m as concerned for our junior inexperienced colleagues as I am for myself, who faces stints of 7 consecutive days’ on call each time my turn on clinical service comes round (about one in 4-5 weeks). There is no doubt about the adverse effects of sleep deprivation and sleep disruption. We really do not consider these as seriously as (say) the effect of alcohol, even though the measured effects of “normal” clinician sleep deprivation to 6 hours has been shown to cause significant deterioration of cognitive skills. Then we need to consider that individuals have differing susceptibilities to the adverse effects of sleep disruption and also (for younger colleagues) that learning capability is impaired with insufficient sleep, a fact does not apply to those of us more “senior”. Lastly, the effects can be devastating; as a trainee, I fell asleep twice at the wheel and I know colleagues who have lost their lives in this way. Surely, this is an issue we should take far more seriously?

  7. Sue Ieraci says:

    There has to be an answer that incorporates some of the old and some of the new. Many long hours spent in “training” in previous generations were trial-and-error training, where one learned as much by mistakes as exposure. Yes, exposure is essential, but learning from the exposure is better if one is supervised and guided in learning, shown the signs, explained the significance of clinical features and outcomes, debriefed from the poor decisions. Training should be at least as much cognitive as motor – even in the procedural specialties. A new approach to shift work and hand-over must also be taken – handover is an error-prone procedure but can be handled in a standardised way.

  8. Peter Schlesinger says:

    Agreed.

    Of course hours can be a problem but in the main there never was an incessant flow. With larger units and faster throughput nowadays there is no rest.

    The ideal is a working week of 60 odd hours but the 4 year model would still mean that one wouldn’t see enough.

    The Americans perhaps should change to a 60 hour/5year plan, the UK should do something about the 48 hours and adopt 55-60 hours over 5-6 years to appease Europe and the Australians follow suit. The ideal would be that everyone follows the 60/5 model.

    60 hours a week is still possible over 60 years of age so long as the 40-60 hours part is as second on to a trainee.

    In Private Practice you have to work your own system out, but training and teaching units should consider the above and trainees cannot expect to learn if they are not present.

  9. Sue Ieraci says:

    The other aspect to consider is work intensity. In my area (emergency medicine), it is no longer viable to work long hours while managing an unrelenting clinical load, also under time pressure and constant scrutiny. Our trainees see plenty of patients over 40 – 50 hours a week, working rotating shifts, and with routine out-of-hours supervision. There is no doubt that fatigue can impair critical decision-making. As can shift work – but there seems to be no way to make the patients arrive only during office hours.

  10. Rudolfo says:

    “For example, senior clinicians might work extended hours and, as a consequence, provide valuable clinical training beyond “office hours”. It also suggested that hospital processes must be explicitly configured to support high-quality medical education.”

    What a load of meaningless, airy fairy edu-theory crap. And yeah, great thought bubble – just get consultants to come in and teach at night.

  11. Sue says:

    Rudolfo – on the contrary – aspect of this are already reality.
    “Extended hours” means outside “office hours” – not MORE hours. Some hospital-based specialties already have out-of-office-hours consultant sessions – which match patient needs. The same concept could be applied more widely with some imagination – patient needs aren’t necessarily greatest between 9 and 5 on weekdays. Certainly those running private rooms might have some restrictions in flexibility, but this should not apply to staff specialists.

  12. Peter S says:

    I thought the original issue was with regards to trainees hours.

    For senior staff the issues are different and agreed there are differences between self employed and employee. Once again I blieve that it is intensity which is the key factor, not merely hours worked.

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