Thursday, September 16, 2010

Junior Doctors Hours

The topic of hours and fatigue in medicine continues to rumble on with no real resolution in site. A couple of recent articles and news items highlighted the continuing challenges.

The Daily Mail reported the Coroners' comments and verdict in this piece (Coroner hits out at doctors' hours after patient dies) and Doctors.Net also featured the report: Junior Hours Blamed at Inquest (membership required)
An elderly man died in hospital after waiting five hours to see a doctor. After being told how Roland Holbrow died without seeing a doctor, a coroner yesterday criticized European rules that restricting junior medics' working hours.
Michael Rose described the European Working Time Directive....'Hospitals are running into problems,' he said. 'I can see the clear warning signs, although I am not going to refer this to Mr Lansley as I think he will already be aware of it.
There's no shortage of views from both sides of this discussion:

Those in favor of restricting hours
..I don't agree that anyone should work that amount of hours, its not safe, and it courses problems in the future.
..criticise the PCT for not employing enough Doctors.
..Hospitals at fault here for NOT recruiting sufficient staff to provide proper shift cover... instead, they've been reducing manning levels instead so as not to exceed the WTD hours limit
..At the end of the day though do we really want to be treated by a doctor who has been on duty for over 12 hours. Pilots and the like are restricted on hours worked for safety reasons so should we really be seeing a doctor who is dead on his/her feet and then expect them to make the correct diagnosis first time every time. I doubt if many hospital administrators have a clue what happens overnite in their hospital and how bad things are they will have left by 5 30 in any case

And those that think we need to return to longer hours so junior doctors get "more experience"
..Good to see such a courageous coroner and Clinical Director, both willing to speak unpopular truths. We must unshackle Juniors from the restrictions of the "New Deal", and EWTD, whilst maintaining a sensible work / not work life balance. Also we need a 24/7 365 days a year fully active acute sector i.e. more flexible working all round, and likely more doctors
..can some one explain to me why FY1's were taken off doing night shifts and regular weekends? It seems ridiculous that we have a national shortage of doctors yet a massively under used resource of Dr's needing exposure so as to mature into decision making
..A few facts about EWTD. 1. It was never intended for the professions. I know of no professional (or other successful person in other walks of life) who has worked ONLY 48hrs pw when 'on the way up' (or indeed having 'arrived'!)

Even some senior surgeons weighed in in a letter to the Telegraph suggesting limiting hours will have a significant adverse impact on patient care. In fact they have been arguing that junior doctors need to work more hours
The College and others have consistently argued that junior doctors need to work more than the 48 hours per week permitted by the European Working Time Directive in order to amass enough experience and learning to become safe and competent surgeons.

Interesting a study just out in the Journal of Amarican Medical Association: "Presenteeism Among Resident Physicians" and was featured in the NPR Shots Blog Doctors-In-Training May Give More Than Medical Care:
nearly 60 percent of respondents said they had worked while sick at least once and nearly a third reported having worked while sick more than once. At one "outlier" hospital not named in the study, 100 percent of the respondents reported having reported to work while sick.
A related problem, the survey found, is that busy medical residents (who are already known to not get enough sleep in the early years of post-medical school training, despite rules attempting to ensure they do) also reported not having enough time to see a doctor for their own medical care.

One thing is for sure - tired people are not giving their best. As one junior doctor put it
In the last 2 weeks I have worked 105 hours without a day off. This is my rota and includes no overtime. I would say my patient care was compromised at the end as was my love for the job. ....I have maximum 2 hours of teaching every other week as the wards are too busy to leave the rest of the time

Managing the hours and providing a good working environment is going to be essential. Technology will play a role in helping reduce work burdens and creating efficiencies but updating our training system must be included in the update to our health systems