The furore over doctors’ long working hours in Queensland reminds me of a recent conversation I had with a new intern who failed to take a half hour lunch break every day of the past fortnight.
The industrial award requires us to pay 150% until the break is taken. The young doctor felt she was so busy that a lunch break would be impossible. Our public hospitals are under such pressure at present that junior doctors feel unable to take time off even for lunch.
Twenty-five years ago, 36 or even 48 hour shifts for junior doctors were commonplace. The “House Officer” was literally that. They lived at the hospital, when not working they were sleeping. Recent industrial arrangements have insisted that the trainee doctors have at least one day off in eight, have eight hours off between shifts and cannot work more than 14 hour shifts.
While these arrangements are more humane, they have been introduced without any thoughts regarding the effects on training, handover or patient care.
Training of young surgeons requires close supervision of experienced surgeons. This largely takes place during elective operating lists, clinics and ward rounds during daylight hours.
Trainees value these interactions but the hospital also needs to be staff overnight and on weekends. Who wants to sacrifice valuable training time for after hours emergency calls?
These after hours calls are important but usually low volume and repetitive. Six months at such on-call usually adequately exposes most trainees to the needed cases.
Is it reasonable to extend training by years so a hospital can cover its emergency work at night and weekends?
The old system of 36-hour shifts provided two days of training in exchange for the night on call. Did patients suffer? Apart from occasional anecdotes, little evidence exists that any patient suffered.
In fact, with shift work care it may be that patients are worse off. With a loss of continuity of the patient, changes in condition may be missed. It is difficult to accurately transmit deteriorating clinical condition from one doctor to the next. Systems of reliable handover have lagged within the Australian healthcare system.
Hospitals are reluctant to fund additional time for careful handover to occur. Even if it does occur, little agreement exists on what it should include.
Traditionally, an individual doctor took responsibility for the patient they admitted to hospital. Now this responsibility is diffused over a number of individuals with the ultimate responsibility unclear.
It is interesting to note that while trainees in the public hospital system are provided with controlled hours and mandated rest periods, no such requirements are afforded to the consultant staff in either the public or private system.
The evidence is still not present on the effect on surgical performance of 36 hours continuous duty.
If one goes out into rural Australia many GPs and surgeons are on call without break weeks or months at a time.
It is hard to predict how much longer we can expect such dedication from these members of our medical workforce, particularly when the new trainees as they graduate will be used to a completely different rostering structure.
Guy Maddern is professor of surgery at the University of Adelaide. St Anywhere is fictitious, but the events and issues are real.
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As someone who is about Prof Maddern’s age who obtained fellowships in both Anaesthesia and Intensive Care before practicing these disciplines for a decade or two I can say the need to work for more than 18 or so hours without an opportunity for some un-interrupted sleep is utterly un-necessary and just plain dangerous. Sadly I used to get stuck with shifts running to 60 hours on the trot, usually with some very broken sleep, quite regularly and feel very lucky I did not just plain kill a number of patients. Had something un-expected happened you can be sure after 48 hours the chances of a good outcome were greatly diminished.
This attitude of ‘we suffered for our training’ and so should you is just nonsense.
David.
“It is hard to predict how much longer we can expect such dedication from these members of our medical workforce, particularly when the new trainees as they graduate will be used to a completely different rostering structure.”
No, it’s easy to predict. They just won’t do it.
Australia has a fantastic medical system thanks to people like you Guy Madden. (Thank you, by the way.) Especially when you look at the mess that is the US system. But Australians will increasingly realise that if you want guaranteed great care (if you can afford it), you will:
– go private; and
– be willing to pay extra excess for the best.
This is unpopular but true.
To minimise (as a patient) the possibility of getting an untrained overseas doctor with a blunt spoon, we are already picky about our hospitals. Or would you really say to a loved one; “Go to any hospital. It doesn’t matter”? Maybe we should have hospital league tables (and you thought that school league tables were controversial).
“The industrial award requires us to pay 150% until the break is taken. The young doctor felt she was so busy that a lunch break would be impossible. ”
Sounds like someone gaming the system to me.
The European parliamentary regulations decreed that as from 1 August 2009 junior doctors hours should not exceed 48 per week, down from 56 hours in 2007. We do love to make our medicos as well as paramedics and nurses work hours which guarantee they are in a constant state of fatigue. We do this because so much money is ripped out of the public health system by subsidies to doctors, specialists and private health insurers that there is none left for humane working hours for public doctors. Last year I visited Venezuela to observe the elections and while there received treatment from both Venezuelan and Cuban doctors working with the Barrio Adentro (slum health) scheme. The treatment and dressings were excellent and greatly helped my recovery. There was no charge of course. Doctors hours there are a lot less than here, but they are not fee for service doctors, but on a salary which is fairly low by our standards. They were not tired and seemed quite alert and on the ball. Since then I have watched the movies “sicko” by Mike Moore and “Salud” about the Cuban overseas doctors program where they send doctors to work in poor countries, well worth watching for those who may tremble at the thought of “socialised’ medicine.
Meski, far more likely that she did the work anyway, missed lunch and didn’t claim for it. That’s what most of us do. I know of doctors who “game the system”, but I’m far more familiar with the system gaming us.
As an example, I have recently been told that junior doctors in my department will now be expected to work 80+ hours per fornight but only be paid for 76. If they want to “quibble” in the head of department’s words, they can “miss out on the teaching” which happens during the normal work day.
To put it in perspective, 12 months ago in the same department I was routinely working 90-100 hours per fortnight and being paid for 80. As part of cutting costs, the junior doctors have had their paid hours cut, their training opportunities restricted and been openly blackmailed into not complaining about it. There has been no reduction in the amount of work to be done in that time. Same work, less money, less training.
This is the second time Prof Maddern has suggested that the system ain’t broke and young doctors should stop asking to be paid for what they work and not worry about excessive hours. I hope he has noted that with the current situation in Queensland it is senior doctors who are complaining about excessive hours just as much as the junior ones. Of course it is valuable training to do the on call and after hours work, but it doesn’t need to be on top of long day shifts as well. And if you’re concerned about the training they’re not getting, why not convince some of your colleagues to walk away from their lucrative private lists and spend some time with the registrars instead.
This is a complicated issue and different specialties and sites have different requirements. Saying “it worked ok in the past” ignores the fact that the training system and the health system has changed. And besides, given the number of crap middle aged and older doctors I’ve encountered, I’d suggest that the old way wasn’t necessarily that good either!