Working time regulations for trainee doctors

doi:10.1136/bmj.b4488

Published 5 November 2009, doi:10.1136/bmj.b4488
Cite this as: BMJ 2009;339:b4488

Editorials

Working time regulations for trainee doctors

Creating more flexibility around current working is the solution

In the linked analysis article (doi:10.1136/bmj.b4260), PurcellJackson and Tarpley describe their concern that surgical traineesin the United States might be forced to work within a maximum80 hour week.¹ Meanwhile, the European Working Time Directive(EWTD) demands that all trainee doctors in Europe work an averageof only 48 hours a week,² and the Royal College of Surgeonsof England is appealing for all their trainees to be alloweda 65 hour average week.³ Although Purcell Jackson and Tarpley’sconcern that a maximum of 80 hours a week is insufficient forsurgical trainees to gain the necessary experience, their argumentthat all surgical trainees need to be available all the time—forexample, to observe rare procedures such as elective surgeryon conjoined twins—overstates the case. How can we strikethe right balance between gaining sufficient experience, ensuringsafe working practices, and allowing doctors to have a lifeoutside work?

The American College of Surgeons reflects Purcell Jackson andTarpley’s position by also rejecting the 80 hour week;this implies that American surgeons believe that working withlittle rest is necessary for successful surgical training.⁴However, evidence shows that patients do not want a familiarbut exhausted person operating on them.⁵ Perhaps the next timea surgeon tries to obtain informed consent before a procedurethey should tell the patient how much sleep they have had.

The EWTD was introduced in 1993 without a risk assessment (unlikemore recent European directives), and its adverse effects onhealth care have been serious.⁶ Nor are we yet experiencingits full effect. The European Union has failed to publish itsown 2008 survey of medical trainees’ compliance with a56 hour week, but we know that many countries are not complying;the Greek government and Irish employers are already in courtfor non-compliance. Meanwhile Britain’s shortage of doctorsis being masked by moonlighting and allegedly fraudulent workreturns as some juniors work many more than the requisite 48hours per week.⁷ This is neither safe nor sustainable. Memberstates are realising that they cannot just ignore the regulations,so what is to be done? Revision of the EWTD may take years ofnegotiations, but solutions are needed now.

Creating greater flexibility around current working would beone possible solution, rather than the blanket 65 hours a weekfor all trainees being called for by the Royal College of Surgeons.The EWTD has two separate elements: the first is strict entitlementto an 11 hour rest period in every 24 hours, plus 24 or 48 hoursoff every week or fortnight, respectively; the second is thelimitation of an employee’s work to an average 48 hoursa week. Almost all the safety benefits for doctors and patientscome from the entitlement to rest.⁸ Although safety is one driverfor reducing long hours, the limitation of working hours probablyhas as much to do with creating employment for European workersin general, which is not appropriate for health care in 2009when we have too few doctors.

Could we not leave the rules about rest unchanged but exploitthe existing flexibility around the number of working hours?This would not be easy—many disciplines require a seamlesssupply of doctors for 168 hours a week, and people increasinglyexpect to work fewer hours, to be able to work part time whentheir families need them, and to have a life outside work. However,medical training is no longer a matter of serving time but ofacquiring skills and will inevitably vary in length dependingon the discipline and the balance of full and part time workduring an individual’s career. So why can’t we developand implement a flexible system of training and service provisionin place of the present "one size fits all"?

The present working time regulations can already be appliedflexibly. Every employee in the United Kingdom can choose toopt out of the 48 hour week to work up to 78 hours a week; juniordoctors can decide to opt out and to return immediately to a56 hour week, but they are limited by the New Deal—thejunior doctors’ employment contract that, by enforcingan absolute 56 hour limit, is even more restrictive than theEWTD.⁹ In addition, they can also be non-resident on call forup to an average 72 hours a week.¹⁰ Few surgical trainees inEngland or their consultants now operate at night. Hence, juniorsurgeons can be non-resident on call for up to 72 hours a weekand can choose to work up to 56 hours a week—essentiallywhat is demanded by the Royal College of Surgeons in England.

The old ways of training, time serving apprenticeships, andinflexible (essentially continuous) work are over. The trainingand service elements of each post need to be identified andconsidered separately, as do emergency and elective clinicalwork. Much effort needs to be invested into researching andimproving continuity of care, because none of the workforcenow works continuously—not even consultants.

The current system of rigid rotas is not ideal. In future, rotasmust take account of part-time working, individual decisionsabout opting out of the working hours regulations, and the dayto day measurement of hours of work when non-resident on call.The Department of Health must move from their single mindedimplementation of the 48 hour week, to the flexibility thatcan now be provided by sophisticated rostering, thereby helpingto improve patient safety, service delivery, and medical training.

Cite this as: BMJ 2009;339:b4488

Roy Pounder, emeritus professor of medicine, chairman¹^,2

¹ University of London, London WC1E 7HU, ² RotaGeek Ltd, London NW3 6BT

roypounder{at}gmail.com

Analysis, doi:10.1136/bmj.b4260

Competing interests: RP is an investor in RotaGeek Ltd, whichprovides software as a service to manage junior doctors’working hours.

Provenance and peer review: Commissioned; not externally peerreviewed.

References

Purcell Jackson G, Tarpley JL. How long does it take to train a surgeon? BMJ 2009;339:b4260.
Directive 2003/88/EC of the European Parliament and of the Council of 4 November 2003 concerning certain aspects of the organisation of working time: Article 22, para 1. http://bit.ly/1b8Iys.
Black J (Royal College of Surgeons of England). Letter to secretary of state. 9 May 2009. www.rcseng.ac.uk/news/docs/Alan%20Johnson%20EWTD%20Reply.pdf.
Britt LD, Sachdeva AK, Healy GB, Whalen TV, Blair PG; Members of ACS Task Force on Resident Duty Hours. Resident duty hours in surgery for ensuring patient safety, providing optimum resident education and training, and promoting resident well-being: a response from the American College of Surgeons to the report of the Institute of Medicine, "resident duty hours: enhancing sleep, supervision, and safety". Surgery 2009;146:398-409.[CrossRef][Web of Science][Medline]
Fletcher KE, Wiest FC, Halasyamani L, Lin J, Nelson V, Kaufman SR, et al. How do hospitalised patients feel about resident work hours, fatigue, and discontinuity of care? J Gen Intern Med 2008;23:623-8.[CrossRef][Web of Science][Medline]
Goddard A, Pounder R, McIntyre A, Newbery N. Implementation of the European Working Time Directive in 2009—implications for UK clinical service provision and training for the medical specialties. Royal College of Physicians, 2009. http://bit.ly/4AbjEp.
Newshound. EWTD hitting patient safety. BMJ Careers 2009 http://careers.bmj.com/careers/advice/view-article.html?id=20000443.
Lockley SW, Barger LK, Ayas NT, Rothschild JM, Czeisler CA, Landrigan CP; Harvard Work Hours, Health and Safety Group. Effects of health care provider work hours and sleep deprivation on safety and performance. Jt Comm J Qual Patient Safe 2007;33(11 suppl):7-18.
Pounder R, McCullough C. An introduction to RotaGeek.com—part 1. EWTD and the junior doctors’ opt-out—what do they mean? 2009. http://bit.ly/2xRwNh.
McCullough C, Pounder R. An introduction to RotaGeek.com—part 2. The on-call solution. 2009. http://bit.ly/461WLu.