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Hopefully, doctors in future may not have horror stories! At least not of this kind!
- Padmini Venkataramani (5 August 2004)
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No one dies of over work
- Ashish Goel (5 August 2004)
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Re: No one dies of over work
- David Carvel (7 August 2004)
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Doctor's Horror in Developed and Developing Countries
- Matiram Pun (7 August 2004)
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Mixed feeling
- Halina M. Iwanowska (7 August 2004)
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Re: No one dies of over work
- mike green (7 August 2004)
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TOO MUCH WORK IN BRAZIL
- CELIO LEVYMAN,MD,ScM (7 August 2004)
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Readying for lengthy working hours
- Laxmi Vilas Ghimire (7 August 2004)
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India needs to think differently
- Abhijit M Bal (7 August 2004)
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Stay hungry and feel the joy
- Abhijit M Bal (7 August 2004)
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Re: No one dies of over work
- Alan E O'Connor (8 August 2004)
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Where are the data to support our gut feeling?
- Pinchas Halpern (8 August 2004)
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Do a billion Indians think the same?
- Jayaprakash Gosalakkal (8 August 2004)
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Death Of The '104-Hour' Working Week : Fiat Justicia Pereat Mundus
- Joseph . C . Obi (9 August 2004)
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To err is human , but...
- Farheena N Mecci, Akheel A .Syed,Specialist registrar,University of Newcastle,Newcastle upon Tyne NE2 4HH (9 August 2004)
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Amazing debate
- Ashish Goel (9 August 2004)
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"He took eighty calls in one shift"
- Phillip J. Colquitt (10 August 2004)
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Re: Amazing debate
- P.N Kiran (11 August 2004)
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Ethical Working Time directive & junior doctors adaptation
- Ruchir D Trivedi, Northern General Hospital, Herries Road, Sheffield S5 7AU (11 August 2004)
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Limited hours of working during training period?
- Arun Bharthuar (12 August 2004)
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Re: No one dies of over work
- Matthew L Keating (12 August 2004)
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Stop the torture...
- Raha Shojai (12 August 2004)
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Managing hours, stress, continuity of care and junior doctor training
- Steven M Rudolphy (6 September 2004)
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Re: No one dies of over work
- shripada rao (9 September 2004)
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Horror begins at home.
- Abid Rashid, Noina Abid (6 January 2005)
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The real reason behind endless working hours
- vineet gupta (12 January 2005)
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Padmini Venkataramani, Associate Professor, Paediatrics Faculty of Medicine & Health Sciences, UNIMAS, Jalan Tun Ahmad Zaidi Adruce, Kuching, 93150,Sarawak
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Your Editor’s Choice “All doctors have a personal horror story” by Dr Abbasi made interesting reading and brought back memories of my days in training in India! I remember the posting in the neonatology unit where one was on call everyday and if lucky on alternate days. I still remember a 48-hour continuous shift with no sleep and practically nothing to eat, at the end of which I had no idea whether I was awake or sleeping, though I was still on my feet! Other memorable days were during my masters’ training when we had close to 100 children admitted during admission days! When I think of it now, I do not know how I managed to survive! However, we had no choice because we were so short of staff most of the time. I am not sure if there is any merit in having the trainees go through such a hectic schedule. I am happy to see that the present day trainees in UK and Europe are likely to have have a more reasonable work schedule. Hopefully it would apply to all junior doctors, whether in training or not. The training would probably be more meaningful if a junior doctor spent reasonable hours at work with adequate time to study and rest rather than in a blur of hectic activity for days on end. This would also help their patients more. Let us hope that this would become a global trend in the future. Competing interests: None declared |
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Ashish Goel, Senior Resident, AIIMS, New Delhi AIIMS, New Delhi 110058
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The 58 hour week is an interesting and an attractive directive. But there is something we all miss out when charmed by limited work directives. When one goes off call after a continuous on call week, the thrill and the confidence is divine. People have done it before, and people can do it. No one dies of over work. But you get the confidence to deal with anything after you have worked in this manner. In India we have no working hours. And for those for whom work is fun, there need be no working hours. Competing interests: None declared |
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David Carvel, GP Biggar ML12 6BE, UK
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I am not sure the families of suicide victims who cited overwork as a factor would necessarily agree with such a sweeping generalisation. Competing interests: None declared |
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Matiram Pun, Medical Student Institute of Medicine, Kathmandu,Nepal
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Well,probably you will have more of its kind of horrors in your editorial period in BMJ Dr. Kamran Abbasi!The Doctors in developed countries not only have sleepless nights but also terror of being sued with any sort of iatrogenic problems.That is ,of course, due to consumer consciousness among the civil society.And Kamran Abbasi,you will have more horrors due to very conscious readers of your journal BMJ from around the world. The Doctors from the developing countries are facing horrors due to lack of their fellow knowledgeable citizens i.e.lack of manpower. We are,currently,having the figure of around Fifteen Hundred People per Doctor.Along with that , we have to work blindly due to lack basic Diagnostic facilities.What kind of Horror you can have more than you have to wait and see an innocent patient dying in front of you due to lack of basic health facilities ! You know about it, you can treat it , BUT you can't do it here. Real Horror, Yeh! Matiram Pun Institute of Medicine,Nepal Competing interests: None declared |
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Halina M. Iwanowska, retired surgeon Medical Academy Gdansk, Poland
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Absolute necessity in introducing the new 58 hours doctors works week, taking into consideration first: the patients and last but not least the doctors (very authentic horror story) I have to emphasize that never in my life I was so proud and elated as after finishing my over 60 hours weekend duty! Competing interests: None declared |
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mike green, general practitioner Liverpool L8 6QP
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That no doctors die from overwork is debatable, (what role does overwork contribute to high suicide rates amongst medics?) However, I think what is without doubt, is that patients die because of mistakes made by overworked doctors. Perhaps no one dies "of overwork" but people certianly die "because of overwork." Competing interests: None declared |
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CELIO LEVYMAN,MD,ScM, Senior Neurologist Headache and Neurology Clinic of São Paulo,São Paulo,SP,Brazil
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This very interesting editorial about a horror day in a medical career in UK is something strange to a Brazilian doctor. After the basic formation in basic and clinical areas, comes the intern stage – usually the medical student act as a messenger, an office boy, a surgery intrumentador – in short words, a slave factotum. After the graduation, as a junior doctor, he comes to a residence program: the most of them do not pay the attention to the legislation about hours of work and study, and the whole program can be considered a “horror” period of two,theree or four years: in some areas, like neurosurgery, there are institutions that have only one post to a resident, and such human being works continued every day and night; other programs in the same area have two or three positions, and the work is a little hard. And this are comprehensive fellowships: ER consultations, in-patients care, surgery training and procedures, classes, symposia, tests and so on. In other fields, in very important hospitals linked to traditional medical schools, the pediatrician resident could in the first day of work appointed to make alone an umbilical cord transfusion… But after the residence the things don’t change too much: if the doctor wants to perform a post-graduate program to obtain a Master or Ph.D. degree, he or her must to elaborate the reseach,the thesis, the credits with various classes and, of corse,continue to evaluate patients in the ER,etc. In the professional life, there are a lot of doctors, and the average physician in Brazil work in one or two public services, in a private hospital, in an office and complete the budget with night and week end shifts, usually in a ER…And these typical doctor can work, if he or her obtain a hole in the schedule, as a tutor or assistant professor in a medical school or a residence program in a hospital… Why this occur in Brazil? Doctors are generally not well pay, and they need a lot of employs. Here few physicians work in an unique hospital and have adequate payment. These kind of things occurs because there are so many medical schools in the country, and the graduates do not want to go to the Northwest region, a poor area with few doctors, nor for the North, the region of the rain forest. They contribute to a major concentration of physicians in the South/Southwest regions of Brazil, the more developed areas (with cities like Sao Paulo, Rio de Janeiro, for example).As the WHO criteria, there are a bad relationship in regard to doctors/population, and these is the cause of the high number of physicians in these regions of the country. Despite these facts, the market rules play an important role: the private secure plans pay little honoraries for the doctors and also limits ancillary examinations, based in the managed care programs. The public, governamental employees are another options, but the physicians must to care a lot of people and receive few money at the end of the month. In other words, the majority of Brazilian doctors works very hard, have few moments to study and continued medical education and also have an strange competition of illegal doctors that come from the countries near from Brazil – these people runs away from Bolivia,Equador,etc. because there are not market for doctors in they native countries, and accept any kind of work in Brazil, exploited by bad physicians or health enterprise men, and the Federal Police and the Medical Councils have enormous difficulties to locate these irregular doctors and apply the law, generally the deportation. For many and many doctors in Brazil, specially junior and young graduates, the horror is continuos,day by day, and we don’t have an horizon to put the things in order. I by myself work in private clinic and in one of the best hospitals of Latin America – I could work with properly guidelines, evidence-based medicine, and all neurological machine stuff (from EEG to PET), perform programs of continued medical education and so on. But this is not the case of most of my colleagues.Coronel Kurtz is a kind and gentle boy in the jungle of medical profession here. My apologizes for these comments, hard of course, but I think that is necessary to the international community know the high-tech medicine and research in some centers, and the work condition of the doctors in the whole country: is clear that not only the physicians have problems – the population suffer with these things (40 millions of Brazilians have private health plans and more than 100 millions uses the public system, here named SUS, when and where they exist. Competing interests: None declared |
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Laxmi Vilas Ghimire, medical student TUTH, Kathmandu
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Since my early days in medical schools I have been reminded that to become a doctor you have to go through much pain in comparison to other profession. When my seniors shared their experience of working continuously for 48 hours we could hardly imagine how we would do such duties. We used to consider it to be even inhuman to involve students in duties for such a long time.In my early clinical course when we used to be exhausted within four hours of bedside work our teachers constantly told their tales of residency and junior doctor period and make us alert that we have to be ready to work for even days without any rest. Still many of us believe that hard work and lenghthy exhaustive experience boost our confidence and skills. So now I have made up mind to tolerate any length of time of work during my junior doctor time and during residency. Competing interests: None declared |
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Abhijit M Bal, Specialist Registrar Department of Microbiology, Aberdeen Royal Infirmary, Aberdeen AB25 2ZN
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I beg to difer with you Ashish. It may be fun for you but the more important question is whether the patients benefit from this hectic schedule of doctors. Are you providing quality care to all your patients? Are you not distributing your time in such a manner that every patient under your care gets your time but none get enough attention. May be you are able to do that at your hospital but AIIMS is an exception and not the rule. "I can work that much" is a mere bravado akin to "We are poor" kind of statements we are so fond of. India needs to think differently. Criticism is welcome. Competing interests: None declared |
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Abhijit M Bal, Specialist Registrar Department of Microbiology, Aberdeen Royal Infirmary, Aberdeen AB25 2ZN
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Further to what I said earlier, your comment Ashish "When one goes off call after a continuous on call week, the thrill and the confidence is divine" sounds something like "Stay hungry for 4 days and you will feel the pleasure of eating bread". Now that might be true. Fortunately I have no first hand experience of hunger. However, there is no greatness in staying hungry, no greatness in poverty and there is no greatness in excess unmeaningful work (such if the SHO has to compensate for all kinds of hospital work only remotely connected to active patient care) not contributing either to patient care or to your career. Competing interests: None declared |
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Alan E O'Connor, Director of Emergency Medicine Peel Healh Campus, Mandurah , WA 6210, Australia
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Except, perhaps, your patients.............. Competing interests: None declared |
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Pinchas Halpern, Chair, Emergency Medicine Tel Aviv Medical Center, 6 Weitzman Street, Tel Aviv 64239, Israel
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I'm repeatedly amazed that, after so many years of discussing the issue of physician overwork, its POTENTIAL effects on physicians and its POTENTIAL effects on patient care, we still have no meaningful data. Not many fields of medicine would have accepted such a state of affairs for so long. We will never progress in this area, unless and until, we have information that is credible to decision makers. It takes money to change the situation, money that is objectively hard to come by, and subjectively inappropriate in the minds of decision makers. We can wait for a few documented horror stories to move the public (such as the New York case which moved the US system a few years ago), or start working hard, in a concerted effort to prove what we feel is right. Competing interests: None declared |
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Jayaprakash Gosalakkal, Consultant Paediatric Neurologist UHL Leicester
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Come on ! an Indian resident feels happy after a long period on call dealing with patients so should the entire country and everyone else from the same geographical area of origin have a rethink of their morals and their priorities?Is poverty always related to a persons efforts or accoplishments?give the old country a break! A Billion Indians do not think alike and if a resident in Delhi enjoys long periods of contact with patients and their treatment so be it.Does it automatically mean they do not treat their patients well.That would be political correcteness gone mad.Well ! Competing interests: Bit sick of Indians and PIo s taking pot shots at the auld country |
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Joseph . C . Obi, Professor Of Complementary and Alternative Medicine (CAM) Research ; College Of Natural Medicine , Larnarca , Cyprus , European Union . (www.CollegeNaturalMedicine.org)
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Doctors in the United Kingdom have never ever had it so good. In fact , they have just had it so good that they should all gleefully start skipping round the 'Blossoming Evergreen Forecourts' of their various places of work ; singing profound praises of 'Hallelujah' to which ever 'Heavenly Deity' that they joyfully choose to offer 'Profound Clinical Psaltery' to. In my day ; I had to find an exceedingly miraculous way of ethically combining a '104-Hour Working Week' at an 'Exceedingly Racist NHS Hospital' in 'Mid Yorkshire' with the 'Finishing -Off' of a 'Long Overdue', 'Self-Sponsored', Master of Public Health (MPH) Dissertation at the University of Dundee.( Yes : You perfectly did hear me right. Don't ask me how I did it ). Not that Norman MacKay ever even cared 'Tuppence' (about my 'Excessive Working Patterns' or 'Constant Racial Abuse') when I summarily found myself innocently standing before his 'Interim Court Of Session' at 'Great Portland Street'. But that is 'Story Enough' for yet another 'Vengeful Literary Day'... Let it be humbly proclaimed that the European Working Time Directive (EWTD) is probably one of the best policies to have ever emanated from Brussels ; and I very sincerely hope that (eventually) no Licensed Medical Doctor in Great Britain will ultimately be forced to work more than 40 hours a week (for a jolly good wage at that). The onus will then be upon the various NHS Hospital Managers to spend a little bit less time on 'Idle Administrative Gossip' ; and duly concentrate (much more eminently) on 'Consistently Optimizing' the Quality and Efficiency of Baseline Clinical Services. Competing interests: Professor Joseph Chikelue Obi FRCAM (Dublin) FRIPH (UK) FACAM (USA) also serves as Provost at the Royal College of Alternative Medicine (RCAM) , Dublin ; where an Interdisciplinary Revalidation Initiative (IRI) has recently been proposed for Seasoned Practitioners in Complementary and Alternative Medicine (including 'Emeritus Physicians'). Please kindly visit www.RoyalCAM.org for more details. |
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Farheena N Mecci, Clinical Tutor,Community Paediatrics Dr.Ambedkar Medical College,Bangalore-560045, India, Akheel A .Syed,Specialist registrar,University of Newcastle,Newcastle upon Tyne NE2 4HH
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As junior doctors of many years’ standing (and several more ahead of us) with experience of work and training in two different parts of the world, we can empathise with Dr Abbasi’s sentiments better than most people [1]. The thrills of 56-hour continuous shifts are highly over- rated. The heady mixture of sleep deprivation, adrenaline and substance P plus or minus caffeine makes for an euphoric, addictive cocktail. But this can’t be good for doctors, less so for patients. It has been estimated that between 44,000 to 98,000 patients die in hospitals in the US each year as a result of medical errors, numbers far in excess of deaths due to motor vehicle accidents (43,458), breast cancer (42,297) or AIDS (16,516) [2]. The vast majority of preventable incidents result directly or indirectly from human error. How much of this is due to physician fatigue is, for obvious reasons, difficult to quantify but there can be little doubt that it is a major factor in fatal and non-fatal medical errors. One of us has experienced the very real horror of a colleague’s suicide whilst on-call (no, it was not due to lack of work) and the dubious pleasure of treating another for a generalised seizure, again whilst on-call, brought on by sleep deprivation. Sentiments such as ‘no one dies of over work’ [3] are, therefore, ill advised and espouse unnecessary bravado. This, however, does not detract from the commendable dedication of the many doctors who, of necessity, work beyond any working time directives in both the developed and, particularly, the developing world. References 1. Abbasi K. All doctors have a personal horror story. BMJ 2004;329(7461):0-g-. 2. Committee on Quality of Health Care in America, Institute of Medicine. To err is human: building a safer health system. Washington, D.C.: National Academy Press, 2000. 3. Electronic responses. All doctors have a personal horror story: bmj.bmjjournals.com 2004. http://bmj.bmjjournals.com/cgi/eletters/329/7461/0-g (accessed 08 August 2004) Competing interests: None declared |
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Ashish Goel, Senior Resident, AIIMS, New Delhi AIIMS, New Delhi 110058
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I am amazed at the volume of response and amount of debate generated to my pragmatic comments stating that overwork does not kill. Maybe I should ask the families of those who have died of stress…. People have died in Road Traffic Accidents as well, but still we do not stop driving cars. Maybe I should also ask the family members of those who have died in RTAs It is those who do not like their work, that complain of overwork. No earthshaking achievements were achieved in limited hour jobs. The sweat and toil of the dedicated few, gave them the tools to change lives of those who wished to work on 58 hour weeks. And then Charles Darwin wrote the Theory of Natural Selection….. I like the point of staying hungry for four days to enjoy the taste of bread. I agree that I have also had the fortune, (I don’t say good or bad) not to stay hungry for four days on end. But this much I say that those who have stayed hungry for four days, and eaten on the fifth, are the only ones in this world who know the real value of food. How many reading this mail, may I ask have never wasted a morsel of food? One more point, it is my observation (at least here in India) that, every single day in an average hospital it is not impossible to identify one case where the patient had been grossly neglected and a fatal error had been committed in his management on the part of the doctor or the paramedical staff, which should in all probability, have killed the patient, but the patient survives. It is also similarly possible to identify one case where the patient presented with non critical symptoms, where everything was done right and the patient had no reason to deteriorate. Where best care was provided to him and yet, he mysteriously succumbs to death. Competing interests: None declared |
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Phillip J. Colquitt, Technician and RN Independent comment
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At least that's one resident describing the horror of his colleague's last shift. I did the math. Hmmmm....."mild mannered reporter for a metropolitan newspaper.....truth justice....the American way". And when he takes his glasses off it gets even more impressive. Just in case the general reader doesn't realize it, and in keeping with the broad sweep of contributions to this global publication, most calls to see patients that young doctors(called residents) get, come not from their own predictive inner voice, but from nurses. Australian hospitals at least, feature no doctors at all in the wards. Doctors usually only come if asked, though they do make preemptive strikes on occasion. Nurses are the only staff who are really there all the time. More fool they, some might say. In a twenty four bed surgical ward for example, you will see about three RNs(Registered Nurses) on night shift, and about eight on the previous(afternoon shift). The doctors are there(sort of) during the day shift, but mainly for want of them being somewhere - with computers they can check any patients latest blood test results from any terminal on campus network, and the telephone does a lot of work. Many doctors appear to believe that the power of their science is such that you can plan a patients medications and IV fluids a few days in advance. Over the weekend for example. That rarely works, and you find the resident being called to change this or that - hypo and hyperkalaemia is a favorite alert from the lab(serum potassium levels outside parameters compatible with wellness). Admittedly, many junior nurses call these junior doctors for next to nothing(Paracetamol etc.). That cuts into efficiency a little. Competing interests: None declared |
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P.N Kiran, SHO LONDON
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Well Asish,being a postgraduate from India i fully appreciate your views.I feel the stress is more here because you are more accountable.Also you have to explain everything to them,involve them in everything we do.Its not like back home where people shout at patients,do not invole them in their own care and we shower all the stress on the patients!! Competing interests: none |
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Ruchir D Trivedi, MMedSci Student University of Sheffield, Northern General Hospital, Herries Road, Sheffield S5 7AU
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I realise the vastness of debate Mr. abbasi has generated by this scintilating article, but there seems to be a sense of empty feeling in my mind about hospital training. Most comparison drawn with developing countries to me not the correct response to existing medical infrastructure in those societies. Man & Medicine evolved with time and surrounding and i am sure all would agree that any sort of time directive implementation in africa or asia would be a farce exercise at least as of today. There needs to be more work in that area and somebody might be doing it there. I believe , medicine's greatest resource is its patient population. Following compromises are more than likely in present situation of less working hours. from Training perspective of doctors, 1. There will be less continous care so junior doctors have to adapt their way of clinical learning, we may see patches of clinical situations. 2. There will be almost no outpatient commitment of most Ho/SHO in specialities deducting them from valuable clinical experience. extremely short experience in one specility would jeopardise clinical acumen. we will produce more doctors looking at reports rather than at patients. 3. valuable time will be wasted in giving and taking effective hand overs, most hand overs are not still complete and new SHO needs to have a long look at notes before deciding future course of actions in a new shift. 4. there will be less and less interaction with consultants and i am not sure how one can critically evaluate a student without carefull prolong interaction. this will affect the entire reference system of our hospitals 5. there is no constant team so there is no constant team spirit. from perspective of patients, 1. i have seen few patients talking to me that they see far to many doctors in short stay at hospital and when they discharge to attend the clinic they could not find the same face. according to one patient " our medical histories are like sven affair which everybody gossip and ask again and again and when we are fed up of answering same questions we add glamour to it(intensify or febricate ?????) " From consultant's perspective 1. Needless to say they will be more sceptical about a junior doctor as quality time interaction is less. this will result in gross underutilisation of a potentially intelligent junior doctor in many area of direct patient care ( supervised care ). i believe consultants are ever so busy finishing paperwork and clinical commitments and if their load is not partially shared in issues where it can be done by a trained junior doctor , situation of educational commitments is going to deteriorate. what we can do as a good doctor is to follow ethical time directive , this is for all of us to workout for ourselves bearing in mind there is someboby out there who needs us. In new era it is our responsibility to gain knowledge , to learn to treat than to dispense , to deliver with care and empathy as old days of direct one to one learning is almost over. It may be a good thing but can we adapt? Competing interests: None declared |
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Arun Bharthuar, Consultant General Surgeon Prince Salman Hospital,PO Box 56773,Riyadh 11564
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It is really tragic that in these modern times medical practitioners under training deem it necessary to fight for fixed and limited hours of work ,when all those who had the privilege to be trained a few decades back,had little complaints when work hours were flexible and often extended way beyond the contracted hours. A lot of time spent during those formative years was exclusively utilised in following patients through their whole period of hospital stay ,only for the sheer enjoyment and satisfaction of seeing one's diagnosis being confirmed by batteries of diagnostic tests ,and then see them recover from operations often performed beyond duty hours. Nothing is more enjoyable than seeing one's patients recover and if one cannot enjoy one's work then the work is not worth doing at all.All this debate about hours per week may increase one's pay packet but nothing can match the enjoyment one has in devoting oneself to one's work and this is especially true when one is under training. Competing interests: None declared |
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Matthew L Keating, Resident medical officer Joondalup Hospital, Perth 6027
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It's obvious that Dr Goel has never been to Japan. Death from overwork is a real problem across many work places in Japan. Japanese businessmen in particular are known for their extreme devotion to work and the long hours that go with this. The Japanese even have a specific word in their language meaning 'death from overwork' - karooshi. When visiting Japan many travellers will board the famed shinkansen or bullet train. The tourist literature will gladly point out that there has never been an accident or fatality involving the bullet train in all its years of use. However, what is not written is that a few hundred people each year commit suicide by jumping in front of the speeding trains and it is thought that overwork plays a large role in their demise. No one dies from overwork? I have to disagree. Competing interests: None declared |
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Raha Shojai, Specialist Registrar Department of Obstetrics and Gynaecology, CHU Nord, Marseille, France
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While little is still known of the long term effects of duty hour restriction on resident education it may certainly improve the quality of life of junior doctors and theoretically leave more time for reading EBM and doing clinical research. Cognitive abilities are clearly impaired by fatigue and we all remember falling asleep behind the wheels and anecdotes of near-miss accidents on our way home after endless and drowsy hours on call. In another context, let us not forget that sleep deprivation may be used as an instrument of torture… Competing interests: None declared |
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Steven M Rudolphy, General Practitioner Principal & Snr Lecturer in GP Mt Sheridan Medical Practice, Cairns , Australia
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I think Ruchir D Trivedi's comments are most pertinent. Though I have no great wish to see junior doctors repeat the 1.3 and 1.4 rosters of my training I do sometimes wonder if the new trainees get the clinical exposure and capacity for hard work on shift systems. The best system I have seen to manage these competing interests (hours, stress, continuity of care and junior doctor training) was at Cook County Hospital in Chicago during my elective in the mid 1980's. 1st year residents did a 1.4 roster would be on call from 8 am for 24 hrs and do the morning ward round tidy up loose ends and go home by 11-12 o'clock the next morning. 2nd year residents did no on call and would take over from the team after on call days allowing the team to sleep. They sorted out in house referrals and were active in clinics. This allowed time to consolidate the practical learning of year 1 and have time to hit the books for professional exams. 3rd year residents supervised 1st years on call and would have a greater chance of getting some sleep. Consultants/attendings had a team to look after their patients and were highly involved though usually in day light hours. PS you know when you are working too hard when you are more concerned about your self than your patient. Competing interests: None declared |
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shripada rao, neonatal senior fellow australia
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no one dies of overwork! well I nearly died when I was working as a senior registrar in gastroenterology in one of the so called premier institutes. It was every day morning shifts plus alternate day night shifts. With so many patients having hematemesis and other emergencies, I used to be awake whole night and was expected to be as fresh as a rose for the morning consultant rounds. I lost 5kg of weight in three months. I was so much frustrated and started committing mistakes. Finally lost confidence in myself. Believe it or not, the most gentle and well mannered professor that i had met in entire medical career was totally oblivious to my difficulty.It was a most prestigious seat of DM gastroenterology which I had earned after one year of studying hard. But I left it within three months. My lifetime ambition of becoming a gastroenterologist was nipped in the bud courtesy of overwork and our hospital's apathy for the difficulties faced by the trainees. Competing interests: None declared |
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Abid Rashid, Specialist Registrar in Plastic Surgery Ulster Hospital, Belfast. BT16 1QR, Noina Abid
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Despite criticisms, resentments and logical explanations, on August 1st last year, healthcare systems throughout Europe including the National Health Service in the UK were no longer excluded from the provisions of the European Time Directive (ETD). The advocates of this law had argued that there was overwhelming evidence that sleep deprivation and unnatural circadian cycles led to motor and cognitive impairment and therefore could cause error in judgment. This obviously in the case of healthcare providers could cause harm to themselves and more importantly to their patients. It was therefore prudent that they got proper rest so that they were more efficient and less risk to the patients. The concerns raised against this law related to poor training of junior doctors, especially those in surgical specialities, and the impact on their social life. It will not be wrong to say that healthcare workers perhaps comprise the largest group of ‘couples’ working in the same industry i.e. health services. Doctor-doctor, doctor-nurse, doctor-radiographer, the list is endless. It is but natural that these ‘couples’ can have children, wholly dependant on their parents. If both parents were to work shift pattern, as it seems it is going to be sooner or later in all medical specialties, then it would not take much imagination to understand the absolute necessity to have a close co-ordination between their rotas. A tired mother could be a risk to her child when she comes home after a long night being on call as the partner goes out for his call. Also the father might not be able to take the family on a holiday, as his annual leave could not be co-ordinated with that of his wife’s because the rota was only distributed on the 1st of each month. Obviously both mom and dad are frustrated and the horror goes on. The nurses have seen this problem more than anybody else in the health services and have adapted well to it, as shift pattern has been a part of their training since time immemorial. This concept is however new for doctors. What one cannot not understand is, when so many regulations have been laid out and directives implemented, which purposely have been designed to provide safety to patients and avoid a large number of law suits and out of court settlements for the trusts and perhaps a few suicides committed by overworked doctors, why a law cannot be drafted that actually provides safeguards to the families of these health workers to whom they return, deprived of natural sleep accompanied with motor and cognitive impairment? Firstly, all trusts should be obliged to provide a six month written roster to doctors joining the trust, in the same way as they are obliged to run introductory days to acquaint the new-comers of the trust policies and emergency exits! This would at least help couples to know what common nights they would be working and make arrangements in advance regarding care of their dependants. This would also obviate the need for running after colleagues for their favours at the eleventh hour to change the call, which can ironically hold the employer for breech of the ETD. This is especially a nightmare when a week of night calls has to be changed at the start of the month if one is working full shift. The trusts can start off by conducting an audit of the timming when the rosters are distributed in the various departments. Second is to introduce monitoring among health workers to assess how much time were they able to give to their families and that were they able to take holidays together with their partners or spouses as they wanted. This should be done on the same lines as is mandatory for doctors to participate in the trusts’ monitoring of working hours. We hope common sense prevails. After all an unhappy healthcare providing couple is at least equal to two unhappy patients on two different wards. Competing interests: None declared |
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vineet gupta, junior resident,emergency medicine aiims, new delhi, india,110029
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I think Dr. Ashish Goel’s bravedo statement of cherished desire of endless working hours is an attempt to mask the lack of resources and resolve even in a premier institute of a sound developing nation. Why can’t more doctors be recruited (especially at the super specialist trainee level) to expedite better patient care and in the process relieve the onerous scheduling for the doctors? Moreover , it may help prevent shattering dreams as exemplified by Dr. Sripada ,who couldn’t acclimatize to the torturing routine of her ambitioned gastroenterology superspecialization.At the same time , lack of consumer consciousness can’t be an explanation for sustaining long working hours as people (or patients) in India are fast becoming aware of their rights(courtesy: consumer protection forums). The need of the hour is to introspect the underlying cause of tireless working schedule for doctors especially in developing nations. I urge upon the authorities to look seriously into the matter and uplift the doctors of their dilapidated stressful conditions consequent of unwholesome working hours. Till that very time our compulsion to work endlessly will force us to come up with miraculous reasons like charm, thrill of work and jeopardize the real essence of medical profession i.e. delivering safe patient care. Competing interests: None declared |
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