Rapid Responses to:

ANALYSIS: Yasmin Ahmed-Little Implications of shift work for junior doctors BMJ 2007; 334: 777-778 [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

perhaps a way of working re-think?

Jeffery C McILwain   (13 April 2007)

no special treatment for women doctors

clarissa d fabre   (16 April 2007)

Banning of ‘passive’ night shifts on economic and health grounds?

Amit Patel   (18 April 2007)

"All Work and No Play Makes Jack a Dull Boy..."

Shariha Khalid Erichsen   (18 April 2007)

perhaps a way of working re-think? 13 April 2007
Jeffery C McILwain, Consultant, Clinical Risk Management St Helens & Knowsley NHS Trust, Prescot, Merseyside, L35 5DR Send response to journal: Re: perhaps a way of working re-think?	Yasmin Ahmed-Little does justice to the concept of the implications of shift work for junior doctors and has given a list of that research that focuses primarily on cardiovascular effects. It would be interesting though to widen the inclusive factors. In Risk Management terms, James Reason has done much work on human error. His chapter1 in Clinical Risk Management cites work from the engineering field that ranks “disturbed sleep patterns” as 15th of 17 ranked error producing conditions. The risk factor stated is 1.6 as opposed to the top factor “unfamiliarity with the task” which is valued as a risk factor of 17. Whilst this is to do with human error and not staff health it nevertheless points to a wider contribution from the consequences of disturbed patterns of work / sleep. There is possibly more that could inform the debate, by referring to the airline industry that imposes strict working times and rest periods as well as acceptable levels of alcohol intake prior to work. It would likely be a service disaster for the NHS is doctors followed the safety aspects of rest periods as legally delivered by the airline industry, although the quality of care might be driven up! Further, airlines do not follow the 9-5 Monday – Friday traditional primary modality of NHS work delivery and focus upon a 364 day year. This means that the rosters for aircrew follow on-off work patterns unrelated to the weekly or monthly calendar. It would be interesting if the NHS followed such a pattern of service delivery. Finally, though a junior hospital doctor’s working life is not permanently bound to a shift pattern throughout their working career. Aside from fellowships and research the shift pattern will largely evaporate on appointment to a salaried career as a consultant or other senior post. Whilst not ignoring the potential perils to health as the author describes, nevertheless it has to placed into the framework of a) the length of a medical career overall and b) the service needs of the NHS. No -one should suggest that junior doctors working hours or welfare should be ignored; however the NHS as it currently stands, with targets and political manifesto policies, is a pint pot into which a quart is being placed. Consequence analysis would show that whatever effect occurs in one NHS sector (reduction in working hours) will have an effect in another sector. Abolishing shift patterns in regard to health will have a consequence somewhere else either with senior staff or patients. Any improvement in Junior Doctors working conditions must be subject to such Consequence Analysis otherwise the problem remains but is shifted from one arena to another. When the heat of politically motivated intense and compressed service delivery is removed from the NHS then issues of work pressure, patient and staff safety and clinical error will also be reduced. If political speeches remain in place to compress the NHS to political sound bites for election then a likely outcome is that doctors will resort to the examples of other industries which identify and respect their employees who are there to deliver professional service and care. References 1. Clinical Risk Management. 2001. Ed. Charles Vincent. Second Edition. BMJ Publishing Group. Page 22 table 1.1 Competing interests: None declared
no special treatment for women doctors 16 April 2007
clarissa d fabre, honorary secretary medical women's federation london WC1H 9HX Send response to journal: Re: no special treatment for women doctors	Yasmin Ahmed-Little in her article in last week’s BMJ ‘Implications of shift work for junior doctors’(1) suggests that future planning must accommodate the potentially increased health risks for women. She reports an association between shift work and an increased risk of breast cancer (2), coronary heart disease (3), miscarriage, low birthweight babies and premature births . It is difficult to imagine how shift work can have an effect on such diverse conditions, and one should be wary of inferring a direct causal relationship. Moreover it is crucial to know whether the findings have been validated since they were originally published. However that may be, many workers, such as nurses, ambulance staff and others in many areas outside medicine have always done shift work, and will continue to do so. It will always be necessary for doctors to cover hospitals and emergency services at night. Men have also been reported to have a higher incidence of coronary heart disease and other serious conditions (4), so a special case should not be made for women doctors. The solution suggested by the Royal College of Physicians of limiting consecutive night shifts to a maximum of four and reducing the duration of shifts is a step in the right direction (5). 1. Ahmed-Little Y, BMJ 2006: 334: 777-8 2. Hansen J. Increased breast cancer risk among women who work predominantly at night. Epidemiology 2001: 12:74-7 3. Kawachi I, Colditz GA, Stampfer MJ et al. Prospective study of shift work and risk of coronary heart disease in women. Circulation 1995;92:3178 -82 4. Knutsen A. Health disorders of shift workers. Occupational Med 2003:53:103-8 5. Horrocks N, Pounder R. Designing safer rotas for junior doctors in the 48-hour week. London:Royal College of Physicians,2006.www.rcplondon.ac.uk/pubs/contents (Dr) Clarissa Fabre Honorary Secretary Medical Women’s Federation www.medicalwomensfederation.org.uk Competing interests: None declared
Banning of ‘passive’ night shifts on economic and health grounds? 18 April 2007
Amit Patel, Academic Clinical Fellow & Specialist Registrar in Haematology Imperial College London & Hammersmith Hospitals NHS Trust, Charing Cross Hospital, London, W6 8RF Send response to journal: Re: Banning of ‘passive’ night shifts on economic and health grounds?	Ahmed-Little reviews a number of studies implicating night shift working patterns as a risk factor for poor health, including cancer, ischaemic heart disease and miscarriage.[1] She also points out the lack of consent sought for doctors, particularly juniors. If exposure to passive cigarette smoke is unacceptable because it causes lung caner,[2] and the recipient is exposed to an adverse risk factor against their will, is there a difference with shift work? Have the economic implications of enforced morbidity and mortality among doctors been adequately considered, and the pressures it will put on the NHS? With breast cancer is an example, in 2003 the Office of National Statistics recorded a UK incidence of 120 per 100,000 women.[3] 35,384 shift working junior doctors applied for ST3 training posts within the failed MTAS and MMC application system in 2007.[4] Assuming half are women (an underestimate) and their risk increases by 50%[1], 21 extra women may unnecessarily develop breast cancer. Although very crude and rudimentary, it illustrates the risks doctors are taking working night shifts. There may be legal and litigation issues relating to their occupational health. Will there be a government ban on ‘passive’ night shift working on economic and health grounds? References [1] Ahmed-Little Y. Implications of shift work for junior doctors. BMJ 2007;334:777-78 [2] Hackshaw AK, Law MR, Wald NJ. The accumulated evidence on lung cancer and environmental tobacco smoke. BMJ 1997;315:980-88 [3] http://www.statistics.gov.uk/cci/nugget.asp?id=575 [accessed 16 April 2007] [4] https://www.mtas.nhs.uk/info/ST_2007_1/st3_ratios_II.pdf [accessed 16 April 2007] Competing interests: Contributor to: 1. Horrocks N, Pounder R. Working the night shift: preparation, survival and recovery. London: Royal College of Physicians, 2006. [www.rcplondon.ac.uk/pubs/books/nightshift/nightshiftbooklet.pdf]. 2. Horrocks N, Pounder R. Designing safer rotas for junior doctors in the 48-hour week. London: Royal College of Physicians, 2006. [www.rcplondon.ac.uk/pubs/contents/09446ffc-7f46-4f18-a1d0-fb5b8607b0c4.pdf]
"All Work and No Play Makes Jack a Dull Boy..." 18 April 2007
Shariha Khalid Erichsen, Clinical Fellow, Plastic Surgery Rigshospitalet, 2100, Copenhagen, Denmark Send response to journal: Re: "All Work and No Play Makes Jack a Dull Boy..."	I read with interest Ahmed-Little's article discussing the implications of shift work for junior doctors. As a junior doctor myself who has worked all the different work rotas imaginable, both full-time and flexibly over the last 7 years - from on-call rota to full shift and in 3 countries - the UK, Malaysia and now Denmark, I believe I can offer some valid viewpoints on this subject. When I started my house jobs, on-call rotas were the norm. I saw my working hours (and by this, I mean actual working hours) reduce from 80 to 56 hours, as NHS hospitals were actively working towards implementing the European Working Time Directive. Then I went to work in Malaysia, being 'pleasantly' surprised by the average 100-hour working week (admittedly, I chose to work in an unpopular specialty amongst the junior workforce there hence the lack of staffing resources in that particular department). Did I survive? Well, I am still here to tell the tale. Did I harm any patients in that time? Well, I would definitely not recommend overworking to anyone.... Now, I work full-time but just 37 hours a week, maybe 40 on a bad day and this includes on-call hours. Where in the world...? Well, welcome to Denmark where your working day starts at 8am and ends by 3pm. It seems that the Danish government actually did something to improve quality of life for their citizens, perhaps guided by those 2 studies quoted by Ahmed -Little (1,2). One may ask how the Danish public health system functions with such reduced doctors' working hours? Perhaps it is because Denmark has more doctors (they are still looking for more...) AND they are more efficient at time-keeping during an average working day. The department I work in performs over 200 cleft cases, 150 free breast flaps in a year and of course, all the skin cancer cases and burns injuries on top of that - these figures are similar to teaching hospitals in London. The downside? The training takes longer but quite honestly, who cares if you can still have a good social and family life as well as enjoy your work? And there is no special treatment for women either - both parents are entitled to a shared maternity/paternity leave of up to 9 months. Perhaps the UK needs to take a leaf out of this Scandinavian country's book. This is especially so with the impending effect of the jobcuts and unemployment that has arisen out of the MMC/MTAS fiasco. Additionally, Ahmed-Little was correct in suggesting that potential physical health effects should be taken into consideration when planning work patterns for doctors. However, she failed to include the known effects on psychological health and acute decision-making abilities (3). Her suggestion that doctors' informed consent should be obtained before they sign up to the work rota and that they form part of the decision- making process is slightly out of touch with reality. In the real world of the NHS, there is very limited space to do so due to various constraints in place. And the use of coffee and bright lights to keep the workforce going? Is drugging the doctors really the solution? Surely there must be others? Until then, I will stay put in Denmark. References: 1. Olsen O, Kristensen TS. Impact of work environment on cardiovascular diseases in Denmark. J Epidemiol Community Health 1991;45:4 -10. 2. Hansen J. Increased breast cancer risk among women who work predominantly at night. Epidemiology 2001;12:74-7. 3. Costa G, Sartori S, Akerstedt T. Influence of flexibility and variability of working hours on health and well-being. Chronobiol Int. 2006;23(6):1125-37. Competing interests: None declared