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Rapid Responses: Rapid Responses published:
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Junior Doctors and the European Working Time Directive.
- Andrew R Thornley, Ram Moorthy, Peter Maguire. (6 August 2008)
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European Working Hours: diagnosis good, management plan poor
- Bryan G Vernon (22 August 2008)
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Calculation of cost-effectiveness of resident medical cover for psychiatric hospitals
- Rudolf N Cardinal (24 August 2008)
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Speed = Distance / Time
- David R Warriner (26 August 2008)
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Full implementation of the EWTD would definitely be a step too far …
- Hooman Soleymani majd, Lamiese Ismail (27 August 2008)
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Training HAS suffered from the EWTD!
- Peter J Mahaffey (27 August 2008)
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All time on duty is "work"
- Dylan G Harris (27 August 2008)
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Surgical training cuts that may not heal
- Guy F Nash, Manish Chand, SpR Wessex (27 August 2008)
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Outcomes of EWTD
- Alistair Flowerdew (27 August 2008)
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Outcomes of the European Working Time Directive- SiMAP ruling
- Anthony V B Bathula, Swapna Alexander (27 August 2008)
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Inaccurate death certification and unecessary autopsies as a result of shorter working hours
- Laurence JR Brown (27 August 2008)
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Re: Outcomes of the European Working Time Directive- SiMAP ruling
- Syed M Tariq, Randhir S Bhatia (27 August 2008)
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Less hours, not more.
- Adrian R. Leahy (28 August 2008)
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Do not shut the window of opportunity
- Miguel D Seixas (29 August 2008)
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EWDT editorial: in whose interest?
- Paul J Caldwell (29 August 2008)
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48 hours: a bridge too far
- G Y Shin (29 August 2008)
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Sports Training
- Vimal J Gokani (31 August 2008)
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Maslow’s Needs Not Being Met
- Allan M Conway, Simon D. Carley, Consultant in Emergency Medicine, Manchester Royal Infirmary (1 September 2008)
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Outcomes of the European Working Time Directive
- Stephen MF Saunders (2 September 2008)
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The demise of surgical training
- Oliver D Starr (4 September 2008)
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All junior doctors not the same..
- Juhi Sharma (10 September 2008)
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EWTD in the Netherlands
- Onno T. Terpstra (11 September 2008)
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Less hours, not more
- Muhammed R S Siddiqui (11 September 2008)
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Outcomes of the European Working Time Directive
- Allan P Corder (12 September 2008)
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The effect of implementation of European working time directive on the current Orthopaedic training by multicentric hip fracture reaudit in 14 NHS Trusts in Northwest of England
- AJAY SAHU, Neil Jain, Sam Dalal, Gary Cook, Brian D Todd (3 October 2008)
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Andrew R Thornley, SpR in Cardiology, British Medical Association Junior Doctors Committee lead on the EWTD James Cook University Hospital, Middlesbrough, TS4 3BW., Ram Moorthy, Peter Maguire.
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Dear Sir, Cairns et al.(1) raise some important points in their editorial on the European Working Time Directive (EWTD). In particular they highlight the concerns that many junior doctors have relating to the potential impact the directive will have on their training. Unfortunately the authors make errors both factual and in interpretation of the data they present. The EWTD introduced the requirement for 11 hours continuous rest in a 24 hour period and has applied to junior doctors since 2004. It is probably this stipulation in combination with the SiMAP judgment(2) that has had the biggest impact on 24 hour resident on call working patterns. The authors state that the SiMAP judgment applies to both on call from home and resident on call. This is incorrect in that the judgment specifically relates to time spent resident on call at the behest of an employer. If a doctor is on call from home only time ”linked to the actual provision of services” counts as work in terms of the EWTD. The authors suggest that the working time legislation has had a negative impact on the working life and free time of junior doctors. We understand that this is not a view shared by a large proportion of trainees. A survey(3) carried out by the BMA’s Junior Doctors Committee (JDC) demonstrated that 55% of respondents said that the 48 hour limit would improve the quality of their lives (25% no effect, 20% negative, 464 respondents) and 53.5% of respondents reported that the EWTD would have a positive impact on their personal health and safety. The authors quote heavily from a EWTD survey of surgical trainees(4) from 3 years ago, but this group make up approximately only 10% of junior doctors and the findings from this survey can not be extrapolated to all juniors. Unfortunately the editorial also misrepresented the JDC‘s concerns about the impact of the strict interpretation of the EWTD on current surgical training methods . Changes to current surgical training including lengthening the number of years spent training may help to compensate for the decrease in weekly hours. Junior doctors’ hours can no longer be considered in isolation. They need to be protected from working excessive hours just like any other employees. Incidents such as the Selby rail crash(5), caused by a driver having “barely any sleep” the night before the crash must have a bearing on the safety of junior doctors particularly those who have to drive home following a busy 24 hour on call. Legislation relating to corporate manslaughter should also make medical managers consider the risks of asking junior doctors to work without adequate rest. There is an assertion in the article that patient care is not safer with a 48 hour limit. As yet the 48 hour limit has not been imposed and there will be no evidence that mortality and morbidity rates have been affected until sometime after August 2009. The quality of clinical care is clearly of vital importance for both patients and doctors and the impacts of the EWTD must be monitored carefully. It is true that junior doctors’ views on aspects of the EWTD are split, but the BMA’s survey(3) showed that only 30% of juniors wanted the BMA to campaign for a delay in the 48 hour week, in contrast 76% wanted the BMA to work with employers, Royal Colleges and deaneries to protect training. Whilst Cairns et al. highlight some of the key problems with the EWTD, it is by no means clear that junior doctors are supportive of their suggested solutions. Andrew R Thornley
Peter Maguire
Ram Moorthy
1 Cairns, H. Hendry, B. Leather, A. and Moxham J. Outcomes of the European Working Time Directive. BMJ 2008; 337: 942 2 Judgment of 3 October 2000:Case C-303/98 Sindicato de Medicos de Asistencia Publica (SIMAP) v Conselleria de Sanidad y Consumo de la Generalidad Valenciana. European Court Reports 2000; 1-7963. 3 BMA. BMA Survey of members’ views on European Working Time Directive. 2008. www.bma.org.uk/ap.nsf/Content/SummarysurveysEWTD?OpenDocument&Highlight=2,ewtd. 4 Lowry J, Cripps J. Results of the online EWTD trainee survey. Bull R Coll Surgeons Engl 2005; 87: 86-7. 5 Tragic results of driver fatigue. BBC news website http://news.bbc.co.uk/1/hi/england/1703935.stm Competing interests: None declared |
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Bryan G Vernon, Lecturer in Health Care Ethics Newcastle Medical School, NE2 4HH
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Cairns et al (1) raise important issues when they discuss the European Working Hours Directive. The change from 56 to 48 hours may not be entirely benign, but there are other solutions to the problems they highlight. If the training of junior doctors is likely to suffer, it would be possible to increase the training period, by extending either the Foundation programme or specialist training by a further year. It is not clear why trainees cannot have several complete weekends off even though some will be split. It may be worth consulting those who arrange train drivers' rotas. With 48 hours to spread across the week it is reasonable to assume that some of the remaining 128 hours will fall at the weekend. They express concern about the continuity of care. From a patient's point of view the majority of care is provided by nurses, and there is no evidence that patients are dissatisfied with their shift patterns: indeed they understand that hard-working professionals need a break. In today's risk-averse climate patients are even more likely to prefer safe treatment by people who are not too tired: there is also an evidence base that suggests that tiredness is associated with errors. Complaints about continuity of care are more frequently expressed about outpatients’ appointments, where patients are likely to meet a different trainee on each visit. Where there is poor communication between junior doctors and nursing staff and junior doctors and the on-call consultant, this is a training issue which urgently needs addressing. If a reduction of working hours achieves this, it would contribute to safer health care. (1) Hugh Cairns, Bruce Hendry, Andrew Leather, and John Moxham Outcomes of the European Working Time Directive BMJ 2008; 337: a942 Competing interests: None declared |
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Rudolf N Cardinal, Academic clinical fellow in psychiatry Cambridge CB2 0QQ
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The forthcoming maximum working week of 48 hours [1, 2] and financial pressures from junior doctors' pay banding system [3] provide strong incentives to Trusts to reduce hours. Whereas general hospitals can pare out-of-hours cover down to a core Hospital At Night team [4], psychiatric hospitals often have medical cover provided by a single on-site doctor. Their urgent out-of-hours work comprises medical and psychiatric emergencies, some of which are life-threatening. Salary supplements cannot be reduced from 40% to 20% without making doctors non-resident [3]. Should mental health Trusts make junior psychiatrists non-resident? How should they make this decision? National recommendations provide one source of guidance. The David Bennett Inquiry recommended that "there should always be a doctor in every place where a mentally ill patient is detained, or if that is not possible, foolproof arrangements should be in place twenty-four hours a day to ensure that a doctor will attend within twenty minutes of any request by staff to do so", adding that it is "highly unsatisfactory for doctors to be available in an institution where mentally ill patients were treated only if they came by car or taxi in a wholly unpredictable fashion" [5]. These recommendations are supported by the Mental Health Act Commission, who noted the "risk... [of spreading] available medical and other expertise too thinly, so that no inpatient units can realistically have immediate access to a doctor when emergencies arise... [w]here patients are detained for their own safety, such a lack creates an ethical dilemma, if not a legal one" [6, 7]. The National Institute of Clinical Excellence (NICE) guidelines on restraint recommend that that a doctor must be available within 30 minutes of being called to an alert, and add that "dialling for emergency services... is not sufficient in itself" [8]. An additional technique is to establish the cost-effectiveness of resident medical cover. This requires establishing (A) how many quality- adjusted life years (QALYs) need to be saved per year by resident medical cover for it to be cost-effective, and (B) whether resident medical cover does in fact provide this level of benefit. Establishing (A) is simple. Making juniors non-resident saves an amount of money £a per year. To ensure that their rota complies with a 20% -or-less banding, it may be necessary to employ additional non-medical staff (e.g. to perform psychiatric assessments in emergency departments overnight). Suppose this costs £b per year. The annual cost saving is thus £(a - b). A price must then be put on a QALY. NICE currently values one QALY at £20,000 to £30,000 [9]. To be cost-effective by this standard, resident medical cover must save between (a - b)/20000 and (a - b)/30000 QALYs per year. A QALY may be saved in many ways. Most simply, life may be saved. General adult psychiatric wards typically cater for patients aged 17-65. Across the population, males aged 41 have a life expectancy of 44 years, and females 47 years [10]. Psychogeriatric wards typically cater for over- 65s. At the age of 75, the population life expectancy for a man is 12 years, and for a woman 14 years [10]. So, saving the life of an inpatient on a general adult ward might save about 46 life-years, and on an old-age ward about 13 life-years. If the patient had an enduring poor quality of life, the QALY figures would be correspondingly reduced. On a scale from 0 (death) to 1 (perfect health), one study estimated the quality of life of outpatients with enduring mental illness at ~0.95 [11], while a population survey found that quality of life was reduced by psychiatric disease from 0.900-0.949 to 0.848-0.899 in the young and from 0.788-0.873 to 0.721- 0.811 in the elderly [12]. Another way to save QALYs is to prevent enduring serious morbidity. A third way is to reduce the probability of death or serious morbidity. For example, reducing the probability of death from 30% to 20% is equivalent to saving one-tenth of a life. Establishing (B) is difficult, because it involves the monitoring of low-frequency events, and using clinical judgement to guess what would have happened if a doctor had or had not been able to attend with the speed that residence brings. Suppose a Trust's calculations show that resident medical cover costs £60,000 net per year; at £30,000/QALY it would be cost-effective if it saves 2 QALYs per year. This could mean that saving one life in an emergency on a general adult psychiatric ward every 20 years would nonetheless make resident cover cost-effective. Distinguishing an average of zero lives saved from one life saved every 20 years is not easy to do with short-term monitoring (unless a serious emergency occurs during the monitoring, in which case it is very much easier); very long-term monitoring is difficult, and there is an important role for ad-hoc case reporting. Likewise, small short-term studies that fail to find a clear dangerous effect of removing resident medical cover may convey a misleading impression through extreme lack of statistical power [13-15] or through lack of appreciation that an apparently low adverse event rate may still far exceed the threshold for cost- effectiveness [16]. References 1. Council of the European Union (1993). Council directive 93/104/EC. (At http://eur-lex.europa.eu/LexUriServ/site/en/consleg/1993/L/01993L0104- 20000801-en.pdf; accessed 23 August 2008.) 2. Her Majesty's Stationery Office (2003). Statutory Instrument 2003 No. 1684: The Working Time (Amendment) Regulations 2003. (At http://www.opsi.gov.uk/si/si2003/20031684.htm; accessed 23 August 2008.) 3. UK Department of Health (2000). Pay banding criteria. (At http://www.dh.gov.uk/assetRoot/04/05/38/77/04053877.pdf; accessed 23 August 2008.) 4. UK Department of Health (2005). The implementation and impact of Hospital at Night pilot projects: An evaluation report. (At http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4117968?IdcService=GET_FILE&dID=1804&Rendition=Web; accessed 23 August 2008.) 5. Blofeld, J. et al., Inquiry to the Secretary of State for Health, and Norfolk, Suffolk, and Cambridgeshire Strategic Health Authority (2003) Independent inquiry into the death of David Bennett. (At http://www.nscsha.nhs.uk/resources/pdf/review_inquiry/david_bennett_inquiry/david_bennett_inquiry_report_2003.pdf; accessed 23 August 2008.) 6. The Mental Health Act Commission (2005). In Place of Fear? Eleventh biennial report 2003-2005. London: The Stationery Office. (At http://www.mhac.org.uk/files/MHAC%2011%20TEXT%20FA.pdf; accessed 23 August 2008.) 7. The Mental Health Act Commission (2007). Risk, rights, recovery. Twelfth biennial report 2003-2005. London: The Stationery Office. (At http://www.mhac.org.uk/files/pdf%2012th%20biennial%20report.pdf; accessed 23 August 2008.) 8. NICE (2005). Violence: the short-term management of disturbed / violent behaviour in inpatient psychiatric settings and emergency departments. National Institute of Clinical Excellence, Clinical Guidelines, 25 February 2005. (At http://www.nice.org.uk/nicemedia/pdf/cg025fullguideline.pdf; accessed 23 August 2008.) 9. NICE (2008). Measuring effectiveness and cost effectiveness: the QALY. (At http://www.nice.org.uk/newsevents/infocus/MeasuringeffectivenessandcosteffectivenesstheQALY.jsp; accessed 23 August 2008.) 10. Government Actuary's Department (2006). Cohort expectation of life, 1981-2056; principal projection; United Kingdom. (At http://www.gad.gov.uk/Demography_data/Life_Tables/docs/2006/wUKcohort06.xls; accessed 23 August 2008.) 11. Wilkinson G, Croft-Jeffreys C, Krekorian H, McLees S, Falloon I (1990). QALYs in psychiatric care? Psychiatric Bulletin 14: 582-585. 12. Saarni SI, Suvisaari J, Sintonen H, Koskinen S, Härkänen T, Lönnqvist J (2007). The health-related quality-of-life impact of chronic conditions varied with age in general population. Journal of Clinical Epidemiology 60: 1288-1297. 13. Nicholls JE (1992). Role of the duty psychiatrist. Psychiatric Bulletin 16: 218-219. 14. Mason J, Irani T, Fountoulaki G, Warwick S, Da Roza Davis J, Sudbury P (2006). Psychiatry at night: experience of the senior house officer. Psychiatric Bulletin 30: 329-333. 15. Palanisamy V, Agarwal V (2006). First on-call psychiatrist: resident or non-resident? Psychiatric Bulletin 30: 468. 16. Lawrie A, Serfaty M, Smith C (1996). Should the on-call psychiatrist be residential? Psychiatric Bulletin 20: 12-14. Competing interests: The author is a junior psychiatrist on a resident rota. |
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David R Warriner, ST1 Respiratory Medicine Northern General Hospital, Sheffield, South Yorkshire
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Training boils down to simple mathematics, if I remember correctly from my secondary school days: speed equals distance divided by time. Thus if time spent in training during a fixed period is reduced, one must lengthen the period or face hastening inexperienced and ill prepared doctors to consultancy. Lengthening training will enable the clinicians of tomorrow to share in what makes those of today great, a wealth of experience born out of a sheer number of patients seen at home or abroad, for which there is no substitute. Without the loss of friends, sanity and relationships. But who can say whether a true on-call system is better than an rolling shift system for service or training as very few have worked both. Nurses, for example, have worked shifts for decades, developed comprehensive hand over and have never called their own post-graduate training into question. The current system is not without its flaws, as a trainee and someone in the middle of a 91 hour week of nights can testify, but demand for doctors will always outstrip supply thus we must work with not against change. Competing interests: None declared |
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Hooman Soleymani majd, ST3 in Obstetrics & Gynaecology Wexham Park Hospital, Slough, SL2 4HL, Lamiese Ismail
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It is with great interest that we read this rather topical and thought provoking article published in the August 23rd edition of the BMJ. As specialist registrars working in a surgical discipline, we have certainly experienced all the problems mentioned in this article. However, we would like to add a few more salient points to the negative psychological and educational impact that the European Working Time Directive (EWTD) has had on our profession and indeed on the Hippocratic oath we took when we qualified as doctors. We have a number of grave concerns about the EWTD. For one, shift “hand-overs” are becoming a potentially risky aspect of our work. Regardless of how efficient we may attempt to make it, the process is often still imperfect. People are generally in a rush to go home and often fail to express the urgency or priority of cases to one another. Sometimes important facts are inadvertently omitted, thus creating an environment fraught with the potential for catastrophe or near misses. In addition to this, when receiving a hand-over about a number of patients completely unfamiliar to you, you are obliged to adapt yourself very quickly in order to address the needs of your new patients, which at times may be very complex and difficult. The prospect of this would be quite daunting even to veteran doctors, let alone junior trainees. Another rather important short coming of the EWTD is that is minimizes the potential for continuity of care. Not only for the patients but for doctors as well. The fact is that no sooner have you managed to build up trust and a good rapport with your patient when you have to leave and entrust their care to someone else. Many of us feel a great sense of personal responsibility to patients who we have cared for for many hours. Often at the end of a shift you don’t want to go until you know what has happened to your patient and will often go back to see them the following day and find out how they have fared. Trying to provide a sense of continuity which is so intrinsic to patient and professional satisfaction, in a time when our job patterns do not accommodate for this. There are many clinical occasions where patients and families need to be comprehensively debriefed about the circumstances and events of their treatment. The EWTD has limited the opportunities for the involved clinician to be able to do this. Unfortunately, this often means that a “stranger” has to do this on someone else’s behalf or the debriefing has to wait until the managing clinician is available, which could be days later. Surely none of these options is appropriate. The “team” structure has been another victim of the EWTD and now seems to be a concept relegated to the past. In the vast majority of cases trainees don’t get the opportunity to attend theatre sessions or even clinics with their own consultants and then also lose the opportunity to follow their team’s patients because they are simply rostered to do something else. Another unfortunate consequence of this is the loss of accountability to the team, creating a mood of apathy and malaise in performing tasks. This invariably has an impact on patient care. Most importantly, we think that most doctors would agree that for skills to be perfected they should be continuously practiced and enhanced. Thus if skills have yet to be developed by junior doctors then the full implementation of the ETWD, will require a significantly longer times for trainees to acquire these skills due to the lack of training opportunities. Similarly, even if people have acquired skills previously, they run the risk of losing these if the opportunity to maintain their skills is reduced. How can we ensure we do not compromise our patients care by lack of experience and skill and how do we ensure that we are able to maintain and develop these skills ? It is not an uncommon practice for many junior doctors to make the conscious decision to stay on after their shifts have ended, in order to have the opportunity to perform a surgical procedure to completion or gain exposure to an operation which if they went home on time, they would have missed out on. Many junior doctors are warned that they would not be “legally” covered if they encountered complication in a procedure performed outside of their normal working hours. These warnings have created an atmosphere of fear, disillusionment and frustration at having to hand over surgical procedures to someone else and in so doing losing their own training opportunities, which have already been limited because of partial implementation of the EWTD. The planned full implementation of the EWTD for next year, has sparked fears that this will inadvertently lead to a class of newly qualified consultants who are effectively inexperienced. Despite good theoretical knowledge, many of them will not have the skills to perform a number of surgical procedures with confidence when called upon to do so, due to their previous lack of training opportunities. Cairns et al is absolutely correct when they say that medicine is not like other “professions”. By restricting the time doctors spend with their patients and at work, the government would be jeopardizing the training of doctors and the quality of care that they provide for their patients. Invariably, leading to an environment of gross dissatisfaction for health care users and equally important for health care providers. Further reducing work time to 48 hours per week would undoubtedly be a step too far. Rather than creating a “better quality of work environment” for doctors the planned full implementation of the EWTD in August 2009 would ultimately have the complete opposite effect. It would only serve to intensify problems that already exist with the system and would further escalate feelings of stress, tension, inadequacy and unhappiness at work for doctors in training. Competing interests: None declared |
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Peter J Mahaffey, consultant surgeon bedford hospital mk42 9dj
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As a surgeon who trained intensively in pre-Calman days (AND enjoyed a colourful social life during whatever hours were free), its been salutory to realise that I was head and shoulders above present day specialists in clinical skills and confidence at the times of our respective appointments. Its not for nothing that one repeatedly hears colleagues exclaim "Who, under present day training regimes is going to have the skills to look after me when I'm old?". Cairns and colleagues are understating the case when they call for a halt to the reduction in training hours. Furthermore, they fail to mention that it has been our own 'trade union' who has been a principle exponent of these profoundly damaging directives. And it really isn't sufficient 'mea culpa' for the BMJ to give their views prominence as a leading article. Nor does the squirming rapid response of Thornley and his BMA colleagues say anything to justify past errors. Cairns and colleagues maintain that "British medicine is highly respected worldwide". By what yardstick? Up until the early 1990's medical graduates from advanced Western countries (Australia, Germany and even the USA) competed in their thousands to get experience in British hospitals. Now they are hardly ever seen, and it isn't the immigration laws which are responsible. Similarly,up until the same period, foreign patients flocked to seek private medical treatment here. Now they hardly come. And why does almost every Premiership footballer who needs top class knee surgery go to Germany or the USA? In the final analysis, this sad decline in our international medical status comes back to the intensity and quality of the training of medical graduates. Cairn's article should represent only the opening salvo in a fightback to recover ground from those who have, almost unopposed, done so much damage to our profession. Competing interests: None declared |
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Dylan G Harris, Specialist Registrar in Palliative Medicine Velindre Hospital, Cardiff CF14 2TL
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The exploration by Cairns and colleagues (1) and suggestions for future direction with the European Working Time Directive are of high interest and importance to all doctors, particularly those of us that have worked and experienced the traditional on-call system as well as more recently shifts and partial shifts. 32 hour on calls with an hour of broken sleep wasn’t in the best interests of patients, doctors or other road users on the drive home and there would be no justification to return to this. I agree with the comments with regard to training opportunities in the current system but the length of training should be increased rather than a return to old dangerous practice. The author’s suggestion of maintenance of the current limit of 56 hours but not a further decrease to a maximum of 48 hours seems optimum. However, the suggestion that not all time on-call should be counted as work is worrying. Any time on duty for the NHS should be work, when not actually engaged in clinical activity or even when on-call from home this is not free time but restricted time when doctors can do a limited number of activities in case they are required to resume “work” activity at immediate notice. Not counting all time on duty as work will predictably lead to much longer shifts. Working a 48 hour weekend but only actually being paid for half of it because the rest was not “work” (but equally not free time that the doctor could use constructively as they wished) is not acceptable but likely to be the position adopted by NHS trusts if the rules are changed. (1) Hugh Cairns, Bruce Hendry, Andrew Leather, and John Moxham Outcomes of the European Working Time Directive BMJ 2008; 337: a942 Competing interests: None declared |
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Guy F Nash, Surgeon Wessex, Manish Chand, SpR Wessex
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We agree with the timely points made in this editorial that summarises the fictional pros and factual cons of the European Working Time Directive (EWTD). In the absence of net benefits for patients or staff, one wonders if there were political advantages of the EWTD so readily uptaken by the current British Government but largely ignored by other European countries. A survey of the impact of MMC and EWTD on 440 doctors in training conducted by our group recently showed that much of the core training necessary to confidently progress to specialty training is being neglected. Thus leaving trainee surgeons inadequately prepared, and in some cases misguided, for the demands of a surgical career. To avoid permanent damage, other than to this generation of trainee surgeons whose potential now may never be realised, it would take courage from this Government to act. Perhaps the accumulating evidence may be studied by a National Institute for Health and Clinical Excellence to offer helpful guidance in avoiding the death of British surgery. Competing interests: None declared |
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Alistair Flowerdew, Medical Director Salisbury NHS Foundation Trust SP2 8BJ
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Dear Sir, The anxieties about EWTD on service delivery, training of doctors and most importantly – patient safety, are widespread but do not justify the retrograde proposals suggested in the editorial by Cairns et al(1). Many Acute Trusts in the country are developing solutions that will address all three aspects simultaneously. The Royal Colleges are working collaboratively to find solutions and the Royal College of Surgeons of England recently published its own forward thinking views(2). The EWTD is presenting new and unique opportunities for doctors to develop generic handover, leadership and team working skills. Many Trusts, sponsored by the National Workforce Projects (NWP) and led by Wendy Reid, the postgraduate Dean for London, have contributed to a range of solutions for Hospital at Night and can be found on its website www.healthcareworkforce.nhs.uk. As a Medical Director with a significant interest in surgical training and governance, I have led an internal EWTD project addressing all the issues that arise from reduced hours and having a Hospital at Night team to maximise trainee time in the day and evenings. Workforce requirements, handover and ways of working are constantly reviewed and improved depending on access and safety monitoring. On a nightly basis, there are numerous educational opportunities for the stream-lined night team of doctors and outreach nurses. Escalation protocols for seeking a senior opinion have been established to ensure more senior doctors do not do routine full shifts at night but are contacted appropriately. The number of learning events at night for a trainee doctor covering only one specialty in the past could never match what is available now. The transition to a new way of working does not simply happen. In my Trust there is a group of consultants and senior nurses from a spectrum of specialties who have all contributed to a new philosophy and approach to team working. Trainee input has been a vital component. The Trust has developed an IT system in collaboration with NWP and support from the EWTD working party of the Royal College of Surgeons of England. It is about to be launched and will become available to all Trusts. Trainee doctors have played a key role in the development. A Hospital at Night Tutor (a consultant) oversees the generic requirements of education and the Executive Boards and Chief Executive regularly monitor progress. Like Cairns et al, I come from a generation who were ‘working’ very long hours. In my experience, the learning opportunities diluted significantly with progression up the specialist training pathway. The EWTD presents a unique opportunity to provide better training and quality of life for doctors, improve safety for patients and clinical outcomes for acute hospitals but a very different approach is required, that is from 'Ward to Board'. 1 Cairns, H. Hendry, B. Leather, A. and Moxham J. Outcomes of the European Working Time Directive. BMJ 2008; 337: 942 2. Working Time Directive 2009: Meeting the challenge in surgery. Royal College of Surgeons of England, June 2008 Competing interests: None declared |
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Anthony V B Bathula, STaff Grade Doctor Glan Clwyd Hospital, Rhyl. LL18 5UJ, Swapna Alexander
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Dear Sir The recently published above article has given a comprehensive overview of the European Working Time Directive (EWTD). The article mentions that 'A court ruling by the European Court of Justice that every hour on call- even when at home undisturbed or asleep in the hospital-is an hour worked has added to the difficulty (SiMAP ruling). This infers that the off site on call (on call- available away from work place) and undisturbed (not contacted) hours are counted as hours worked. This view is in a complete contradiction to the SiMAP (Sindicato de Médicos de Asistencia Pública ) ruling and its interpretation by the Department of Health (DH), United Kingdom. The DH in its interpretation of SiMAP ruling stated 'If they (on call doctors) must merely be contactable at all times when on call, only time linked to the actual provision of ... services must be regarded as working time. The SiMAP ruling is a judgment made by the European Court in October 2000 in answer to a claim by doctors in Spain, that the time spent off site resident on call be defined as work (Department of Health, 2005) SiMAP ruling 3. Time spent on call by doctors in primary health care teams must be regarded in its entirety as working time, and where appropriate as overtime, within the meaning of Directive 93/104 if they are required to be at the health centre. If they must merely be contactable at all times when on call, only time linked to the actual provision of primary health care services must be regarded as working time. The Advocate General in a statement opines (with regard to primary care teams of Spain) that the situation was different for doctors on call by being contactable at all times with out having to be at centre. Though the on call doctors were at the disposal of their employer, and contactable leaves them in a situation where they may manage their time with fewer constrains and pursue their own interests. Therefore in these circumstances, only time linked to the actual provision of services has been regarded as working time (CVRIA, 2000). In the United Kingdom the General Practitioners who provide the primary care services do not fall within the remit of the EWTD as they are self-employed (RCSE,2004). For the hospital doctors who provide secondary and tertiary care, off site on call for many specialties is more than 'merely contactable' for advice from distance. Many acute Medical Specialties and all the Surgical Specialties off site on call, often does involve returning to workplace with a view to providing their professional services. This is in violation of EWTD minimum daily consecutive rest period. Off site on call requires total commitment from the doctors and is not possible to pursue their own interests while being on call. The DH must revise its interpretation of SiMAP ruling as it is not applicable with regard to the provision of on call services in the hospital based practice in the United Kingdom. Therefore in my opinion that every hour on call-even when at home undisturbed or asleep in the hospital is an hour worked. Thank you Yours sincerely Mr Anthony Victor Babu Bathula Bibliography CVRIA (2000) SiMAP Judgement of the court. [Internet] Luxembourg. Available from http://curia.europa.eu/jurisp/cgi- bin/form.pl? lang=en&newform=newform&alljur=alljur&jurcdj=jurcdj&jurtpi=j urtpi&jurtfp=jurtfp&alldocrec=alldocrec&docj=docj&docor=doco r&docop=docop&docav=docav&docsom=docsom& docinf=docinf&alldocnorec=alldocnorec&docnoj=docnoj&docnoor= docnoor&typeord=ALLTYP&docnodecision=docnodecision&allcommjo =allcommjo&affint=affint&affclose=affclose&numaff=& ddatefs=&mdatefs=&ydatefs=&ddatefe=&mdatefe=&ydatefe=&nomusu el=&domaine=&mots=SiMAP+Ruling&resmax=100&Submit=Submit Accessed on 24th of August 2008. Department of Health (2007) What is the European Working Time Directive? [Internet] London. Available from http://www.dh.gov.uk/en/Managingyourorganisation/Humanresour cesandtraining/Modernisingworkforceplanninghome/Europeanwork ingtimedirective/DH_077304 Accessed on 24th of August 2008. The Royal College of Surgeons of England (2004) European Working Time Directive [Internet]. London. Available from http://www.rcseng.ac.uk/fds/nacpde/eea_qualified/ewtd.html?searchterm=EWTD Accessed on 24th of August 2008. Competing interests: None declared |
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Laurence JR Brown, consultant histopathologist UHL Leicester LE1 5WW
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A little publicised effect of shift-working and the reduction of trainees' hours is the ignorance of the circumstances leading to a patient's death. This often is the case when death occurs over a weekend or holiday. A junior member of the team will be asked to complete a death certificate having had no knowledge of the patient in life or the terminal events. The other members of the team who could perhaps provide this information have gone off shift and the relatives will be anxious to receive the certificate to proceed with burial. Medical students now receive little teaching in pathology, death certification or the role of the Coroner. Consequently, trainees are puzzled by what to put on the death certificate and whether to refer the case to the Coroner. In many cases this results in unnecessary autopsies, delayed funerals or inaccurate certification. Competing interests: None declared |
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Syed M Tariq, Consultant Physician Queen Elizabeth Hospital, King's Lynn, PE30 4ET, Randhir S Bhatia
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We concur with the issues raised by Cairns and colleagues (1) regarding the implementation of the European Working Time Directive (2), which will lead to a reduction of junior doctors working hours next year to forty-eight per week. Of particular concern is its negative impact on their hands-on training and on the continuity of patient care. Even with the current fifty-six hours a week, and allowing no more than 12 hours of shift work at a stretch, it is a major juggling act to set a workable rota. As a result the annual leave of every junior doctor is now tied up into virtually inflexible chunks within the rota, whether they like it or not. Also, with these complicated rotas, it has become much harder to make duty swaps at short notice. The way things are, every trainee doctor would be better off warning their parents, partner or any other loved ones who really matter, not to fall ill or even have an accident within certain dates when it is particularly difficult to have time off work. We would also advise the junior doctors to plan ahead their special occasions such as a wedding or a birthday, as per their rota, while fully accepting that some of their colleagues and friends would not be able to attend their big day because of being on call. Although, on average, the number of junior doctors per firm has increased in the past few years, it is now seldom that the whole team is available to us at any given time, as one doctor could be doing nights for the acute take, while another might be away on annual or study leave. We had two Foundation Year 2 trainees working in our unit for the six months till August 2008, and they were both together in our ward for just three days during the entire six months. This situation is causing serious problems with continuity of care and promoting a consultant-led service by default. With the fixed shifts, protected times and reduced working hours, we also dread the development of an undesirable attitude of continually watching the clock while at work. This attitude could easily be taken a step further by frequently ‘passing the buck’, that is leaving unfinished clerking and other work to the next person on-call. References: 1)Cairns H, Hendry B, Leather A, Moxham J. Outcomes of the European Working Time Directive. BMJ 2008; 337:a942. 2)Council of the European Union. Council directive 93/104/EC.1993.http://eur-lex.europa.eu/ LexUriServ/site/ en/consleg/1993/L/01993L0104-20000801-en.pdf. Competing interests: None declared |
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Adrian R. Leahy, Staff Grade Psychiatrist Bolton BL6 6HG
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Why is it that clinical care amongst nursing staff has not broken down when nurses only work for 37 1/2 hours a week ? Why is it that doctors feel this need to suffer for their art so much ? The answer to the latter is that we have inherited habits from our predecessors who, pre-NHS worked in "Firms", much like Chambers of barristers, who trained junior staff by a process akin to indentured apprenticeship. An old Professor of mine once told me how he had had to ask his Consultant's permission to leave the hospital and cross the road to the shop during his house officer year. He was always on duty. But it was during the Second World War. When he told me this, it was not to tell me that this was how he had gained his invaluable experience, but to remind me that life for junior doctors used to be far worse. Maybe we all should look to how we would like to work in the future and try to achieve this ideal. I say less hours, not more. If I were training a pilot, the usual profession we compare ourselves with when looking at risk management, I would not expect the trainee to efficiently acquire skills when tired and resentful during the training sessions. I would focus on the trainee actually flying the plane, not polishing the windows or emptying the waste-paper basket. In my experience as a junior doctor, training has always been highly diluted with service provision, and so long hours were needed to distill any meaningful training experience out of the hours of unnecessary tedium. During this process, "in the good old days", disillusionment had to be constantly fought off when for example on call, one was paid at one-third time and the hospital management thoughtfully closed the restaurant for those working out-of-hours and clamped your car. Trainee pilots might at least get a smart uniform and would not be expected to be pre-occupied with hunger pangs mid-flight. But they were never "t'apprentice lad", to be used and abused by the Firm. The simple fact is that we are trying to train our juniors on a shoestring budget, and with a shoestring mentality. Nurses appear to have rewarding careers and acquire skills without the need for inhumane hours. I often observed that despite the nurses changing shift three times a day, patients would often say how wonderful they were and leave them a box a chocolates. The poor junior medical staff in the good old days of 83 hours a week rarely got remembered. Why ? Their quality of the patient interactions may have been high, but the quantity low. For continuity it would be far safer for all to have juniors working with the same team of nurses on their rota system to provide the service component of clinical care, and to be intermittently sent away to "flight school", a few weeks of clear training, not confused by "being on duty", and then on return given more responsibility. Start by polishing the cars, then be allowed to open the bonnet. You will then need to start training a new polisher however. You will need more staff. It will be more expensive. That is inescapable. What is needed here is a total change of training philosophy and expectation, not just trying to force the old system into a new shape that may look new, but as has been pointed out, is not fit for purpose due to the inherent flaws and weaknesses of the recycled tired old design. Finally, I would ask all the readership to consider Oxford and Cambridge Universities. These are both sucessful educational establishments with a long history of teaching over hundreds of years. If being tired assisted learning, if holding down an additional full-time job assisted learning, if sacrificing personal development and neglecting a social life assisted learning, why have they never attempted to ruin their students' lives in the same manner that our profession continually encourages us to ? I say again, "Less hours, not more". Competing interests: None declared |
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Miguel D Seixas, TG - Forensic Psychiatry Fulbourn Hospital, Cambridge CB21 5EF
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The presumed aims of the Council of the European Union as listed in the editorial(1) fail to address the initial purpose of the Working Time Directive, which was simply to protect the health and safety of workers (2), medical or not. Assumptions on the impact it may or may not have in old habits within the medical profession and how it will translate into patient care are speculative, entirely based on personal opinions which can be diametrically opposite and totally out of the remit of the Working Time Directive. This latter point was reinforced by the SiMAP(3) and the Jaeger(4) rulings. Both the European Working Time Directive and the Modernising Medical Careers project (5) can contribute to a welcome shift in speciality training if adequately nurtured. The underlying principles are laudable and relevant, despite the difficulties that different professionals are having in putting them into practice, often but not always of a covert financial nature. It is recognised as important that doctors become more responsible for their own continuous education and assume a clear role as active and reflective learners. Such a redirection in speciality training, and even in career approach, should be supported and not compromised by management difficulties and service provision. This will have the potential to help young doctors become better clinicians who will not, restrained by fear, become merely safe providers of a given service. The Working Time Directive was, as stated in the editorial, was produced by the Council of the European Union in 1993 and incorporated into British law in 1998. This would have allowed the medical profession enough time to reorganise itself in terms of training of its new members and provision of services. The Working Time Directive itself should not be blamed for the failure in a smoother implementation. Although this was not its initial aim, the European Working Time Directive should be seen as an opportunity to redirect specialty training, giving more emphasis to purpose rather than merely procedure. Ref: (1) BMJ 2008;337:a942 (2) Council Directive 93/104/EC of 23 November 1993 (3) http://eur- lex.europa.eu/smartapi/cgi/sga_doc?smartapi!celexplus!prod!CELEXnumdoc&lg=en&numdoc=61998J0303 (4) http://curia.europa.eu/jurisp/cgi- bin/gettext.pl?lang=en&num=79969090C19020151&doc=T&ouvert=T&seance=ARRET&where=() (5) http://www.mmc.nhs.uk/default.aspx?page=310 Competing interests: None declared |
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Paul J Caldwell, GP Bartholomew Medical Group, Goole DN14 6AW
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I note the editorial decrying reduction in JHD hours to 48 pw, but:
In summary, was the article written truely in the interests of JHDs and patients or was it more about power? Competing interests: None declared |
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G Y Shin, Locum Consultant Virologist Infection and Immunology, 5/F North Wing, St Thomas' Hospital, London SE1 7EH
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Sir, I could not agree more with Cairns et al in their recent BMJ Editorial [1]. I doubt that the Council of the European Union was thinking about British junior doctors when it produced the European Working Time Directive (EWTD) in 1993[2]. The words peg, round, square and hole spring to mind. Although I agree in principle that there should be an upper limit on weekly working hours for safety reasons, I am opposed to the 48 hour limit for British doctors. I find it hard to believe that a 56 hour week is unsafe. I believe that the status quo is a broadly acceptable compromise between safety concerns and the provision of adequate training opportunities for junior doctors, although personally, I would not oppose a higher limit. Ultimately, all these working time limits are arbitrary - there is no peer-reviewed objective evidence that a 48 hour working week would be more or less safe than 56 hours or 52hours or any other number below e.g. 80 hours per week in the context of 21st century hospital medicine. As a doctor who worked up to 104 hours per week as a house officer (during a week with a weekend on-call), it is not easy to sympathise with those who feel they cannot safely cope with working more than 48 hours per week. My contemporaries & I just got on with it. I think the experience was what is sometimes referred to as “character-building”. Having said that, I don’t advocate a return to triple-digit working hours, but 48 hours seems a bit feeble. Like Cairns et al, I am increasingly worried about the impact EWTD is having on British medicine. It is inconceivable that the reduced hours are having anything other than a deleterious effect on the acquisition of medical knowledge and experience in many contemporary junior doctors. The authors of the EWTD editorial stated that: "British medicine is highly respected worldwide because of the training provided and by the breadth of experience and clinical expertise displayed by most consultants and general practitioners." Once the rest of the world becomes aware of the double whammy of EWTD and MMC on British postgraduate medical training, only the most optimistic idealists will expect this international respect to persist. In my opinion, we owe it to our profession and all future patients to resist the 48 hour EWTD limit. References 1. Cairns H, Hendry B, Leather A, Moxham J. Outcomes of the European Working Time Directive BMJ 2008;337:a942 2. Council of the European Union. Council Directive 93/104/EC 1993 Competing interests: I was previously an SHO on the Renal Unit at King's College Hospital and worked for Dr. Cairns & Prof. Hendry. I am about to finish a one year term as a member of the BMA Junior Doctors Committtee, but am contributing this as a personal opinion. It is not clear to me from the BMJ website that these necessarily constitute competing interests, but I declare them in the interests of transparency. |
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Vimal J Gokani, FY2 Broomfield Hospital, CM1
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Sir, I read with interest the above article. My junior surgical trainee thoughts on EWTD are linked to my squash training. If my coach told me that I could only practice for 4 hours a week, I would seriously re-consider whether his training methods were really going to help me to train for the 2012 Olympics. Although I have no intention of entering the Olympics, I would still like to be given the option to be an excellent good player. My question is this: are we really serving the public of tomorrow, or are we puppets of the government of today? Competing interests: VG is rather keen to be a good doctor |
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Allan M Conway, Foundation Year 2, Emergency Medicine Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, Simon D. Carley, Consultant in Emergency Medicine, Manchester Royal Infirmary
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Sir, In 1943 Maslow developed his “hierarchy of needs” motivation theory (1). This model consists of five levels which must be satisfied to enable individuals to develop (figure 1). His pyramidal design shows four lower levels termed “deficiency needs” which must be met in order to achieve the final level and so enable self actualisation. If a level is not met then one can not progress. This theory remains valid today for human motivation, training and personal development.
The report by Cairns et al. in their recent BMJ Editorial (2) was met with a warm and welcome response by many of my fellow junior doctor colleagues. As mentioned, the intention had been to improve the working lives of employees. However, the reduction in hours and the abolishment of firms now means it is a rarity for a full team to be present. The combination of nights, shift work and “zero days” (where the doctor is not allowed to attend work to keep weekly hours compliant with EWTD) means day time staffing is at a minimum and patients are cross covered by already stretched teams. EWTD places a great emphasis on Maslow’s lower two levels “physiological and safety” such that “love and belongingness” can no longer be achieved (Figure 2). Doctors of all levels have been deprived the basic necessities required for personal growth and so self actualisation within this profession cannot be met. We agree with Cairns et al. in that EWTD is not achieving any of its presumed aims.
1) Maslow A.H. (1954). Motivation and Personality. New York: Harper. p. 236. 2) Cairns, H. Hendry, B. Leather, A. and Moxham J. Outcomes of the European Working Time Directive. BMJ 2008; 337: 942 Competing interests: None declared |
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Stephen MF Saunders, Consultant General Surgeon Barnet Hospital, Wellhouse Lane, Barnet, EN5 3DJ
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Dear Sir, Having read this editorial I was left perplexed. The article was one sided and contained many inaccuracies. It was completely at odds to a similar article published in the BMJ two months previously (1). Doctors have always have been paid a basic salary for a 40 hour week or 10 sessions. The introduction of pay banding with the new Junior Doctors Contract in 2002 brought about the realisation that the majority of junior doctors were working many hours above their contracts and at last were going to get recompensed for this. Only now did it become costly for a Trust to employ doctors for long hours rather than more doctors for shorter hours. This together with the EWTD led to a substantial drop in the long hours culture in hospitals. It is untrue to say that this lead to a worsening in the quality of life. In many ‘quiet’ specialities that may be true but in General Surgery it was the exact opposite. Partial shifts ensured that quality training could take place as the trainee would have had at least 24hour at home every weekend, and they were not operating or doing outpatients in the late afternoon having been up working the previous night. This has been seen as a break up in the Traditional working of the Hospital firms. Indeed smarter working rather than harder working has led to the separation of emergency and elective working. But with the introduction of ‘Surgeon of the Week’ and Hospital at Night this can bring back the team spirit. It is not easy to organise a rota but with a well thought through rota training can be improved. Time in Training has been reduced but this should not prevent us from maximising teaching by using every patient contact as a learning opportunity. References 1. How the European Working Time Directive already works. Eaton L. BMJ 215 -6 28 June 2008 Competing interests: None declared |
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Oliver D Starr, General practice registrar Regal Chambers, Hitchin, Herts, SG5 1LL
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Cairns et al provide a robust argument against the EWTD. There is no doubt that surgical training has become a shadow of its former self. As an ex-surgical trainee and member of the Royal College of Surgeons, I became increasingly frustrated with the relentlessly slow learning curve which is now the norm. There just simply isn't enough "cutting time" for juniors. A week of night shifts is often spent clerking patients, in order for someone else to operate on them during the day. The result is that surgical registrars are now the equivalent of an SHO from, say, the 1980s and a newly appointed consultant surgeon has about as much experience as a junior registrar of old. Of the 8 surgical SHOs on the rotation at a good DGH, one has left to pursue a career in finance and six others (including me) have left to receive better training...in general practice. Competing interests: None declared |
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Juhi Sharma, Specialty Doctor, Psychiatrist WD7 9HQ
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Although it is well agreed across the board that a FURTHER reduction in hours is uncalled for, there is a general satisfaction with the reduction to 56 hours/week. Sadly some specialties suffer the toll more than others, and surgical specialties bear the brunt the most as far as training is concerned. But whatever the impression is outside, we know that we are not a homogenous group. Where Surgery requires more hands-on experience, other specialties including psychiatry relies on quality diagnostic techniques. Even though Emergency Medicine rota does well on full shift patterns like nurses and will do so without any hiccups, it doesn't work that well with junior doctors in Psychiatry. When trainee psychiatrists are on full shift pattern, the week of nights is considered as a period when you can get about your daytime bank and other activities without compromising on your sleep too much, as we can get enough sleep with maybe with 1 or 2 interruptions at the most. I think all specialties should fight their case individually. Competing interests: None declared |
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Onno T. Terpstra, professor of surgery 2300 RC Leiden, Netherlands
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Dear Sir: When in 1993 the Dutch parliament approved a law restricting the working time of junior doctors to 48 hours a week the surgical community in the Netherlands experienced all of the classical stages of mourning as described by Kübler-Ross. A major concern was the reduction in training time, resulting in less experienced young surgeons and also how to fix the rotas. The same worries are felt in the UK (1). The Dutch Ministry of Labour has been making site visits to hospitals since 1997, inspecting the rotas and giving heavy fines if they did not comply with the rules. Now, 15 years after the first introduction of the working time reduction what are the results? Many departments of surgery struggled with the rotas. An extra number of non-training junior doctors were appointed to take care of the routine workload. Surgical procedures were considered to be training episodes unless otherwise stated and staff was made responsible for the continuity of patient care. What was the effect of the introduction of the new law on training experience? Although we do not have data on the amount of overall exposure to patients we do have data on the number of operations performed by surgical trainees over the years. Every year the Dutch Association of Surgical Trainees sends questionnaires to all surgeons-in-training with questions on working hours, working conditions, etc. Although the number of hours per week declined significantly between 1990 and 2005, when we examined the number of operations reported at the time of registration as a surgeon with the National Specialist Registry we found that the mean number of cases per trainee per year did not change significantly during this period (mean no. 195, range 35-450). Working hours reported by the trainees declined from 57 hours a week in 1999 to 55 hours in 2005 (2). 76% of the trainees approved of this while only 19% found this “too little”. Although surgery is still considered by medical students as one of the more demanding specialisations, applicants for the surgical training continue to outnumber the available slots by 2-3 times. With an acceptable workload surgery remains an attractive career option. 1.Cairns H, Hendry B, Leather A, Moxham J. Outcomes of the European Working Time Directive. BMJ 2008;337:a942 2.Wijnhoven BPL, Watson DI, Ende van den ED. Current status and future perspective of general surgical trainees in the Netherlands. World J Surg 2008;32:119-24. Competing interests: The author worked 80-100 hours a week during his surgical training. |
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Muhammed R S Siddiqui, Research Registrar Worthing BN11 2NE
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As a surgical trainee I was encouraged by this article. With regards to Less hours not more rapid response. The reality is that nursing has sufferred and it has sufferred badly. How many times do you go onto a ward and find that noone really knows the patient. How many times do you find excellent nurses siphoned off to become specialist practitioners with out being replaced? The shift system for nurses has impacted on nursing and I do not wish that for doctors. The article mentioned offers real hope for an unheard voice of a either a majority or sizeable minorty of surgical trainees who want to train to achieve excellence. Dupuytron once stated that there is nothing more feared for a person than mediocrity. Indeed I do not want to become a 'competent' surgeon I want to be an excellent surgeon. Now I may not become 'an excellent one' but to deny me my right to try is disappointing. And it is indeed simple mathematics if we want to reduce working hours increase the training time certainly for those who wish not to become consultants with half the experience of the consultants in the past. Competing interests: None declared |
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Allan P Corder, Consultant Surgeon Hereford County Hospital
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Your editorial on outcomes of the European Working Time Directive, page 421, BMJ 23.8.08, is timely and extremely important. I agree with all of the contents. One point which was not made in the article was that the directive is extremely inflexible. It affects large hospitals with a large density of work in exactly the same way as small hospitals with a lesser density of work. A ten hour shift in a hospital serving a population of 500,000 is going to have twice the density of work for a junior doctor compared with a hospital serving a population of 250,000. There is absolutely no acknowledgement of this whatsoever, in the European Working Time Directive. It may very well be practical for a doctor working in a smaller hospital to safely do a 24 hour on-call, being fairly sure of getting a few hours sleep. This may not be the case in a hospital twice the size. It is the complete inflexibility of the Working Time Directive that I have the greatest objection to. May I suggest that the BMJ heads up a campaign against this clumsy legislation which is very likely to do harm to medical training in this country in the long term. Competing interests: None declared |
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AJAY SAHU, Clinical Research Fellow Stepping Hill Hospital, Stockport, Neil Jain, Sam Dalal, Gary Cook, Brian D Todd
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We have measured the outcome of implementation of European working time directive on the current Orthopaedic training by our multicentric hip fracture reaudit in 14 NHS Trusts in Northwest of England. This audit was performed over four month period in 2007 (1st April to 31st July ) collating information on 1010 hip fracture patients undergoing surgery in 14 NHS hospitals in the North Western deanery of England. We have analysed the results of this audit and have identified a potential area of concern. Our results showed that an orthopaedic trainee of registrar level (Speciality trainee year 3–6) was the lead surgeon in 37% of cases while only 4% of operations were performed by a Speciality trainee year 1–2 or Foundation year 2 (senior house officer grade) in 2007. These findings varied amongst the audited hospitals but in one hospital, trainees operated on only 12% of hip fractures. Overall, a trust grade surgeon (non -training grade) was the lead surgeon in 24% of cases. Comparing with the previous audits performed in the same hospitals, the number of hip fracture operations performed by trainees have reduced drastically. In 2003 and 2005 audits, Orthopaedic registrar’s operated on 52 % and 50% of hip fractures respectively. Similarily senior house officers had hands on experience on 11% and 9% of hip fractures in 2003 and 2005 respectively. There was a definite trend suggesting decline in number of operations performed by trainees since the implementation of European working time directive as it has been introduced in a phased manner since 2004. In NHS, Current target is to achieve it fully by next year which may make the situation even worse from training point of view. Hip fracture surgery is one of the most frequently performed operation on the trauma lists and hence it is considered mandatory to independently able to perform hip fracture surgery in the registrar training curriculum. Our reaudit proves that European working time directive has reduced the working hours, leading to decreased hours of surgical training. On the other hand, the modernising medical curriculum (MMC) emphasises demonstration and record keeping of core competencies of surgical skills. The Orthopaedic Competence Assessment Project (OCAP)1 and the Intercollegiate Surgical Curriculum Project (ISCP)2 expects trainees to achieve core competencies in key procedures such as hip fracture surgery. The curriculum outlines the basis of procedures that trainees of all levels should be competent at supervising with, performing assisted and eventually unassisted. As the trainee advances through their training, they are expected to be clinical competent at performing an increased number of more advanced procedures, proved via trainer appraisal in the form of procedural based assessment. In the context of shorter training and reduced working hours, to achieve these core competencies it is imperative to maximise operative exposure and experience for trainees. If the findings of this reaudit in England are mirrored elsewhere in Europe, the implications for orthopaedic training are significant. We are setting very high standards for training on one side but on practical grounds, not able to achieve the requirements set by educational bodies like OCAP and ISCP. References: 1. Orthopaedic Competence Assessment Project (OCAP) T & O Curriculum 2007 / 2008- http://www.ocap.org.uk/orthocurriculum/Content/04_Syllabus_160707.pdf; last accessed on 02.10.08 2. Intercollegiate Surgical Curriculum Project (ISCP) - http://www.iscp.ac.uk/Syllabus/KeyConditions.aspx?Spec=TO; last accessed on 02.10.08 Competing interests: None declared |
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