Jobs for sleepBMJ 1996; 313 doi: http://dx.doi.org/10.1136/bmj.313.7063.2 (Published 19 October 1996) Cite this as: BMJ 1996;313:S2-7063
Broken sleep can be bad for your health. Alison Howe looks at career options for doctors who, like her, need regular sleep
Many doctors dream of having undisturbed sleep every night, but for some this is more important than for others. Following a diagnosis of epilepsy I have been advised to find a job which will allow me regular hours and a regular sleep pattern, as seizures are most likely to occur during the transition between sleep and wakefulness. This is not a description of any of the jobs I have done previously or of most jobs in medicine. When my personal interests, aims, abilities, and commitments are added this becomes a difficult problem to solve. I can still function just as well as a doctor so why waste all those years of training and experience? Doctors with other medical conditions, or with particularly heavy domestic commitments, may face similar problems.
Junior doctors' hours
Under the conditions of the new deal no junior doctor should work for more than 56 hours a week from 31 December. The total period of rest within contracted hours must also comply with new deal requirements. A partial shift system must allow four hours rest in each 16 hour shift, and an on call system must allow eight hours rest in each 32 hour duty period. This must be distributed to fit in with the work pattern, and allow “reasonable periods of uninterrupted rest.” Of course, this is no guarantee of uninterrupted sleep. The European Union's working hours' directive may force further changes. Different working patterns will improve the position for some doctors. Full shift work, offering shorter but more irregular working hours, may be a better option. Partial shift work avoids working days and nights together, but hours are still irregular and the sleep pattern disturbed. Traditional on call rotas provide regular weekday hours but intermittent disturbed nights.
These controls over the hours worked are not universally welcomed. In certain specialties some juniors argue that reduced hours do not give them adequate experience for training. Some find that doing fewer nights on call results in more intensive nights with more cross cover which can result in increased stress levels. Opinion varies as to whether junior doctors find partial shift systems an improvement over the on call systems they replace. Partners of shift workers are likely to be less happy with this pattern of work.
Flexible training allows the creation of posts which are designed around the individual needs of a trainee, something which cannot easily be done with full time training posts. The aim of flexible training is to allow doctors who are unable to train full time to remain within the NHS. Many of us who require undisturbed sleep will fall into this category. Those applying to work part time must show “well founded reasons” for their application. At present the majority of flexible trainees are women, usually with domestic responsibilities.
Under European Union regulations part time training can be formally recognised only if the hours worked are a minimum of half of those worked by full time trainees in the equivalent post with pro rata on call. Any post established for a flexible trainee must fulfil this requirement if it is to receive the appropriate royal college approval. So it is not possible to train without doing out of hours work whatever the reason. But there is still flexibility in the pattern of the hours worked, and where necessary it may be acceptable for all the on call to be done before midnight, subject again to royal college approval.
Choice of specialty
The working patterns in both training and career posts need to be taken into account when a specialty is chosen. There is no point in surviving flexible training if no suitable career grade post will be available at the end. Similarly, the early years of many sleep friendly specialties will probably have to include busy, acute jobs. It may also be useful to consider the length of training and employment prospects involved.
Career posts are set up by individual trusts so in theory any individual needs can be accommodated. Non-clinical posts are the least likely to involve many disturbed nights, followed by the non-acute clinical specialties. There are, however, many other variables. Consultants on call with a registrar and senior registrar are less likely to be disturbed than those covering just a house officer or senior house officer, regardless of the specialty.
At a junior level the nights are also more likely to be disturbed in the acute clinical specialties, although hard pressed posts do occur outside these. Shift and partial shift systems are an indicator of posts involving heavy out of hours workloads. The table shows the distribution of shift posts by specialty, according to regional task force returns. Junior and senior house officers are most likely to work in shift systems.
Medicine covers a wide range of specialties with large variations in out of hours disturbances. Registrars in dermatology and cardiology, for example, are likely to have very different sleep patterns. Entry to the specialist registrar grade requires possession of the MRCP, so however appropriate the ultimate career subspecialty may be, time spent in acute and possibly hard pressed posts is essential. Paediatrics is another acute specialty where many of the hard pressed posts causing particularly disturbed sleep are to be found. Again, possession of the MRCP is essential to become a specialist registrar. Training in community paediatrics includes substantial periods in hospital posts, and even community based posts may include participation in acute hospital on call.
Psychiatry has usually been more receptive to the specific needs of individual doctors than many other specialties. The changing pattern of psychiatric practice, with the move away from old fashioned psychiatric hospitals towards community based care, is resulting in changes in working patterns but the flexible attitude towards staff with particular needs will I hope continue.
General surgery is traditionally seen as one of the least flexible and most demanding specialties. Flexible training is unusual. Other surgical subspecialties require experience in general surgery and the FRCS which will cause problems for those requiring undisturbed nights even if the final career post is more appropriate Non-clinical specialties, such as the various branches of pathology, will usually offer reasonably quiet nights, with many problems being dealt with over the telephone. In many cases they can still be entered without a postgraduate qualification. The number of jobs available locally, however, will not be high, which may be an important consideration for those with heavy domestic responsibilities.
Public health medicine
Trainees and consultants in the various branches of public health medicine are working in a non-clinical specialty which has a different structure from the hospital based specialties. On call duties should result in fewer disturbed nights than in most hospital jobs. Trainees have to complete several years of postregistration training.
Many of the areas traditionally covered by community health doctors, such as child development and family planning clinics, have now been taken over by general practitioners. Many child health posts have been converted into senior house officer training posts in a hospital based rotation with the postholder participating in an acute duty rota. Thus many of the posts traditionally seen as married women's jobs are no longer available in their previous forms.
As self employed principals, general practitioners are in a potentially more flexible position than most other doctors. In the traditional model of general practice the out of hours commitment is onerous and increasing, and without the prospect of becoming second or third on call. In many areas this is still the case, but in those practices which participate in cooperatives or make use of a deputising service the pattern can be changed, and it is possible to become a principal without suffering broken nights. Practices also employ associates under mutually agreed terms which often include no out of hours work. A greater problem in general practice may be the training which will involve time in the acute clinical specialties where the majority of hard pressed posts are to be found. General practice registrars will still require experience in dealing with home visits and emergency calls, but in a cooperative system it should be possible to provide this without working overnight shifts.
Clinical academic staff hold honorary NHS contracts and will participate in the relevant on call rota. Preclinical academic staff are employed by universities and work under the same conditions as their non-medical colleagues.
There are careers outside the NHS for which a medical qualification is required such as occupational health and pharmaceutical medicine. In most instances entry to these fields requires experience and probably a postgraduate medical qualification. Other options are available for which a medical qualification will be an advantage, such as the medicolegal field. These will require further training. Some doctors also move into trust or health authority management on a full time basis. The work patterns in all these options will be different from those in NHS medical posts.
Jobs for sleep are there if you are sufficiently determined, but they are not readily available. Although a degree of realism is necessary in choosing a career path, you should not be forced to compromise personal aspirations. The report of the BMA's disabled doctors' working party may improve the position for some of us, but it is surely possible for the medical profession to accommodate the needs of those with medical and social problems of their own. I have not yet found my personal solution but it must be out there somewhere.