Can doctors be trained in a 48 hour working week?BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g7323 (Published 10 December 2014) Cite this as: BMJ 2014;349:g7323
- Andrew Hartle, president, Association of Anaesthetists of Great Britain and Ireland, London W1B 1PY,
- Sarah Gibb, chair, Group of Anaesthetists in Training, Association of Anaesthetists of Great Britain and Ireland,
- Andrew Goddard, registrar, Royal College of Physicians, London NW1 4LE
- Correspondence to: A Hartle , A Goddard
Yes—Andrew Hartle and Sarah Gibb
Since August 2009 all UK trainee doctors have been restricted to a 48 hour week (averaged over 26 weeks). The purpose of the European Working Time Directive, implemented into UK law as the working time regulations, is to encourage the safety and health of workers by enforcing periods of rest and annual leave, as well as the maximum working week.
No one could wish a return to the unregulated 100 hour or more weeks of former generations. However, a constant concern with the regulations has been the potential negative effect on the quantity and quality of medical training—and, by extension, patient care. Is there any evidence to substantiate these fears? Is quantity any substitute for quality?
Catalyst for redesign
In his 2010 review on the effect of the working time regulations on the quality of medical training John Temple stated that “high quality training can be delivered in 48 hours [a week].” However, he emphasised that barriers to such high quality training would continue if trainees had a major role in out of hours service, were poorly supervised, or had limited access to learning.1 He argued that the regulations should be a catalyst for redesigning service and training. The traditional model of experiential learning, where trainees spend long periods delivering service and acquiring skills and knowledge should be replaced by a consultant delivered service and high quality training within a service environment with appropriate supervision.
A review commissioned by the General Medical Council in 2012 concluded that although the quality of the literature varied, the balance of evidence suggested that restricting working time is neutral or beneficial in terms of training and patient care. It was doctors’ attitudes towards the restrictions that remained negative, especially among seniors.2
The GMC’s surveys of trainees have shown increased satisfaction with training for all grades and specialties year on year since the implementation of the 48 hour working week,3 and the BMA could find no evidence that fewer doctors have reached the specialist registrar grade since the working time regulations were implemented.4
Some specialties’ training programmes adapted more readily to the regulations than others. The anaesthesia literature contains no evidence of any reduction in anaesthetic trainees’ caseload or access to training opportunities and shows consistent exam success rates, no increase in referrals to regulatory bodies,5 6 and a reduction in sick leave among trainees since the regulations were introduced.7 Data from the Royal College of Anaesthetists show that most trainees continue to complete workplace based assessments on time.8 The Royal College of Paediatrics and Child Health reported that reconfiguration of acute services and implementation of consultant delivered care in response to the working time regulations had maintained adequate exposure to training opportunities.9
Evidence from other countries also seems to support the ability to train doctors within a 48 hour week. Norwegian doctors have had their hours restricted since the 1980s. Between 1994 and 2012 Norwegian doctors in training worked on average 45 hours a week in five to seven years of postgraduate training. This was deemed satisfactory for specialist training by most of a surveyed cohort that was representative of all specialties.10 More supervision and lower workload related to routine treatment were identified as factors that reduced the time to attain a specialist qualification.
But with many of Temple’s recommendations still not yet realised, the UK government commissioned a further independent report into the effect of the working time regulations on the NHS and professionals, published in March 2014.11 It acknowledged that the UK continues to train competent doctors who are fit to practise but that in some specialties doctors work extra hours voluntarily to gain the skills required. The Association of Anaesthetists of Great Britain and Ireland and the Group of Anaesthetists in Training (representing its trainee members) have grave concerns about the government’s acceptance of the recommendation to encourage more widespread use of the voluntary opt-out from the restrictions on working hours. This would allow (or even require) trainees to choose to work more than the average 48 hours (but no more than 56, the limit imposed by the “New Deal”). The Royal College of Surgeons of Edinburgh has also challenged this recommendation and thinks it possible to train a surgeon within a 48 hour working week.12 It fears that any opt-out will simply lead to trainees covering rota gaps, providing more service without any additional educational experience.
It is not the restrictions that cause difficulties but the way in which they have been implemented in the UK, with over-reliance on trainees to provide service. Unfilled slots on rotas that comply with the regulations mean trainees have to fill gaps out of hours, missing out on daytime training opportunities. Attempts to mitigate this with a “voluntary” opt-out do nothing to tackle the underlying problem: too many rotas in too many places. To recommend opt-out as a solution risks patient safety from tired doctors and stifles attempts to reconfigure services and delivery of training. Far better to do fewer procedures well, under supervision, than be left to get on with more, without.
Consultant delivered care is seen as important for many reasons.13 We need to seize the opportunity to put this and Temple’s other recommendations into practice rather than wallow in nostalgia. By doing this we will continue to train doctors who provide excellent patient care within the confines of a 48 hour week.
Not all doctors can be trained to the required standards in a 48 hour working week with the current length of training and service demands. Medicine is a brilliant career. It is rewarding, varied, and has many different career pathways to match the skills and personalities of all. This means that the training needs differ among specialties. The knowledge, skills, and experience needed to be an anaesthetist in theatre are different from those needed to be a general physician at the front door. It may well be that we can train many types of doctor within the current system, but for hospital medicine this is not the case.
Fall in quality of training
Evidence collected by the Royal College of Physicians over the past decade supports this. More than 50% of consultants and trainees are clear that the 48 hour working week has reduced the quality of training.14
The problems of “time for training” are particularly stark for hospital physicians in the early stages of their career. Some 44% of doctors completing core medical training report that they are not sufficiently trained to be a higher specialist trainee.15 When asked why they haven’t had enough training, most cite excessive service pressures.
Most of the medical specialties that core medical training leads to are outpatient based. Patients hope that the doctors they see in clinic will have seen lots of patients in this setting. A third (36%) of those completing core medical training have attended fewer than 10 clinics in the previous year.15 “See one, do one, teach one” is an old medical maxim. When it comes to outpatients, many trainees don’t even “see one.”
Doctors completing core medical training are now voting with their feet, as shown by recent data from the General Medical Council on applications to leave the UK.16 In 2013, 42% of the 1210 doctors completing training did not progress to higher training that year, opting to get further training in the UK or abroad.17 On one hand it is reassuring that these doctors realise that they are not adequately trained and seek further training. On the other hand it indicates that current training is not adequate.
The situation for medical registrars is better and has improved in the past five years. In 2013 only 1% of physicians who completed training reported being inadequately trained in general medicine. However, 18% described themselves as “adequately” trained and 30% as “fairly well” trained.18 Not exactly a ringing endorsement.
Procedural based specialties
The concern for many procedural based specialties is that the numbers of procedures done during training has fallen substantially with the working week. For example, in 1998-2002 the average number of bronchoscopies done by respiratory trainees before they got their certificate of completion of training was 448.19 In 2010-14 it was 287, a fall of 36%. These more recent numbers are enough to get a trainee a certificate (if they do the average number) but, as has been shown for colonoscopy and other procedures, performance and adverse outcomes are correlated with number of procedures.20 21 Surgical specialties have expressed similar concerns about procedural experience and subsequent competency.22
Much evidence indicates that service pressures currently affect the ability of trainees to attend formal training, gain feedback (a crucial and underchampioned part of clinical training), and feel part of a team. The last factor is important because trainees in a supportive and well functioning team show greater satisfaction with training and greater ability to learn.23 It seems unlikely that NHS hospitals are going to get quieter over the next few years (and this may be an understatement). Many medical trainees do informally opt to work longer hours. This isn’t a viable solution as it is inconsistent and doesn’t address the underlying problem of not enough time for training.
Furthermore, there are no plans to increase the total numbers of doctors on the ground to release more time for training as the shift towards boosting the number of general practice trainees bites.24 This is a necessary move, but the impact on hospital training must not be underestimated. Consultants, too, think that they have less and less time to train. Trusts are forcing down the number of “supporting professional activities” in consultant job plans to get more clinical juice from the squeezed workforce. This short term gain will have a long term impact if we don’t set aside time to support training the doctors of the future.
The Shape of Training review25 looms like a storm cloud over hospital medicine, with much talk of shortening training. It seems unlikely that the working week will increase from 48 hours or that service pressures will relent. Given the evidence, hospital doctors will need a lot of convincing that shorter training time will produce better doctors.
Cite this as: BMJ 2014;349:g7323
Competing interests: All authors have read and understood BMJ policy on declaration of interests and declare the following interests: AH is a coopted member of council of the Royal College of Anaesthetists. His partner is a training programme director for the Royal College of Anaesthetists.
Provenance and peer review: Commissioned; not externally peer reviewed.