Outcomes of the European Working Time Directive
BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.39541.443611.80 (Published 31 July 2008) Cite this as: BMJ 2008;337:a942
All rapid responses
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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.
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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.
Competing interests: No competing interests
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
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
Competing interests: No competing interests