Working time directive puts patients’ lives at risk, surgeons claim
BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c4212 (Published 03 August 2010) Cite this as: BMJ 2010;341:c4212
All rapid responses
Thanks to Lynn for this.
Although the category of study (questionnaire survey) is a kind of
anecdotal evidence, the percentile responses regarding working time
directive reflect the factual situation right. This situation not only
threatens the quality care services and patients’ safety, also keeping
away the trainees from their valuable theatre learning, as evidenced. If
you conduct a survey, you will also find the similar situation in other
specialties too--for example, in paediatrics, many of the doctors are
affected severely with their very long working hours. In this context, an unpaid exhausting overtime duty is not uncommon
for paediatric doctors. Every day they have to withstand a lot of physical
and psychological pressures in the clinical setting. On many occasions
they do not have a time to eat their meal, and they return home quite tired
for the preparation of the next long day and/or sometimes 3-4 night
duties/month without having proper rest. In fact, the doctors do not
have any scope for maintenance of their own health, which is essentially
required for the safety of their patients. I think, the health secretary
should come forward to fix the working hour directive convenient for
doctors so that they are happy to perform their job efficiently
and effectively for the safety of their patients.
Competing interests:
None declared
Competing interests: No competing interests
Hurrah for Peter Mahaffey's rapid response. It is high time that the
idea of a 48 hour working week for doctors was debunked. In what other
profession is a 48 hour week observed?
My point is that the Postgraduate
Medical Education Training Board's conclusion that errors due to fatigue
were more frequent where the 48 hour week was not observed does not answer
the question whether the 48 hour week reduces errors over all. Naturally
if there are errors due to fatigue these are more likely to occur where
longer hours are worked. In my experience, though, most serious errors
committed by trainees as well as consultants and GPs result not from
fatigue but from lack of relevant experience. The EWTD is not going to
help from this point of view and from the point of view of science a study
needs to be done of the number of serious errors occurring in those units
complying with the EWTD (if there are any) compared with those occurring
in units where longer hours are worked.
It seems to me that both the previous commentators make a case for
abandoning the EWTD. In the second case because there simply aren't
enough doctors to go round, especially during periods of leave.
Competing interests:
None declared
Competing interests: No competing interests
So the RCS says that a dramatic reduction in the training hours of
young surgeons has reduced the quality of outcomes for patients, and the
"now extinct PMETB" said the opposite. Both were based on responses to
surveys, a method of research hardly likely to fulfil Cochrane criteria.
Does it really matter, because isn't it plain common sense that to reduce
training time by as much as 50% (I often did over 80 hrs a week when
training and it did neither me nor my patients any harm) will produce
vastly less experienced surgeons?
What is saddest of all is the grim determination with which the BMA,
which has spent years whinging on about poor tired little doctors,
continues to cling to the hoary old tale that hard work hurts (mainly
articulated by the voices of activists from the 'soft' specialities such
as laboratory or psychiatric medicine,). They have a big problem now that
this RCS report has got them backed into a corner, because if they were to
concede that surgical training really has been damaged then they're the
most culpable players and it'll take a skill greater than Houdini's to
wriggle out of the blame.
But what is most laughable, if there's any humour at all to be found
in this debacle, is the news that the RCS and the Health Secretary feel
its necessary to opt out of the EWTD to put things right. Not a single
surgical training scheme anywhere on the Continent shows an iota of
respect for the nonsense that comes out of Brussels. They just get on with
their work and takes the rules with a pinch of salt. Why is it that in
Britain we have this self-righteous compulsion to adhere slavishly to
rules & regulations? We made the lives of our greengrocers hell by
forcing them to ditch pounds and ounces and now we're intent on destroying
our surgical profession. For goodness sake, cant we just play the same
game that's played all over Europe? And mightn't the BMA just have the
courage to recognise its mistake and support us on this?
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor,
Regarding the article relating to patient safety , surgical training
and the 48 hour working week.
I am currently a core surgical trainee based in the UK and I would
have to strongly disagree with the claim that the 48 hour week is the
cause of both poor surgical training and a deterioration in patient
safety. From the experience I have gained during my various surgical
rotations what is apparent in certain trusts is a lack of organisation and
team spirit.
When the 48 hour working week was introduced more posts should have been
created to cover for the gaps caused by doctors reduced working hours,
unfortunately this has not been the case. In certain posts that I have
worked in night shifts are no longer undertaken by junior doctors. This
has meant that at the end of the day shift there is no corresponding
junior doctor to hand over to. Instead the registrar has been left to
carry on alone. Clearly this is not right nor is it safe. Other trusts
have chosen to combine specialities at night, so a junior doctor may cover
the night shift for orthopaedics, plastic surgery, urology, maxilliofacial
and ENT, stranger combinations are known to exist. Again this does not
seem to be appropriate especially in large tertiary centres.
I also note in the article that inadequate handovers were mentioned as a
source of potential lapses in patient safety. There can be no doubt that
handovers are vital, more so now with the 48 hour week due to shift
patterns. However, the vast majority of surgical rotations that I have
undertaken have had no formal structure for handovers and a serious lack
of consultant presence. This is both detrimental to patient safety and
training. Interestingly those trust where hand overs were poor, consultant
presence was poor and training was poor as many trainees were unable to
pass their ARCPs when placed in these trusts.
The trusts that I have worked in where both clinical practice and training
were of a high standard were those who had formal structured handovers
with consultant presence and used specialist nurse practitioners to
support the gaps in the rota caused by a 48 hour week.
I think the 48 hour week can work as long as gaps created in the rota are
filled by appropriate personnel and as long as our consultants also spend
48 hours a week in hospital teaching, training and practicing medicine.
Competing interests:
None declared
Competing interests: No competing interests
Shorter shifts and more frequent handover a result of EWTD
Dear Editor,
Despite EWTD and the 48 hour working week hospital trusts are
required to provide 24 hour acute patient care. This has resulted in a
larger number of junior doctors working more frequent, albeit shorter on-
call shifts with an increased number of handovers between shifts. Such
systems reduce continuity of patient care and increases the risk of
adverse incidents.
A local study we performed investigating the frequency and quality of
handover of 'out of hours' urology admissions over a 2 month period in
2009 demonstrated alarming results. Only 27% of admissions were
adequately handed over the following morning and as a result patients were
missed on ward rounds delaying appropriate treatment and investigation.
Although there were no critical incidents resulting in long term
harm, several 'near misses' occurred. The current reduction in working
hours and shift patterns must end in order to prevent serious consequences
to patient care.
Competing interests:
None declared
Competing interests: No competing interests