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
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Let us say an investigation is carried out in a primitive population, half of whom have radios and half have not. If the object is to determine which group is the better informed and if the result shows that the group without radios is better off, then simple reasoning will reject the findings as nonsense. If doctors working a 48-hour week are found to be as efficient and knowledgeable as doctors working, say a 56+ hour week, then we can also dismiss the findings as nonsense.
Competing interests: No competing interests
We read with interest the article regarding training in a forty-eight hour week (1). As Goddard outlines, there are growing concerns from trainees in craft-based specialties as to the impact on training and subsequent competence. This is particularly true for surgical training, which relies heavily on “hands-on” exposure, but is currently bearing the brunt of restricted hours (2)
The European Working Time Directive (EWTD) provides health and safety legislation to avoid fatigue. There is little debate over the adverse effects of this, especially in high-risk surgical practice (3). However, changes to shift work as a result of EWTD legislation has created greater periods of on-call commitments, dominated by routine service provision. This has resulted in decreased training time during working hours and contributed to job dissatisfaction, disruption in sleeping patterns and increased sickness rates amongst juniors (4). The resulting fragmentation of surgical teams has led to inefficiency and poor continuity of care for patients.
One size cannot fit all across the breadth of medicine, and the problems created by the EWTD are unfavorable for surgical trainees due to the inherent need to focus on supervised operative procedures and their sequelae. As Goddard, discusses, procedural outcomes are directly correlated with number of procedures performed, yet in a survey of over 1,500 trainees by the Association of Surgeons in Training (ASiT) and British Orthopaedic Trainee Association (BOTA), over two thirds reported a deterioration in their training following EWTD implementation (5). Surgeons are not alone on this issue, with over four fifths of surveyed Obstetric and Gynaecology trainees also reporting reduced training opportunities (6).
The issue of working hours is an international problem. Other European Union (EU) countries have similarly argued for protected training hours set aside from normal service commitments (7). Outside of the EU, surgeons in the United States have experienced fewer problems for training in reforming duty hours, but maintain a significantly higher restriction of 80-hour weeks (8).
Greater flexibility around working hours for UK surgical trainees will ensure more optimal training, by reducing the focus on rota-driven service work and increasing team-based continuity of care. This may be achieved by relaxation of SiMAP and Jaeger rulings, which stipulate regulations for on-call and compensatory rest. However, any changes made must be made with focus on training activities. Efforts should be directed to ensuring greater supervision and training rather than promoting rota fodder for service commitments.
References
1. Hartle A. Gibb S. Goddard A. Can doctors be trained in a 48 hour working week? BMJ 2014;349:g7323.
2. psos MORI. The impact of the implementation of the European Working Time Directive (EWTD): A qualitative research report prepared for the General Medical Council (GMC). London; 2011.
3. Fitzgerald JEF. Caesar BC. The European Working Time Directive: A practical review for surgical trainees. International Journal of Surgery 10:399-403.
4. Goddard A. Hodgson H. Newbery N. Impact of EWTD on patient: doctor ratios and working practices for junior doctors in England and Wales 2009. Clinical Medicine 2010; 10:330-5.
5. Simpson C. Cottam H. Fitzgerald JE. et al. The European working time directive has a negative impact on surgical training in the UK. The Surgeon 9:56-57.
6. Datta S. Chatterjee J. Roland D. et al. The European Working Time Directive: time to change? BMJ Careers 2014 Avilable at: http://careers.bmj.com/careers/advice/view-article.html?id=20004482 [Accessed: 15th December 2014].
7. Benes V. The European working time directive and the effects on training of surgical specialists (doctors in training): a position paper of the surgical disciplines of the countries of the EU. Acta Neurochir (Wien) 2006; 148:1227–33.
8. Rajaram R. Chung JW. Jones AT. et al. Association of the 2011 ACGME Resident Duty Hour Reform With General Surgery Patient Outcomes and With Resident Examination Performance JAMA. 2014;312:2374.
Competing interests: J Edward Fitzgerald is Past-President of the Association of Surgeons in Training (ASiT) and has previously provided media briefings and interviews on the EWTD and its effects on surgery. All authors are surgical trainees working under EWTD legislation.
The debate is interesting but it’s really about a non-question. To start from the beginning, we need to consider both training and education. Training fits people for today’s job, it will go out of date; education is for life and does not go out of date, educated people change themselves and, equally important, become change agents for those around them. Training enables people to follow a protocol, education enables them to know when not to follow a protocol. Training can be ‘delivered’ and sometimes ‘received’; education is something you can only do yourself, although it can certainly be facilitated or hampered by the environment.
Expertise comes from ‘deliberate practice’, lots of it. Some have said 10000 hours. It’s not enough to have the experience, there needs to be time to reflect on that experience. Reflection is personal but it can be aided by feedback by supervisors and colleagues but more importantly by feedback on the consequences of our actions with patients. There can be few encounters that are without educational potential. Every patient with a myocardial infarction is both the same and different from every other patient with myocardial infarction. The 101st (or 1001st) patient may require all the experience garnered from the earlier ones. This is education.
It follows that we cannot say someone is trained except in the narrow, but important, sense of technical competence. We cannot say that at some defined point a person becomes expert any more that we can say that they have become educated.
What are the implications? Debate about hours of training is largely sterile, education is a continuum. ‘Service load’ only becomes a problem when it prevents reflection, otherwise repeated experience promotes expertise. ‘Protected time for teaching’ (something on which I used to be keen) may be counterproductive as it isolates the learning from experience. The ability of doctors of all grades to follow up their patients over time is vital for developing and maintaining expertise. This has been lost in recent years and this is arguably far more damaging than any curtailment of hours. It is to be hoped that the initiative of the RCP, The Future Hospital may be able to address this.
Competing interests: No competing interests
As a consultant surgeon the answer is a resounding NO. Clearly some specialties can exist on minimal training but in Surgery it is dangerous to pursue a minimal training programme.ln order to see the progression of a clinical problem trainees need to observe the clinical progress of a patient .Knowing when not to intervene 'masterly inactivity' comes with clinical experience which cannot be obtained in a 48 hr week.A generation of drs with minimal experience is now a dangerous reality
Competing interests: No competing interests
Well, trainees cannot be trained in a 48 hour week, if they are doing nothing but service work for 48 hours. That seems unarguable. If you require your trainees to do service work for 48 hours, and you want to train them as well, then they have to work more than 48 hours. The price is that their ability to learn will fall, steeply, as they get more and more tired, and so will their ability to provide safe patient care.
The implication is that, if you are serious about patient safety, staff well-being, or even the European Working Time Directive, you *must* restructure your training. If you want to move away from a trainee delivered service, which is, to a fair extent, what you have, and even more, what we have in Ireland, then you have to restructure your staffing levels, and the roles of fully trained staff.
This can be done cleverly, or poorly. Largely, in the UK and Ireland, it seems to have been done rather poorly. However some specialties, including anaesthetics, amd my own former specialty, paediatrics, show that it can be done right.
You can look, carefully, at what doctors actually do and see are they the best, most effective, most economical staff to do it. Expanded roles for nursing staff, smarter use of ICT, and better use of administrative staff, can all help to make the transisiton to decent safe working lives for trainees much less painful. You have to want to change.
Regards,
Anthony Staines
PS The NCHD strike in Ireland in 1988 was aboout overitme rates (http://www.medicalindependent.ie/27327/the_ethics_of_taking_strike_actio...) . We wanted to make ourselves expensive, so that managers would have an incentive to make more effective use of our time. What happened instead was that our salaries rocketed, (as we were paid time and a half, instead of one-third time, for every hour of overtime), but our working hours did not fall. Never underestimate the willingness of mangers to find the easiest option for them :-)
Competing interests: No competing interests
Re: Can doctors be trained in a 48 hour working week?
Dear Editor
As Chairman of the Independent Working Time Regulations Taskforce which reported its findings to the Department of Health in March 2014, I was particularly interested in two articles related to the subject in the 13th December 2014 issue of the BMJ . The debate entitled “Can doctors be trained in a 48 hour working week?” was naturally polarised (pp 16-17). Whilst this may be considered attractive journalism it simplifies the argument. The findings of the Taskforce (which had representatives from all the key medical bodies including the BMA) recognised that in present circumstances one size does not fit all. Whereas the rigid application of EWTD with the need for a fixed shift system may be beneficial for some specialties, for others, particularly the procedurally based ones, it has proved deleterious both for patient care and training. True, it is possible to mitigate some of these deleterious effects by utilising better rota design and enhancing training opportunities but in our present NHS this cannot possibly solve all the problems. For this reason the Taskforce made certain recommendations designed to introduce greater flexibility into the system for those specialties that require it. One of these, which has attracted particular controversy, is to encourage greater use of the “opt out”. I was therefore intrigued to read Matthew Limb’s article which examined the Norwegian system (BMJ Careers section pages 4-5).
Norway remains outside the EU but nevertheless has had working time regulations in place for doctors since 1994 limiting hours to 45-46 hours per week for juniors and 46-47 on average for seniors. Norwegian employment law, however, allows opt outs where the workload is substantial and permitted by agreement. The Norwegian Medical Association has a national agreement with employers’ organisations that extends working time for doctors in all hospitals up to 60 hours. Limb also notes that “doctors frequently work more than scheduled, both registered and non-registered overtime”. The point is made that doctors in technical specialties work more than others often motivated by the need to develop their technical skills. This echoes the findings of our Taskforce.
More liberal use of the opt out was just one of the Taskforce’s six recommendations. We also urged that “more work should be undertaken to identify ‘service’ and ‘education’ elements in the work of doctors in training. This will include how the possibility of separate agreements may contribute to resolving some of the difficulties identified by this review”
Until it is accepted that in our NHS trainees in certain specialties require more “hands on” training and hence time on the job than in others and that flexibility in the application of EWTD is required, we are in serious danger of continuing to undermine what was once considered to be one of the finest post-graduate medical training systems in the world. No amount of time on simulators can replicate the real life clinical situation.
Our recommendations were submitted to the Department of Health nine months ago and despite being received favourably have yet to be acted upon. So, as we enter 2015, I urge those in a position to initiate the changes required to act with an urgency which has been absent for far too long.
Yours sincerely
Professor Sir Norman Williams
Chairman of The Independent Working Time Regulations Taskforce to The Department of Health, March 2014
Immediate Past President, The Royal College of Surgeons of England (2011-14)
Competing interests: No competing interests