Head To Head

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

European Working Time Directive: More harm than good for surgical trainees

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.


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.

16 December 2014
Stephen J Chapman
Academic Foundation Trainee
Aneel Bhangu (Clinical Lecturer in Colorectal Surgery, Academic Department of Surgery, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, UK); J Edward Fitzgerald (General Surgery Registrar, Department of General Surgery, Royal Free Hospital NHS Trust, Barnet Hospital Campus, High Barnet, EN5 3DJ, UK)
University of Leeds
Leeds, LS2 9JT, UK