Wednesday, December 11, 2013

UK doctors' work hours limits are a fraud

The other day someone tweeted a link to a story that was headlined "NHS junior doctors have little time to eat or sleep." The article—from the Herald in Edinburgh, Scotland—told of a manual from the NHS (National Health Service) that advised trainees to keep water and a food bar handy because they would rarely have a chance to eat.

The manual, which also told the junior docs to "be prepared for dehydration and hunger," is no longer posted on the Internet.

A man whose daughter, a junior doctor, was killed in an auto accident on her way home from the hospital blamed it on the fact that she had worked a long shift. For the record, she had worked a 12-hour shift overnight.

Of junior doctors, he said, "They are under intense pressure, they are working excessive hours, they are getting no respite."

I retweeted the link to the story with a question wondering how it could be that conditions are so bad in the UK. After all, I thought the European Working Time Directive (EWTD) stated that trainees in the European Union could only work 48 hours per week.

A flood of tweets in response soon explained the true situation to me. I was amazed, and you will be too.

It seems that the so-called 48-hour work week is a sham. Trainees can work only 48 hours per week, but it's averaged over 6 months—6 months!

What hospitals apparently do is work the junior docs like dogs and then give them a week off so that the average is 48 hours.

Here are quotes from some of the UK physicians:

That's the key; as long as they give you a week off and the average is ok, all bets off
What the working rules are & what occurs (& are paid for) are 2 very different things.
In my case, was asked to do the 36 hr shift by hospital manager and consultant.
Upcoming survey results from Association of Surgeons in Training show majority [of trainees] come in on their time off.
Shorter shifts with no more doctors means more shifts. Gaps in rotations mean longer shifts
It's not much different to how it was before, just lower pay now!

The Herald piece also said that a survey of 4913 junior doctors in Scotland … "found almost 20% were short of sleep because of their shift patterns and more than half worked beyond their rostered hours daily or weekly [emphasis mine]. Some 40% described the intensity of work as heavy or very heavy." In an editorial, the Herald said, "In practice, the [EWTD] directive is being broken every day in hospitals across the country."

The understatement of the millennium was made by the chairman of the Scottish Junior Doctors Committee, who said, "Although all the rotas [rotations] are compliant with the European Working Time Directive they are not necessarily in the spirit of what the law intended." No kidding?

He also said that junior doctors could be scheduled to work up to 12 days in a row without breaks and confirmed that they sometimes "struggle" to find time to eat.

Some of those who responded to my tweet said they would much rather work a scheduled 24 hours in a row than the life-disrupting shift work that the "48-hour" week has resulted in.

What is my point?

We have all been led to believe that all is well with the 48-hour work week in Europe—clearly not so.

And let's just keep ratcheting down the hours here in the US so we can achieve the same nirvana enjoyed by the trainees over there.

As always, I welcome your comments.


@CLakos said...

Isn't this what's supposed to happen when you set a 48h(or 80h)-week limit without addressing the workload and reduced training hours.

Skeptical Scalpel said...

CLakos, I couldn't agree more with you and the person who tweeted "Shorter shifts with no more doctors means more shifts. Gaps in rotations mean longer shifts."

The same thing is already happening here, There are fewer doctors so the residents must work twice as hard when they are on duty. Here's something I posted on the subject back in May.

Anonymous said...

Being a physician is hard, especially at the beggining. The bulk of knowledge is tremendous, besides the need for practice experience. There are previous posts in this blog stating that people should know where they are getting in (mentioning attrition rates).
I feel sorry for the deceased daughter, but I don't think work hours are to blame ("it's always someone else's fault").
Heavy work hour sucks, but being a bad doctor sucks more.

Skeptical Scalpel said...

Anon, I agree with you that the hours may not have been the problem. It was only a 12-hour shift although it was during the night. Someone has to work that shift. The hospital can't close down just because it's night.

Loïc Martin-Rouillard said...

1. Congratulations for the article
2. The girl who died might be sleep-deprived, and you might be aware that sleep deprivation is a long-term process and you should look around, the weeks before, what she went through...
3. The situation in Quebec, Canada, has become better and better since we have a limitation in working hours. We tend to group together the awkward shifts (one week of night shifts). I can take an example to show how a day is scheduled : a resident works from 8-5 pm; he or another one has a duty this night 5-10 pm and the night shift begins at 10 and finishes at 8 pm on the next morning, being done by a. a person who has a week of night shifts or b. someone who was sent home at 2 pm that day to sleep and come back at 10 pm for the night shift, having a day off on the next day.

Tell me what you think about it.

Skeptical Scalpel said...

Loic, thank you for commenting. I believe the sleep deprivation literature says that one week is not nearly enough time to acclimate to working a night shift. As I recall, it takes at least 3 weeks. From my days as a residency program directory, I can tell you that my residents were ready to mutiny when I tried having them work a month of nights.

If you are happy with your system, that's great. But I don't think it's any better than working 30 hours of call at a time every 4 days as far as the wake/sleep cycle is concerned.

bigjimricotta said...

I agree that it takes weeks to acclimate to different shifts. Before I entered medical school(1977), I actually worked in a factory which my brother in law(a metallurgist) got be the job.I graduated college one semester early so I had 9 months time to work there. I worked at a press machine which compressed tungsten carbide powder into tool bits that would be taken to an oven etc. I started at the 8 am to 4 pm shift and that was no problem, then they rotated me to the 4pm to midnight shift and that was not bad. However, when I went to the midnight to 8 am shift I could not get used to it. I even had to sneak a few winks in the locker room. One of the old timers there showed me how to speed up the press machine so I could make the same number of pieces in less time. You can not do that in surgery. I think the 30 hour shift had it's problems but is better than this bogus system now in place. Perhaps having a PA to cover even a couple of hours would make a difference. I was a believer that even one hour of sleep was better than staying up the whole night without sleep. But, as usual, when the government etc gets involved we get all of these unintended consequences.

Skeptical Scalpel said...

bigjim, interesting comments and supportive of the idea that a midnight shift takes a lot of time to get used to.

By the way, the other problem with a midnight shift in medicine or surgery is that very little teaching takes place on that shift.

Anonymous said...

If residents can't handle a night shift, how do nurses and resp.therapists do it? Why would giving care to PA's be any better if they are also subjected to the same shift hours?

Anonymous said...

This is from a few years ago.

A good surgeon, fresh out of training, ideals still burning bright, had a brutal night on call. Next day, he told his first elective case - a lap Nissen - that he had been up all night and asked if the patient want to reschedule the surgery some weeks later.

The patient opted for later surgery. The surgeon got flack from the anesthesiologists, the hospital admin, and his senior partners. He never did it again.

Doing the right thing may hurt you.

bigjimricotta said...

In response to anonymous about how nurses and resp therapists do it.

They probably have the same issue and would make the same mistakes if their shift hours are being changed frequently. It comes down to money regarding hiring PA's to provide some coverage. If a hospital can pay their CEO $1.6 million, then they could hire a couple more PA's to help out. Also, how much "scut" work are residents doing at 1 am that could be done by someone else. I remember starting IV's and drawing blood at 2 am when I was an intern. Also, surgery residents are frequently changing rotations--ICU,trauma, burn, ped surg,general surg etc. A nurse or respiratory tech does not make these changes as frequently. So if you work the "graveyard shift" as a nurse or resp tech you could get used to it after a month or more. I would not feel comfortable with respiratory techs changing their shifts frequently either. Airline pilots, surgeons, nurses, respiratory techs---we are all human----It is really "jet lag" when you change shifts. But it is worse--because when the resident is off for the day or weekend, they go back to their normal time schedule. This makes it hard to get use to the graveyard shift if you just do it for a month.

Skeptical Scalpel said...

bigjim, good answer to the anon question about how others do it on nights. There are papers documenting the amount of scut and clerical work that residents do when they are on call.

Other anon, that's a good story about canceling a case when you are tired. Maybe someday that will be accepted, but I agree that right now it would be received the way your example was.

Anonymous said...

A few years ago, there was a study which reported that the kidney function (GFR) in ICU residents was worse than in their ICU patients, presumably from dehydration.

I think the study was tongue-in-cheek, since the 20-something residents just need to quaff down a few cans of RedBull and (prob.) won't have lasting kidney damage. But, still.

Skeptical Scalpel said...

I'd love to see a link to that study. I have to say that I as a bit puzzled that people are so busy that they don't have time to even drink water. Perhaps they have time management issues or simply have trouble prioritizing.

Anonymous said...

I wish I could find that study; a bit of Googling didn't do it.

I heard about it a couple of years ago at a review course for hospitalists. (I am not a hospitalist but I find it educational every now and again to attend CME's outside my specialty.) This course was given by a well-known institution.

Near the end of course, the director presented his list of what he considered the most interesting published papers in the past year. (This was a crowd pleaser, interesting, and wish it was done more in review courses.)

The ICU resident renal function study was one of the annual papers. My recollection is that some of the residents were not just dry; they were in renal failure.

Sorry I can't pulled up the study.

I don't think that it is just time constraints. Thinking back to my residency days, perhaps it's the stress and pressure that overcomes thirst, hunger, and common-sense.

Skeptical Scalpel said...

Thank you for trying to find it. After I thought about this, I can recall a few times when I realized at 8 pm that I hadn't had anything to eat or drink all day. Your last paragraph is correct.

Anonymous said...

Wait, but if we don't have useless minutia to test for then how will med students get a 240 on Step 1 to get that coveted dermatology residency? Testing for minutiae is a great jobs program and has several advantages: PhDs maintain employment both at the undergrad and med school level, failing out students who don't have supercomputer like memory (but still getting to keep their money) and rewarding students with great rote memory ability but can't even tie their own shoe laces impress their families with all their new found medical knowledge and thus justifying the RIDICULOUS level of tuition that their parents are happy to fork over.

Skeptical Scalpel said...

Anon, I think you meant this comment for a different post--this one

It is damn near impossible to flunk out of med school these days. In fact, it is very hard not to get an grade of honors

I agree the tuition is very high.

Anonymous said...

As a Glaswegian could I point out that the herald used to be called the Glasgow Herald and it is a west of scotland, Glasgow based paper and not from Edinburgh

Skeptical Scalpel said...

Thanks for the correction. My excuse is that if you click on the link to the article in the post, you will note that the temperature listed near the masthead is that of Edinburgh, not Glasgow. That led me to assume that the Herald was based in Edinburgh.

Anonymous said...

In Spain we have it even worse. In theory there are labor laws regulating the work hours, but in practice they're ignored on a routine basis (in many places they don't even respect the post-shift rest time). The EWTD applies as well, in theory, but in practice it gets even MORE ignored. 24 hour-shifts are common. In many places the mandatory leave after 24 hours of continuous duty is not respected. And the 48 hour limit of the workweek is ignored pretty much everywhere, with no compensation of any sort (I did some math once and I think our workweeks are averaging at 60 to 70 hours).

Goes without saying that all this happens with the usual justifications that every resident in every country in the world usually hears: they're working you to exahustion "for your own good". Yeah, sure :rolleyes:

I wasn't able to fight off the 70 hour workweek at my place, but I successfully lobbied in favor of the leave after a 24 hour shift. I wish you the best of luck in your endeavours.


An anonymous resident physician from Spain

Skeptical Scalpel said...

Anon, thanks for the information about how things are in Spain. I'm beginning to think the European work hours are a bigger sham than ours.

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