Friday, November 28, 2014

Work hours limits in Sweden: It's complicated

A physician in training from Sweden emailed me some questions, and the topic of work hours came up. To protect his identity, I have slightly altered a some of his responses, but I have not altered his message.

It´s quite interesting as physician work hours, or rather productivity, are debated a lot in Sweden right now.

The work hour restriction
[50 hours/week in Sweden] is not enforced at all. This summer I was working as a junior house officer in a surgical specialty at a county hospital, and I can´t say I noticed anyone trying to cap my work hours, on my first day I was encouraged to work as much as I could.

On the other hand I was not put on the on call schedule, as that involved covering the ED (outside of academia EM-physicians are scarce) and all surgical services. It is hard to get to work 50 hours a week covering only a 12-bed service, when the nurses do all the blood tests (except blood gases), urinary catheters, do all patient transporting, and such. I did get some OR time though.

I think there is no enforcement of the 50 hours/week restriction because doctors here don´t get paid as fee-for-service. There is zero difference if you do 5 or 10 cases during your shift. There is no incentive to work more than 50 hours/week, and doctors don´t.

A problem that is more particular for surgery is the limited capacity of operating theaters, in many hospitals productivity is low, case turnover time is long, and you can only do elective cases between 8:30-16:00 (and God forbid you operate past 16:00). In the hospital I worked, we were not allowed to start elective cases after 14:30, and we only had 2.5 days/week when we could operate.

If you want to make money, you take a leave, go to Norway, work 80-100 hours/week in some rural hospital there for a few months, and earn three times as much.
[I was also told about this by some Swedish surgical residents I met while attending a conference there last year.]

We do a lot of administration. A study published in a Swedish medical journal, in Swedish sadly, found that Swedish surgical residents spend 40% of their time on administration and 40% of their time taking care of patients. Their British counterparts did 15% admin and 66% patient care. An average work day was 8.2 hours in Sweden and 12.2 hours in England.

Because of this, few physician hours are "productive" and Swedish doctors see very few patients compared to most Organization for Economic Co-operation and Development (OECD) countries. Queues build up and the hospitals don´t want that. So I guess they want us to work.

There was however a government crackdown on a rural hospital in northern Sweden where the county (which is the governmental body running hospitals in Sweden) was fined for imposing too long work hours. So there may be change, but rural northern hospitals are not in an ideal position to recruit more doctors.

Right now work hours are restricted formally but in practice it is hard to get that amount of meaningful work done. It has some perks however, as residents can pick up their children from day care.
[Emphasis added]

Is this where we are heading in the United States?


Anonymous said...

Hello from Bosnia and Herzegovina. From country that is in transition process I need to ask to whom we need to look at? My working hours are in average 65-70 hours weekly, we don't have a lot of administration. I think if you want to be good surgeon you need to work a lot, but when looking to American or Europe surgeon there is a lot of differences... So what is good model to become good surgeon but also where is a line... or to quote my boss "the most important thing for surgeon is himself".... Please what is your opinion?

Mark said...

Yes that is where I, as a non-physician, think we are headed.

Skeptical Scalpel said...

Azur, sorry for the delay in responding. I'm not sure how to answer your question. Several studies have shown that at least 25% of graduating US surgery residents do not feel confident to operate after 5 years of training. Where is the line? i don't know.

Mark, Could be. Good luck finding a doctor after 5 pm.

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