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JFA Murphy
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Ir Med J. 2013 Feb;106(2):36
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There has been a recent resurgence in the debate about NCHD hours. The argument has waxed and waned over many years and decades. There have been working party reports, pilot schemes and repeated interaction between the IMO and the employers. The hours worked by NCHDs in acute specialties remain stubbornly high. While the maximum shift should be 24 hours many NCHDs have to undertake 36 hour stretches of in-hospital duty. Registrars working in tight rotas in smaller hospitals report working over weekends from Sat 9am to Mon 5pm. They do it because they have to but they dislike it. Long hours blunt their professional, social and private lives. Overtime payments do not compensate for the excessive hours spent at work. When asked whether they prefer shorter hours or overtime pay, the universal answer is shorter hours. These issues appear to be more acutely felt by female doctors. In this issue a paper on women in hospital medicine1 concluded with following statement, ‘what is most striking is the overwhelming regrets some of the mothers expressed at the sacrifices they had made in relation to their children in order to achieve their career goals’.
One of the major issues is that hospitals and their medical staff complements are not a homogenous group. Hospitals are unable to be EWTD compliant because they do not have sufficient medical staff to cover their rosters. Another major obstacle is that the inadequate consultant numbers make the service provision excessively dependant on NCHDs. A third issue is that innovative ways of reducing the work burden on NCHDs have not been widely implemented. Many of the daily duties such as IV cannulas, bloods for investigations, common medication prescribing could equally well be undertaken by nurses and other trained technicians. Better information technology would greatly reduce the current fragmented and repetitive way that medical notes and reports are documented and communicated. The NCHDs are frequently the stop-gap solution for failures in acute hospital service organisation and management.
The embargo on numbers within the health service means that additional NCHDs can’t be employed. Similarly additional nurses, allied health professionals and paramedical staff can’t be taken on to support the hospital doctors. There is an impasse and nobody appears to have a constructive plan on how to move to move things along. The drift continues from one generation of doctors to the next. The date for the implementation of a 48 hour week for NCHDs has long since come and gone. A common eventuality is that trainee doctors leave the country and continue their training in another health service overseas. The exit of experienced middle grade medical staff from the care of patients in Irish hospitals is a significant loss. NCHD staff retention is a good surrogate marker of how a health service is organised and administered. Poor retention is a worry. Consultants in many hospitals throughout the country describe the recurring ‘July nightmare’ when they strive to fill their NCHD posts with sufficient and adequately qualified doctors. On the other hand the GP training schemes are extremely popular and over-subscribed.
The 40 hour week has become the standard for most workers. It is strange that there has been such resistance to applying something similar to doctors’ hours. Being tired is something that everybody understands. It is widely accepted across all strands of society that long, excessive hours lead to fatigue. One shouldn’t need complex protracted studies to prove it. It is self-evident.
Fatigue in turn affects concentration levels, problem solving skills, numerical calculations and the quality of the patient-professional interaction. Lockley et al2 reported that interns working long hours had higher rates of attention failure with slow rolling eye movements documented on EEG recordings. It has been demonstrated that doctors whose work does not exceed 16 hours make fewer serious errors. Critics of the study point out that the excess errors did not impact on the total rates of downstream adverse events.
In the US the previous long hours worked by medical residents is changing. Initially a trickle, it is now happening more quickly. Rosenbaum and Lamas3 describe that significant changes were introduced following the Libby Zion medical mishap in New York in 1984. In 1987 the New York State Bell Commission recommended an 80 hour per week working limit with no more than 24 hours consecutive hours on duty. The Accreditation Council for Graduate Medical Education (ACGME) adopted this as a national standard in 1990. Further significant restrictions were put in place in 2010. The ACGME revised the rules. Intern shifts were not to exceed 16 hours but second postgraduate year doctors can work up to 24 hours. The directive stresses the importance of ‘strategic napping’ and implementation of ‘alertness management strategies’. A nap for as little as 20 minutes can be beneficial. There are some concerns about naps in the middle of a duty period. There can be sleepiness and decreased performance immediately after waking up from a nap and must be built into the strategy. The sleep inertia effect can last from a couple of minutes to half an hour4. The quality and length of the rest prior to starting an on-call duty must also be considered.
Those with reservations about reducing NCHD hours raise issues about training, the doctor-patient relationship and continuity of care. The question is whether these are valid arguments or whether they simply represent obstacles. Most trainers will agree however that fatigued NCHDs doing aimless, repetitive tasks are learning very little. Postgraduate training programmes recognise that optimal training consists of high quality clinical teaching, case scenarios, data interpretation and a balanced amount of service duties. Trainees are fully aware of this and they will continue to travel to centres that provide it.
It is time for the Irish healthcare system to face the problem of excessive hours for NCHDs. Solutions are available as long as there is the necessary administrative and political will. It would be a reasonable start to follow some of the US directive, such as a limit of 24 hours for NCHDs. One continuous day and night on call should be the absolute maximum that any doctor should have to work. The other US directive of only 16 hours per shift for interns would be problematic in Ireland because of insufficient staff.
Long hours are not good for either patients or doctors. It is not in a patient’s interest to be treated by a fatigued doctor with a reduced concentration span and decreased professional interaction. Furthermore the patient is at greater risk at being at the receiving end of an unintended error. The equipoise between good quality care and consecutive hours worked has not been conclusively demonstrated. However there must be a limit. That limit is certainly no more than 24 hours at any one stretch. Post on-call work must cease.
JFA Murphy
Editor
1. Meghen K, Sweeney C, Linehan C, O’Flynn S, Boylan G. Women in hospital medicine: facts, figures and personal experiences. Ir Med J 2013;106:39
2. Lockley SW, Cronin JW, Evans EE et al. Effect of reducing interns’ weekly work hours on sleep and attentional failures. N Engl J Med 2004;351:1829-37.
3. Rosenbaum L, Lamas D. Residents’ duty hours-towards an empirical narrative. N Engl J Med 2012;367:2044-9.
4. Purnell MT, Feyer AM, Herbison GP. The impact of a nap opportunity during the night shift on the performance and alertness of 12-h shift workers. J Sleep Research 2002;11:219-227.
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Author's Correspondence
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No Author Comments
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Acknowledgement
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No Acknowledgement
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Other References
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No Other References
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