In the linked analysis article ‘How long does it take to train a surgeon?’, Purcell Jackson and Tarpley describe their concern that surgical trainees in the United States might be forced to work within a maximum 80 hour week. Meanwhile, the European Working Time Directive (EWTD) demands that all trainee doctors in Europe work an average of only 48 hours a week, and the Royal College of Surgeons of England is appealing for all their trainees to be allowed a 65 hour average week.
Although Purcell Jackson and Tarpley’s concern that a maximum of 80 hours a week is insufficient for surgical trainees to gain the necessary experience, their argument that all surgical trainees need to be available all the time – for example, to observe rare procedures such as elective surgery on conjoined twins – overstates the case. How can we strike the right balance between gaining sufficient experience, ensuring safe working practices, and allowing doctors to have a life outside work?
The American College of Surgeons reflects Purcell Jackson and Tarpley’s position by also rejecting the 80 hour week; this implies that American surgeons believe that working with little rest is necessary for successful surgical training. However, evidence shows that patients do not want a familiar but exhausted person operating on them. Perhaps the next time a surgeon tries to obtain informed consent before a procedure they should tell the patient how much sleep they have had.
The EWTD was introduced in 1993 without a risk assessment (unlike more recent European directives), and its adverse effects on health care have been serious. Nor are we yet experiencing its full effect. The European Union has failed to publish its own 2008 survey of medical trainees’ compliance with a 56 hour week, but we know that many countries are not complying; the Greek government and Irish employers are already in court for non-compliance.
Meanwhile Britain’s shortage of doctors is being masked by moonlighting and allegedly fraudulent work returns as some juniors work many more than the requisite 48 hours per week. This is neither safe nor sustainable. Member states are realising that they cannot just ignore the regulations, so what is to be done? Revision of the EWTD may take years of negotiations, but solutions are needed now.
Creating greater flexibility around current working would be one possible solution, rather than the blanket 65 hours a week for all trainees being called for by the Royal College of Surgeons. The EWTD has two separate elements: the first is strict entitlement to an 11 hour rest period in every 24 hours, plus 24 or 48 hours off every week or fortnight, respectively; the second is the limitation of an employee’s work to an average 48 hours a week. Almost all the safety benefits for doctors and patients come from the entitlement to rest.
Although safety is one driver for reducing long hours, the limitation of working hours probably has as much to do with creating employment for European workers in general, which is not appropriate for health care in 2009 when we have too few doctors.
Could we not leave the rules about rest unchanged but exploit the existing flexibility around the number of working hours? This would not be easy – many disciplines require a seamless supply of doctors for 168 hours a week, and people increasingly expect to work fewer hours, to be able to work part time when their families need them, and to have a life outside work.
However, medical training is no longer a matter of serving time but of acquiring skills and will inevitably vary in length depending on the discipline and the balance of full and part time work during an individual’s career. So why can’t we develop and implement a flexible system of training and service provision in place of the present “one size fits all”?
The present working time regulations can already be applied flexibly. Every employee in the United Kingdom can choose to opt out of the 48 hour week to work up to 78 hours a week; junior doctors can decide to opt out and to return immediately to a 56 hour week, but they are limited by the New Deal – the junior doctors’ employment contract that, by enforcing an absolute 56 hour limit, is even more restrictive than the EWTD. In addition, they can also be non-resident on call for up to an average 72 hours a week.
Few surgical trainees in England or their consultants now operate at night. Hence, junior surgeons can be non-resident on call for up to 72 hours a week and can choose to work up to 56 hours a week – essentially what is demanded by the Royal College of Surgeons in
The old ways of training, time serving apprenticeships, and inflexible (essentially continuous) work are over. The training and service elements of each post need to be identified and considered separately, as do emergency and elective clinical work. Much effort needs to be invested into researching and improving continuity of care, because none of the workforce now works continuously – not even consultants.
The current system of rigid rotas is not ideal. In future, rotas must take account of part-time working, individual decisions about opting out of the working hours regulations, and the day to day measurement of hours of work when non-resident on call. The Department of Health must move from their single minded implementation of the 48 hour week, to the flexibility that can now be provided by sophisticated rostering, thereby helping to improve patient safety, service delivery, and medical training.
