Sunday, 31 August 2008

The Hours: (not the depressing film about Virginia Woolf, something different entirely. Still fairly depressing though...)

Posted by Dr. Jane Doe.

Out of hours. This phrase haunts my life. It’s in the papers, as in “GPs don’t provide out of hours cover properly due to golfing commitments”, or “Women doctors won’t work out of hours for fear of breaking nails” or “Out of hours access to such and such a service is shite” etc etc etc.
It’s not a phrase that is misunderstood very often though. Traditionally “out of hours” is taken to mean outside the hours of approx 9am to 5pm. Night work. Weekend work. That sort of thing. People have a fairly good understanding of what it means.

One phrase, however, that people outside medicine do NOT have any kind of understanding around is the phrase I think I hate more than any other phrase in the whole world. “On-Call”.

I didn’t really understand about “on-call” properly myself before I graduated and began working as a doctor. People often get really angry at me when I say this, for whatever reason. They say “Oh you expect us to believe you trained as a doctor without knowing about the working hours.” “You knew what you were getting into before you started so you can’t complain.” And of course, the single most oft trotted out “But you get paid overtime for those hours so you can’t say anything”.
You see, most lay people think that “on-call” is done from the end of a phone, from the comfort of your own home, or perhaps a nice doctors lounge. They think you get called once or twice a night, order some meds per phone, and generally sit around raking it in while doing nothing.

I don’t blame these people, because I didn’t understand about “on-call” before I DID it and I can see where they are coming from.

My very first day as an intern, we all drew straws to see who was doing the first night’s call. I and three other unfortunates ended up doing this. It was at this moment that I really understood that I had come to work at 8am, and would not go home that night, but stay in the hospital working. Not only that but I would be in the hospital starting a new days work at 8am the next day and would remain there until at least 5pm. 36 hours straight in the hospital, working, bleep on.
I felt sick, and most NCHDs will tell you that nauseous feeling of dread you get when you wake up the morning of a day you are rostered on a 36 hour shift, or “on-call” that night cannot be reproduced by any other set of circumstances.
It gets worse though. Oh, so much worse.

I also drew ANOTHER short straw, and that was to do the first weekend also. I asked the SHO what that entailed, and I still remember the shock I felt when I heard her reply.
“Oh”, she said, looking half regretful, half sympathetic. “It’s um, it’s not good here. They don’t split the weekends here. You come in Saturday morning and you go home Monday evening at 5pm”.

I felt the blood go from my face. “That can’t be right”, I said. “Don’t you even go home to sleep? That’s three days and two nights in a row!! Is that legal?”
She gave me a pitying but also amused look, “Probably not, but you can’t do anything about it if you’re a junior doctor.” She saw my face. “Look, at least you’ll get it out of the way, you won’t have another weekend for a while. And you’ll get double time on Sunday”.
I couldn’t have cared less if I got quintuple time on Sunday. And a foreign holiday thrown in. The first “on call” had been bad enough. I had slept for two hours from 4am to 6am, and gone on to work a full day the next day. I remember as I was getting dressed in the tiny hospital residence room saying to myself “I survived.” My eyes were burning all day long the next day. My muscles ached. I was constantly thirsty for some reason. I was emotionally labile-the slightest cross word (and in Irish hospitals junior docs will hear a lot of these) made me want to cry. And the fatigue made every single little job sound like an insurmountable hurdle.

The 56 hour weekends from Saturday to Monday are still happening in Irish hospitals all over the country. I can’t even describe how bad these are. You will have worked all week already, leaving work on Friday evening like everyone else. You then come in on Saturday morning (in some hospitals they make this Saturday at noon) and you pick up your cardiac arrest bleep and get to work. There are no scheduled meal breaks when one is “on-call. You eat when you can and you often have to leave your food to answer bleeps and attend to jobs. Even going to the bathroom is subject to when you can. You have no, I repeat, NO scheduled breaks.
You work all day Saturday doing whatever it is you do, if you’re an intern, doing scutwork and reviewing ward patients, if you’re an SHO, down in the A&E admitting or reviewing sicker patients on the wards, if you’re the registrar, also in A&E, or seeing consults on the wards, or reviewing the sickest people in the whole hospital and supervising the other two when you can. You work all night Saturday night and try to get to bed when/if you can. You may be lucky and get three or four hours total sleep, or you may get none, as is more often the case. You have a shower the next morning and get working again, and do the same all day Sunday, and all night Sunday night. At this stage you are incapable of safely driving a car. You are sick with fatigue. And here’s the killer-the next day, Monday, the start of a brand new week for everyone else-you have to do your day job EXACTLY the same as though you hadn’t just worked 48 hours straight with no sleep. No slip ups in performance will be tolerated. You’re so so slow to respond to anything or do anything at this stage that all your work takes you twice as long, and you usually get home later than you would on an average day.

So here’s where normal people say “Ah, sure at least you’ll have a day off now, yeah?”
WRONG. You’re back into work Tuesday morning, bright and early. You work all that week too. Making a twelve day week with a 56 hour weekend in the middle.

You see, the reason I didn’t really think this would happen before I started work as a doctor was that doctors are meant to be pretty smart people. It takes a lot of points in the Leaving Cert to get into medicine. It takes a lot of academic work and study to get your medical degree. It takes many post graduate exams and continuous courses and study afterwards to become a consultant. I couldn’t really fathom why these intelligent and motivated young people were all doing this. Within minutes given the total number of staff I could whip you out a rota where someone did a week of nights and had a few days off afterwards and spared everyone else this kind of horrific, dangerous and extremely stupid caper. In fact I did once or twice. But no-one will have any of it. And no-one will listen. Why?

A lot of people will say that it is better for “training” to work marathon shifts of 40-60 hours at one stretch. I will say this now-anything I have learned of any value that I remember was from a consultant or senior registrar during the DAY when they had time to teach me and I had any inclination to learn. The fact is that in Irish hospitals “on-call” you end up doing so much work that in any other developed Western country is performed by other staff (staff on shift work, not being paid overtime, which is CHEAPER, by the way) that you learn shag all. The antiquated idea that it “toughens you up” is illogical in the extreme. How? I’ve personally been forced to stay awake for 40 hours straight on average once or twice a week for a few years and all I got out of that was ill health and a vague feeling that I might have PTSD. I think it weakens people, if anything. It certainly makes them leave and go to the UK/Oz/NZ, that much I can attest to.

I wouldn’t want my relatives in the care of exhausted and suboptimally functioning junior doctors like these. I worry about a time, maybe years from now, maybe not so far away, when one of my parents or grandparents may need to be in hospital, and people in the depths of exhaustion, struggling just to live through their own extended shifts, are half heartedly treating them in the night where services are already at a minimum and any mistakes or problems tend to have much worse consequences then in daylight hours.

What’s so bad about doing a week of nights, people?

Here, down under, we still have what we think of as “on-call”. It is also known as “a long day”, from 08:00am to 23:00. You come in, do your days work, and then from 16:00 onwards you do whatever it is you are allocated to do until 22:30, where there is a scheduled supervised handover to the night team in a designated meeting room. Ah. Like a breath of fresh, common-sensical air. Better for training, patient care, and doctors wellbeing.

TRAINING:

Shift work is BETTER for training than the Irish way. Not worse. Here’s why:

In my experience here, from doing acute medical “on-call”, the registrar and SHO admit on average about 15-20 patients from 08:00-22:30.

In Ireland, this would be unthinkably busy. Maybe A&E put in an IV line, maybe they didn’t bother. 15-20 IV lines, making up all those first dose IV meds and giving them and signing for them, taking any repeat bloods that need taking, doing ECGs, resiting the IV lines as they invariably fall out, the hassle and hell trying to organize even one CT scan “out of hours” not to mind getting it read.

Here, IV lines and bloods that need to be done will be done by the IV technicians who come on at 16:30. So will repeat bloods. Just write in the notes what time. ECGs and first doses ALL done by nursing staff. Basically your job is what a doctor’s job is supposed to be. You admit the patients, take histories, examine them, diagnose them, order investigations and follow up as needed. And you see more cases by 23:00 than you would have seen in your 36 hours constantly awake back home. And you aren’t exhausted so you remember them. And you have time to do procedures, and back up if you fail at doing them. Everyone back home has been in the situation of trying to get a lumbar puncture at 4:30 am and calling the reg, who blearily and exhaustedly says “just keep trying”. If people aren’t exhausted, they will do better jobs. Not rocket science.

CONTINUITY OF CARE : As for continuity of care-that is another weak excuse for dangerous working hours and workloads. Unless the same doctor is on the premises 24-7, 365 days a year, there IS no continuity of care. In this day and age, with increasing complexity in medicine and increasing caseload, what is of paramount importance is continuity of information. Formal handovers at designated times and places, supervised by senior staff and co-ordinated by a team co-ordinator minimize anyone “falling through the cracks”. By the way-there are NO formal handovers that I know of for doctors in Ireland. Some may conduct their own informal ones if they are worried about someone.

Also-if your team are on acute medical take here, the patients remain under your team. You know the 15-20 you admitted. Maybe 9 more overnight, nights tend to be less busy. They will have been admitted and thoroughly assessed by a well rested doctor and all you really have to do is read the notes and go see the patient yourself. So what if you didn’t admit them, you can familiarize yourself with them fairly quickly, you are supposed to be able to do that with any patient if you are any kind of a doctor at all, and they will be your patient from now until discharge. Put a well organized summary in the notes for the night/weekend teams and continuity of information and hence preservation of good care are maintained.

In Ireland it is not usual for the registrar and the house officer of the same team to be “on call” on the same night for their own consultant. Some services in good hospitals do try to arrange it like that, but with differing numbers of every grade of staff and rotas made out by management, it is not usually the norm. Hence the pretence of continuity of care being preserved by extended shifts of 40 hours is farcical anyway. You’re on call admitting for a different consultant, and the reg from a different team is also on call for a consultant not their own. What’s so continuous about that?

Surgical services appear to be different, and need more exposure to time in theatre necessitating longer hours than most other services. However, they still go home and sleep for 7 or 8 hours here, and surgical outcomes appear to be just as good as at home.

One final point, (speaking of “hours”, it’s going to take anyone “hours” to read this longwinded post), I feel I must correct anyone who thinks that we should suck it up as it’s only for one or two years and then we’ll be registrars.
You see, a lot of people, I have discovered, think registrars are NOT junior doctors! Even some nurses think this.
Registrars are NCHDs, that is Non Consultant Hospital Doctors, same as SHOs, same as interns. They are required and forced to work the same hours and often more than SHOs or interns. It’s true, they’re not junior in the sense of the word, but their working conditions and entitlements are, and this is all the more shameful. Hence the years spent working dangerous extended shifts can be as long as ten or fifteen years.

I hope this has shed a little light on the antiquated reality of the archaic working practices of the junior medical workforce in a first world Western developed country. It’s embarrassing, frankly. Far from being tough, we are simply not adapting to suit the times and the needs of patients and doctors. And it needs to change.

9 comments:

  1. I vomited at 8am after my first night on call as an intern... and that was in one of the rare hopsitals in Ireland where nurses do an ECG for every chest pain they ring the intern about!

    Can't really add anything to another wonderful post. I wish the truly horrendoud nature of call in Irish hospitals was more widely exposed.

    ReplyDelete
  2. Jane

    I feel exhausted just reading about those horrendous hours. It's a ludicrous practice when you consider the dangers posed through exhaustion.

    It doesn't take much to work out that the most dangerous time for an acutely ill patient to present themselves at A&E for assessment, is late on a Sunday night when the junior docs have been on-call since Friday. I know I'd choose to remain at home overnight rather than submit myself to any unnecessary risks in the hands of exhausted docs.

    It's a crazy practice and it's time someone shouted stop!

    ReplyDelete
  3. What a brilliant post. I hope things are better here in England. We keep hearing about the working time directive but then who knows if this is being adhered to.

    Do you think you will ever go back to Ireland? It sounds like NZ have things much more sorted.

    ReplyDelete
  4. Things are a bit better in England, in terms of hours. But morale in the NHS is at rock bottom. It was one of the most miserbale environments you could work in when I was there up until a year ago.
    The working time directive just means you don't get paid for the extra hours you work

    Dr. Thunder

    ReplyDelete
  5. It's a crazy system - you don't realise just how crazy until you get out & leave it behind I think. When you're in it, the mentality can be that you're just doing the same hours as everyone else around you - no more, no less.

    I lost 3/4 of a stone in weight during my intern year. Don't think I ever worked anything less than a 1 in 5 rota and did a 1 in 3 pretty regularly. Even did a 1 in 2 twice (my max was 148 hours in one week) - in the end I changed career away from clinical work because I'd no time or energy left for anything outside the hospital. Do miss things about the job, but don't regret the move - I've a life now.

    A friend of mine went to train in Australia instead - I remember the rest of us could hardly believe it when she told us about "Duvet days" & "Stress days"!!!

    ReplyDelete
  6. Point and counter point.
    I suspect my views won't be overly popular, as I represent the dinosaur view of the 'older generation'. Working long hours definately has drawbacks, and in fact my weekends went from friday morning to monday eve, but I will never be that young again. I learned much of what I know on call, and in emergencies, having to just 'get on with it'. Bad for the patients? I never killed anyone, and my experience nowadays is that they get rested doc who don't know anything.
    Actually that's not fair; of course they know something, they just seem less able to cope. All the acute patients are seen by registrars; where's the acute exposure? In ten years all the regs will be seeing acute patients by themselves, for the first time. Is that improvement?
    Continuity? I was always on - barring leave or sickness - with my team, I knewall my patients, and when I was an SHO and not on, the house staff had my mobile if they were in doubt. My experience of the junior staff on nights now is very different.
    I remain unconvinced that shift work is better; plenty of evidence suggests that it is at least as psychologically damaging as long 'on call' hours.
    The way I worked was hard, but it taught me plenty of valuable lessons; were mistakes made? I'm sure they were; is the current system better. Better for work/life balance, but not for training. Maybe if we were a bit cleverer there'd be a happy medium.

    Slainte

    S

    ReplyDelete
  7. drshroom, you can argue all day about the merits of shift work versus the ridiculous long hours that we've all done.
    I personally think shift work works just as well as on-call. I think the only reason why a year 2 registrar may be less experienced now than a year 2 registrar 10 years ago is a simple issue of having worked less hours.
    BUT, the real issue to my mind, and many others I know....is that I don't want to work 72 hour shifts. It may give me better training. I don't think it does. but even if it does, I don't care. I turned 30 recently. I worked a 15 hour shift with no break the day before, and a 13 hour shift with no break on my birthday. I just went home to bed. I want a life. If it makes my clinical skills a little less sharp....I'm not that bothered to be honest.
    I'm a decent doctor. I'm a paediatric registrar in a large teriary centre, and I do a reasonable job. I have done 1-in-3 24 hour shifts, but learned feck all.
    People who are obsessed with becoming amazing doctors will always favour the crazy hours. but bear in mind that it's just a job at the end of the day.

    Dr. T

    ReplyDelete
  8. I'm of the opinion that it's not quite just a job in the same way that for, example, banking is; but I take the point; my PoV is becoming both unfashionable and unpopular; I feel the way i did was better, but that don't make it so... but someone has to do the hours; the less the juniors work, the more the seniors work. I would rather hav worked all the hours God sent when I was younger, and cut back a bit now. When I was on the house, our Regs were rarely out of bed - because we did all the work. And it seems to me that made me a ittle better prepared than the guys and gals I see doing the job now. Memory's a funny thing tho', so maybe I have a rose tinted view of what it was like, and a deliberately jaundiced view of things now.

    Either way, I enjoy the writing.

    Slainte

    S

    ReplyDelete
  9. I agree that Clinical medicine/surgery/whatever specialty is definately not just a job - it's a vocation and does require a higher level of commitment - but the hours are just too draining the way things are now. In my twenties, I didn't think about them so much TBH, it was what you did & everyone around you was the same, but once I hit my thirties, doing a 1 in 4 (very regularly down to a 1 in 3 to cover holidays) I was just exhausted... After I left & saw what a normal life, with evenings, nearly all weekends off etc. was like, I realised just HOW crazy it really had been. My family & friends (who hadn't seen me that often for the previous few years!) could hardly believe the change in me once I was out for a while - I'd a lot of comments about looking so much better & laughing more...

    ReplyDelete