Thursday, 23 September 2010

Long hours? Or a long time training?

I’m not a fan of too much work. Over the years, I’ve done my fair share of long shifts, nights, weekends, public holidays, and combinations of all the above.

I don’t function well when I’m tired and hungry and thirsty. And most patients don’t want to be seen by an overworked, sluggish, grumpy doc whose priority is a bed and some food. Certainly, I wouldn’t have wanted any member of my family to have depended on care from me after working 27 hours straight.

I always thought my colleagues agreed with me. Enough miserable faces on the corridors of the various hospitals I’ve worked in made me feel a collective yearning for better conditions.

I thought, therefore, that there would be widespread endorsement of the European Working Time Directive (EWTD) when it came into force in Ireland and the UK. The EWTD is designed to limit the working hours of doctors within the European Union. Depending on the stage of implementation, it can mean working a maximum of 48-56 hours per week.

Of course, here in Australia, they’ve managed to do that without relying on international law. Down under, the rules for doctors’ hours seem to be enforced on a regional basis. In fact, from what I can gather, the rules seem to be MADE locally too. But, by and large, it works. Sure, I’ve been miserable and tired and hungry working in Oz, but I’ve never had to work 72 hours on the trot, let alone do it on a regular basis, as happens in Ireland.

Forgetting for a moment that the Irish government has decided to simply ignore the EWTD, and continue to make their juniors work ridiculously long hours, I was amazed to learn that there are significant groups of doctors in the UK and Ireland who oppose the implementation of the EWTD.

These doctors argue that registrars, like me, and other junior staff, need to be exposed to lots of cases in order to become proficient consultants. They argue that patients come to harm at the hands of tired doctors, but also from inexperienced seniors.

I can see their point. However, I don’t buy it. I can’t accept that dangerously long hours are the only way, especially when urban Australia manages fine without total burnout of their medical staff. There has to be a middle ground.

My take on the long hours culture is as follows:

1) If we juniors want to reduce our hours then we have to expect it to take longer to become consultants. Everything in medicine is being streamlined these days, and that needs to stop. We need to return to 5/6 year medical degrees, and long apprenticeships as house officers and registrars.

2) A lot of doctors' time is taken up doing admin work that anybody could do (chasing xrays, filling out blood forms, chasing blood results on the computer etc). These tasks should become the work of someone else, so that doctors actually spend their time doctoring. I remember as an intern working out that about 60% of my tasks could be done by a competent member of admin staff.

3) Our training is important. But so are our lives outside medicine. I sympathise with the wannabe surgeon who wants to work all hours, learning how to do craniozygomatic surgery. But, there are those of us who have wives, girlfriends, kids, and a family life. I want to be a good consultant. But I doubt I’ll look back from my deathbed and say “I’m glad I worked so much”.

4) Patients need to do more. Relatives, friends, patients and strangers are almost always sympathetic towards me, regarding the plight of junior doctors. But how many have ever raised the issue with a canvassing politician? I don't expect the public to have our interests forefront in their mind at election time. But this is about patient safety, as much as it is about modern day slavery. As things stand, the politicos and the media often betray us as greedy and as a vested interest group, and very little of that gets refuted.

5) We have to be wiling to take industrial action. End of. I would be very reluctant to do so in oz, as my job is busy, but tolerable. But if a pregnant junior doc in Ireland who is working 48 hours solid, with no scheduled breaks, isn't entitled to strike, then who is. the media would love it. They would betray us as lecherous public servants trying to bleed the state dry. The media and politicians would distort the facts to make us look greedy. But screw them. I bet we could hold out longer being abused by tabloid readers then they could hold out with no doctors. Obviously, I would never advocate withdrawing acute services. But a work-to-rule or skeleton staffing would cause some browning of pants in the corridors of power.

The Australians do a good job of it (well, in the cities they do, their rural healthcare provision can be pretty piss poor). Ireland and the UK should learn from them. Mostly we’re rostered on for a 38 hour week. We do on-call and out of hours, of course. But those shifts tend to be interspersed with good weeks, where we can catch up with friends and family This is not the case in Ireland and the UK.

I know from experience that some Ozzies will post comments here telling me that they work terrible hours too. And of course that can be true. I once did a paeds emergency medicine job here where my partner was getting seriously worried about my health. I was literally exhausted all the time. I was grumpy, and never seemed to have any joy in my life. That’s not the way to live. And it’s not the frame of mind I want the doctor in when I bring my sick kid to see them.

I know everyone is an expert when it comes to public sector reform. Just look at the comments section of any newspaper article or blog on the issue. So I’ll keep my ideas about system change to myself. But Ireland, the UK and Australia need to wake up to this issue. More complex issues have been dealt with in the history of mankind.

All three countries have started the process of saturating us with medical school graduates. In Ireland and Australia especially, every man and his dog can become a doctor. Of course, there hasn’t been a sufficient expansion in the number of hospital training posts to cope with all these new graduates.

That will have the desired effect of making our young doctors accept crappy conditions, as it’s likely to be the only route to a scarce training post.

Perfect solution, if you’re an administrator or politician. Tough luck if you’re a doctor or patient.

Sadly, doing anything about it is a catch 22 situation. There are those who have tried. But what’s the most common response when you ask local juniors to engage on this issue, and stand up for their rights? Yep, you guessed it....”Sorry, I’m just too tired”.


  1. You might find this interesting:
    Dr James Hawkins is a doctor and psychotherapist - has done a lot of work on stress, impairment and doctors

  2. Yay! Doc Thunder. Excellent post!

    You've made more sense here than any of those highly expensive 'expert' consultant reports commissioned by the HSE, to advise them on how to run (or perhaps that should be 'ruin') our hospitals in Ireland.

    From now on, I shall take great pleasure as a patient, in putting across your point of view to anyone who's willing to listen :)

  3. Agree with everything you said. I work in the US - did a medical scheme in Ireland, decided not to put myself through the misery of an SpR scheme (relocating every year for 5 years? no way in hell) and headed to the States. Got an internal medicine residency in a university program and now doing a fellowship in the same hospital. Yes, I worked hard, but the limit is an 80 hour work week - sounds awful and on some rotations like ICU it can be tough, but all that admin and menial work (blood draws, chasing results) is DONE BY SOMEONE ELSE and we got more lectures and teaching in a day than I got in a week at home.

    You get elective months where you work 8-5 and have weekends off, and the longest shift you are allowed to work by law is 30 hours. If your program consistently violates the 80 hour work week, they get reported to the ACGME (Accreditation Council for Graduate Medical Education) and they are inspected - programs can and do lose their accreditation if they force their residents to go over 80 hours and everyone from the director down was aware of that. You have to fill out regular anonymous surveys on your program where you can tell ACGME exactly what goes on in your hospital and if there are violations, people listen.

    Before I came over my perception was that the US was for people who wanted to be rock stars of medicine, the top 0.001%, work 140 hours a week, a pressure cooker - and it's not. You have to study, read, know your stuff, you are expected to hold yourself to a high standard, but I'll say this - I have met a fair few American residents, graduates of top US medical schools, who went through residency and graduated, who cannot hold a candle to SHOs and registrars I worked with in Ireland. Almost anyone I've met who trained in Ireland, and worked there for any period of time, has done very well over here - our bedside training is far superior and once you get used to the way it's done here you really shine.

    Best of all - a defined career path. Residency -> fellowship if you want -> attending. And there are plenty of jobs. The J1 visa is a hassle, no doubt, and you need to do your three years in an underserved area when you're finished training before you can have that dream job, but there are rural areas in the US where they will throw 400,000+ dollars per year at you if you go and work there. Admittedly primary care is what's most sought after but there are plenty of specialty jobs too, and you can be a hospitalist without doing a fellowship and work 1 week on, 1 week off. If you don't know what a hospitalist is but you're an SHO or registrar, who doesn't want to be a GP but loves hospital medicine without necessarily wanting to specialise, google it - it's very interesting.

    It may not work for everyone, and it has its drawbacks (leaving home, visa issues, insufferable Yanks and their political correctness) but it should seriously be considered. If you're a med student, intern or SHO, especially if you want to specialise or just don't see yourself as a GP, think about it.

  4. I really like your blog.. very nice colors & theme.