Working Directive 'Harming' Doctor Training

Restrictions on the working hours of doctors may be compromising surgical education and patient care, warn two senior US surgeons in an article published on bmj.com today.

Gretchen Purcell Jackson and John Tarpley argue that greater flexibility is needed in applying these regulations.

Not all countries regulate working hours, but in those that do, the maximum hours per week for a doctor in training can range from as little as 37 hours in Denmark to 80 hours in the United States.

The European Working Time Directive (EWTD) decreased the weekly hours for all trainee doctors in Europe to 48 from August 2009.

But do these restrictions provide enough time to train a competent surgeon, ask the authors?

Since working hours were limited, some research has shown worrisome changes in the nature of surgical experiences. For example, one study found a 40% reduction in technically advanced procedures with a compensatory 44% increase in basic procedures done by fourth and fifth year residents.

Studies on the effects of restricting hours on patient safety also show alarming negative trends. At one US trauma centre, complication rates significantly increased and missed injuries doubled after adoption of the 80 hour working week, while research from Germany showed increases in length of stay, complication rates, re-interventions, and readmissions after legislation reduced daily shifts from 12 to 8 hours in 1996.

Strict legislation also poses challenges for staffing and creates ethical dilemmas for trainees, say the authors.

One survey showed that a majority of residents from medical, surgical, and paediatric specialties exceeded their working hours, usually because of concerns about patient care, and nearly half admitted to lying about their hours.

The authors estimate that about 15,000 to 20,000 hours are required to master both the cognitive and manual skills of surgery.

As such, they recommend flexibility, discretion, and common sense for regulations of shift lengths and periods of rest to allow enough time for residents to be exposed to an adequate breadth of cases throughout their training.

"If enough hands-on patient care as well as operative experience cannot be achieved during a restricted working week, surgical training should be extended," they suggest.

"Patient care and physician integrity are the founding principles of surgical training; regulations on duty hours must not be constructed in a way that compromises them," they concluded.

In an accompanying editorial, Professor Roy Pounder from the University of London argues that solutions are possible within the current system.

He rejects the argument that 80 hours a week is insufficient for surgical trainees to gain the necessary experience, and points to evidence showing that patients do not want a familiar but exhausted person operating on them.

The old ways of training, time serving apprenticeships, and inflexible (essentially continuous) work are over.

Instead, 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," he concluded.

(BMcC/KMcA)