The furore over doctors’ long working hours in Queensland reminds me of a recent conversation I had with a new intern who failed to take a half hour lunch break every day of the past fortnight.
The industrial award requires us to pay 150% until the break is taken. The young doctor felt she was so busy that a lunch break would be impossible. Our public hospitals are under such pressure at present that junior doctors feel unable to take time off even for lunch.
Twenty-five years ago, 36 or even 48 hour shifts for junior doctors were commonplace. The “House Officer” was literally that. They lived at the hospital, when not working they were sleeping. Recent industrial arrangements have insisted that the trainee doctors have at least one day off in eight, have eight hours off between shifts and cannot work more than 14 hour shifts.
While these arrangements are more humane, they have been introduced without any thoughts regarding the effects on training, handover or patient care.
Training of young surgeons requires close supervision of experienced surgeons. This largely takes place during elective operating lists, clinics and ward rounds during daylight hours.
Trainees value these interactions but the hospital also needs to be staff overnight and on weekends. Who wants to sacrifice valuable training time for after hours emergency calls?
These after hours calls are important but usually low volume and repetitive. Six months at such on-call usually adequately exposes most trainees to the needed cases.
Is it reasonable to extend training by years so a hospital can cover its emergency work at night and weekends?
The old system of 36-hour shifts provided two days of training in exchange for the night on call. Did patients suffer? Apart from occasional anecdotes, little evidence exists that any patient suffered.
In fact, with shift work care it may be that patients are worse off. With a loss of continuity of the patient, changes in condition may be missed. It is difficult to accurately transmit deteriorating clinical condition from one doctor to the next. Systems of reliable handover have lagged within the Australian healthcare system.
Hospitals are reluctant to fund additional time for careful handover to occur. Even if it does occur, little agreement exists on what it should include.
Traditionally, an individual doctor took responsibility for the patient they admitted to hospital. Now this responsibility is diffused over a number of individuals with the ultimate responsibility unclear.
It is interesting to note that while trainees in the public hospital system are provided with controlled hours and mandated rest periods, no such requirements are afforded to the consultant staff in either the public or private system.
The evidence is still not present on the effect on surgical performance of 36 hours continuous duty.
If one goes out into rural Australia many GPs and surgeons are on call without break weeks or months at a time.
It is hard to predict how much longer we can expect such dedication from these members of our medical workforce, particularly when the new trainees as they graduate will be used to a completely different rostering structure.
Guy Maddern is professor of surgery at the University of Adelaide. St Anywhere is fictitious, but the events and issues are real.
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