The European Working Time Directive (EWTD) was due to be in full implementation from August 2009 limiting junior doctors to a 48-hour week averaged over a 6-month period. The reality of this is somewhat different from the legislation. In truth, the questions needed to be asked were – was it ever feasible? What was the training impact in a craft-based speciality going to be? Where are we now?
The detrimental effects to training in a reduced working environment has been documented in both hemispheres. Canter, in a review of the EWTD in the United Kingdom and Ireland reported ~90% non-compliance of the restricted working week. ‘Time for Training’ reviewed the implications of the EWTD and Professor Temple felt ‘high quality training can be delivered in 48 hours’; however, this is precluded where trainees have a ‘major role in out of hours services’. As most trainees, in all health systems, will attest to junior doctors do play a ‘major role’ in on-call services.
As a current urological trainee, the pressures to develop skills to operate in an ever-changing and exciting field are evident. A limited working week, twinned with health service cut backs and limited hospitals beds is without doubt a concern when filling in our logbooks. ‘Could a passage to India be the way to get more surgical experience?’, a feature in the BMJ in 2012, Elliot sends trainees abroad to gain the invaluable exposure to numbers we are limited by here.
There are two sides to the impact that a limited working week will have to an aspiring surgeon’s experience, the quantity and quality of time spent in the hospital. The debate remains regarding the length of surgical training the current structures are changing in Ireland, led by the RCSI, in an effort to shorten the length of surgical training in line with other jurisdictions. We need to strive to efficiently and effectively train surgeons within an appropriate timeframe within the restraints of legislation without a drop in the standard of skills required.
As time has passed, it remains to be seen if the EWTD will ever be implementable in keeping with the continuity of patient care to the highest standard they deserve and that we aspire to offer them. The EWTD is currently being debated at a European Commission level in order to negotiate a revised directive more in line with the challenges of healthcare professionals in a 21st century health service. Revisions to the directive may allow for longer hours in certain disciplines such as the skill based surgical specialities.
Gregory J. Nason, MRCSI, is currently Registrar in Urology, St Vincent’s University Hospital, Dublin.
I would support a return to a 60h week, but in addition we must keep the ideal of better quality teaching.
With a radical changes in training it should be possible to provide trained surgeons in a 48hr week but this would have significant service implications. I think a more realistic compromise in the NHS would be to work a 64 hour week (which most of us work anyway!). A sensible limit would allow training, service delivery and provide non fatigued trainees who are competent to treat patients and awake enough to learn from their clinical training.
The current economic downturn can only place more pressure on this system.
The EWTD needs updating with a more balanced and realistic approach.
I take Prokar’s and Jake’s point that with the help of simulation we could improve training. This will probably benefit junior surgical trainees most, but will not replace the need for exposure to real cases.
Patient care has been affected and discontinuity of care is the norm all too often! Reliance on locum cover has increased and patients wait for longer for treatment because of this directive. Although one can opt out of the EWTD individually, but this is not possible for the whole team rendering this option pointless.
The Royal College of Surgeons of England supported 65 hours week for surgeons in 2009 and I think this remains a reasonable option.
The optimal solution is probably a combination of 1 and 3, with a slightly reduced cadre of trainees working 60hrs per week to maximise training opportunities and producing a skilled consultant workforce who also play an increased role in delivering an optimal emergency service.
With the increasing use of one surgical resident cross-covering multiple specialties, hospital trusts have made workforce cuts resulting in a busier shift for that one doctor. In fact, the shifts are usually exhausting, but trainees often find that the subsequent day off is not spent resting but teaching or squeezing in admin time before the mandatory sleep preceding another night shift. This impacts the quality of life of the trainee but more importantly reflects the reality that service provision is prioritised over training and that we probably do not have the balance right for the trainee grade.
In addition, communication at handover between shifts has not evolved sufficiently to support the shift-based cover in surgical specialties. Patients suffer as a result of this.
Overall, I think that the EWTD was rolled out prematurely. We did not have the infrastructure or workforce planning to support it and as a result have taken advantage of the keen and willing trainee grade to meet service provision at a detriment to the quality of training and therefore the quality of trainee at the end of the programme.
We need to recognise that service provision in the increasingly bureaucratic system we work in is a distinct enitity and not confuse it with training. This is not to say that trainees stop covering on-calls, on the contrary they need to cover on-calls but within reason, and they do not need to spend that time doing paper work. A separate grade of doctor needs to be employed to cover the shift based 'ward work' and help with the on-call load, permitting those who have successfully competed for training programmes to be trained.
The non-resident nature of most urology on-calls shifts is fortuitous to the acquisition of both elective and emergency training opportunities. I’ve been subject to EWTD throughout my training and do not feel my training experience has suffered. But I know no better. I realise that at the end of training I may not have the breadth surgical exposure as my senior consultant colleagues. However I’m confident that at the end of my training I’ll be proficient in core urology skills and have developed excellence in my chosen sub-specialty. The need to uptake a fellowship is undoubtedly crucial and something that most trainees recognise and look forward to. I will not be afraid to ask for assistance and support from senior colleagues when I start my first consultant post.
The onus on turning out trainees who are not only competent, but rather confident and capable is down to both trainees and trainers. Supervised operating lists with guidance, advice and assistance from consultants is essential. The quality trainers that I have gained most from have mentored me during my placements, highlighted potential pitfalls and examples of good practice. This is achievable during the standard working week and within 5 years.
Do I work hard – Yes. Do I work late on occasions – Yes. Do I want to work 60 or 80 hours a week with remuneration – No. There should be time for a life outside training and work. The chance to spend time with families should be prized and not be sacrificed for that extra TURP or nephrectomy case. With the age of retirement continuing to be pushed back, I’m confident that there will be ample opportunity and time during my career to continue to learn, develop and acquire experience and new skills. Is this not what continued professional development is meant to be?
I do not speak for other trainees. I do not agree with how this prescriptive legislation enforces working practice upon a profession that prides itself on going the extra mile and ensuring patients are safe before leaving work. But I am a trainee of the EWTD era and with the help and tutelage of consultant trainers I believe I will be ready to deliver high level care and surgery to patients at the end of my SpR training.
I currently have moved to New Zealand, and am contractually employed here to work 65 hours a week as a general surgical registrar. In that, I am getting ample amount of time to do my ward work, be in theatre(minimum 2 full days a week), acute operating (there is a separate acute operating theatre daily), clinics and formal teaching. On top of that there are still the "long days" where we work until 2200hrs. I have ample rest and never have gone in feeling tired or drained. That feeling is new to me.
In Ireland, I used to work up to 126hours a week(if I did a weekend), and my hours were not optimally used. Too much paperwork, not enough surgical cutting time and no acute theatre.
The point I am trying to make is that even with an increase in the EWTD, we must be mindful ensure that the hours spent are of benefit to the trainee, and not doing ward jobs( IV cannula insertions, etc) or managerial/paperwork. Perhaps the role of a physicians assistant may be of use to relieve the doctors of these jobs.
It is good to see so many comments.
When I was a trainee, long ago, I used to work more than 100 hours per week. I once complained to one of my bosses Ken Shuttleworth, a Consultant at St Thomas's about feeling tired. He scoffed at me and pointed out that he was on-call continously from 1939 - 1945, the whole of the Second World War! He was a fantastic surgeon. In those days we weren't getting dictats about working hours from Brussels. It was under German occupation!
I would like the bloggers to read Paul Hughes and Nigel Rajaretnam's blogs which show the other side of the coin.
I have been exposed to training for >100 hours a week to 48 hours in their ROTA. Or rather the pertinent question today is unfortunately "what do the managers want these doctors to do if they had more "training" time?". Well, your guess is as good as mine. All of us remember what was being forced on the 'Royal Free' Urology Trainees! For those who are not aware, not so long ago, there was an management initiative to include Urology trainees at a prestigious London hospital into the General Surgery SHO rota. God bless those managers who had purely "training" in mind with a vision of Urology SpRs clerking in Surgical Admissions, taking their bloods and calling in their Surgical Counterparts (Surgical SpRs, some of whom may have been your SHO in urology!) to take the patient to theatre!
It does not really matter whether the trainee works for 48 hours or >72 hours in a week. The real question is, what does the trainee really do in those hours spent in the hospital?
If you ask me, can you can provide high-quality training in a 48 hr/wk rota? I would answer, yes! But it has to be 'trainee oriented' and 'training oriented', which most of the programmes lack today. Unfortunately, the emphasis for the 'trainers to train' has been diluted (in some places, it has reached homeopathic concentration) with the pressures on service commitment (targets, breeches, anaesthetist has to go somewhere, theatre nurses will not stay after 5.30, these patients have to be done today as they have been cancelled twice before and the list goes on). Trainees are diverted more towards service commitments than training commitments. On the other hand, if the theatre lists are focussed to cater the training needs, then you can achieve more than what you would by making the trainee work >72 hours. The classic example which many of us have gone through, is the learning curve of the trainers learning robotic surgery. Many trainees within and around the M25 corridor have sat by the patient side for many long hours sucking, clipping and at the receiving end (as the bleeding is always the assistant's fault!). Of course, it benefitted trainees like me who have embraced robotic surgery and being part of the learning curve of others has helped shorten our learning curve! However, a trainee who is NOT interested in Uro-oncology would have preferred to do TURPs and TURBTs (which are being performed by the Staff Grade in the very next theatre!) instead to "sucking and clipping"!
How can be tackle this problem of providing good training within 48 hours? The emphasis lies on the Deanery. They should make it an Obligation (with a capital O) for the "training centre" to provide the trainee with adequate experience as outlined by the "Educational Contract". This has to be strictly adhered to and if not, the training centre needs to be de-recognised. This unfortunately does not happen as it is a "brotherhood fraternity". Despite the trainee raising concerns, the training centre carries on by getting further trainees and the cycle continues. The deteriorating surgical experience is evident from a seminal paper by Ian Eardley.
((http://www.ncbi.nlm.nih.gov/pubmed/22011261). What was shocking for many was the "least number" of basic endoscopic procedures one can get away with!
TURP - 41
TURBT - 50
Ureteroscopy - 14
(For those in disbelief, this is cumulative 5 years experience and not one year!)
And others
PCNL - 0
Laparoscopic RN - 0
Open RN - 2
Radical Cystectomy - 0
Radical Prostatectomy - 0
Laparoscopic RN - 0
With the above stats, I rest my case!
A huge part of our lives and the direction we have chosen is surgery- it is important though that we have balanced lives and are allowed the time to foster these. In the past few weeks there has been widespread media coverage in Ireland regarding the 'over worked junior doctors'- patients have complained about being seen in OPD by doctors yawning and half asleep after 36 hour shifts or the negative impact fatigue plays on our decision making.
To redirect to the title 'Quantity or quality' I think a balance is needed. The figures quoted by Amrith Rao are a shocking reflection- I even think the idea of the 'least number of cases' a trainee is required to carry out is focusing on the negative rather than the positive. Nothing can match experience- no one wants to be the SpR or Consultant who can't operate or manage a case to the expected standard. We all strive to achieve certain targets- be it allocation to SpR schemes, acceptance to a coveted fellowship or the 'gold dust' consultancy post. Trainees, myself included, often fail to see the wood from forest- this is journey we are on and so long as we are learning and improving our skills we can all reach our target- to be skilled Urologists providing gold standard care to our patients.
1. EWTD is European law. It is not coming in, it is in, and has been in for some time. The European Commission is not seeking a compromise on it, but rather is challenging the Irish health service executive as to why thy have not yet introduced it. This may result in a fine. 2. The idea of practice makes perfect is outdated. What we now believe is that "perfect practice makes perfect". A surgical SHO who has been awake in excess of 24 hours is not engaging in beneficial training the following day. In some instances, this trainee may have been working in excess of 70 hours on site straight.
I would have serious concerns about the quality of training following this. 3. The idea of patient harm arising from such a system fails to appreciate and accept the increased risk patients are put at by an overly fatigued, or in some instances exhausted surgeon. Urology as a speciality are fortunate to not frequently new to stay up all night operating, but since EWTD applies to all, we must be mindful of this fact. The detrimental effects of sleep deprivation on performance of tasks, including driving and manual skills is well documented. Pilots and long distance drivers have their hours limited for his dry reason. While continuity of care is an issue, I'm sure patients would prefer to deal with a new fresh, well rested surgeon than an exhausted familiar face.
4. A car accident because you fall asleep at the wheel after being up 36 hours is not beneficial to training. Nor is a broken relationship. In Ireland there have been well publicised suicides of NCHDs in the last number of months, and while suicide is a complex and multi factorial issue, family and friends have confirmed that excessive working hours contributed to the metal strain of these cases. People are both physically and mentally vulnerable and any proposed system needs to take this into account.
I personally believe that we in surgery have a great challenge in instituting these changes, but I think the above are issues that are often overlooked. While skill acquisition is of course vital, and adequate operative experience is a large part of this, it should not increase risk to patients, or indeed put the health and well being of trainees at risk. Many of these points refer to more junior trainees, but the directive refers to all and do we must come up with ways of ensuring adequate training can be obtained. Finally, the way in which the directive is written into Irish law there is no possible opt out clause.
Firstly, I don’t think that there is a single answer to improve the training that junior Urologists receive in the UK. This is a multi-factorial problem. As we all know ‘time on the job’ and experience cannot be learned through a book or at home. This unfortunately means that more time needs to be spent working, seeing, treating and operating on Urological diseases.
Lord Kakkar sanctioned the EWTD debate at the House of Lords. He realized that this is becoming a problem in the UK for surgical specialties and invited BAUS, (of which I represented), ASIT rep, BMA Junior Doctors rep and the Professor Norman Williams, President of The Royal College of Surgeons, (amongst others) to Parliament. Here the debate of SiMAP / Jaegar ruling, the restricted 48 hours of working for trainee doctors, the discrepancy of monitoring results and how potential changes could be made. The impact of the following were discussed: insufficient training experience to become a competent independent consultant; the shift work on the quality of work and tiredness; and the loss off opportunity to attending daytime hours training lists because of enforced rest periods. There was an awareness that hospitals could not afford to have junior doctors taken off the EWTD as there is a financial penalty for going over 48 hours. The overall effect of the EWTD on the NHS has been to stretch staff availability to the maximum particularly with out-of hours care being provided by locum doctors. This was estimated to cost an additional £200m per year. They concluded that potential solutions that still needed further deliberation included: an increase in hours (up to 65 hours, as suggested by The Royal College of Surgeons), and flexibility of compensatory rest; scrapping or amending the Directive and how exactly to improve the training opportunities and whether there was scope to re-negotiate the New Deal, which would allow trainees and Consultants to work more flexibly.
Currently, I am in Christian Medical College, Vellore, India on Fellowship. The Urology department here runs a tight and efficient system. The team consists of teams of many junior doctors (SHO’s), three registrars, one consultant (post-exit exam) and three professor all of different grades. There is one ‘head of team’, which is the most experienced and holds the most publications. The day starts at 6.30am with ward rounds / consenting, theatre starts at 7.30am and finishes whenever the last operation is done usually 5pm, (but if it over runs, it simply continues). Three theatres run simultaneously with the registrars doing the procedures. The SHO’s start and finish the cases. The consultants help the registrars when the run into problems and every so often the professors join in to help too. First year of training is aimed at investigative / endoscopic / minor surgery, second year at more open cases and third year at more complex procedures / laparoscopy. There are two or three days per week of this, with the other time being OPD or investigative procedures, (seeing in excess of approximately 150 patients per day). The days finishes with either a ward round of all patients or a professor-round looking at the next days operations / indications / results / images and then a professor ward round. The day can finish after 7pm for many. There are no managers, no TCI clerks, and no red tape. The work is done however long it takes. The registrars train in 3 years to our year one UK consultant standard. I have witnessed what concentrated, intense teaching / mentorship and supervision can do to training to become a Urologist. A lot of this is not right, but I definitely think we could learn something from this format.
Such valid views from all. A difficult puzzle to solve. I have been following these blogs with interest and cannot resist the temptation to throw my "two cents" in.
Having myself trained in these waters and then across the water in the US, I see another perspective that might interest some. In Ireland during my training on my Pre-Fellowship Training Scheme from 1980 to 1985 it was more apprenticeship. I assisted and watched my Consultant operate, but I was then more often left to subsequently do the same case on my own.
In the US during my Urology Residency from 1985 to 1990 it was hands on didactic surgical training with the Attending Surgeon (Consultant) scrubbed in with me at all times directing my or watching my every move. My last year was as an independent operator as the Assistant Chief of Service under the Chief of Service (Pat Walsh!). I came to the conclusion that it was better in surgical training to do a procedure 10 times well rather than 100 times badly. In other words, quality was probably more important than quantity. I was on call from home 24/7 and at one point was 102 weeks on the trot with my 2 weeks holiday for those 2 years at the end (i.e. week 103 and 104). At the same time the General Surgery Residents were on call in house and complained when they went to a 1 in 2 call - they complained because they were now "missing half the good cases"!!! (i.e. they used to be on every night in the hospital!!).
Now, I am not advocating these regimes, but it highlights another dimension to all of this: those residents knew the precise date when they would finish their training and the following morning they would be starting their job as an Attending Surgeon (Consultant). In other words, they had only so much time to get their training accomplished in.
Training in Ireland is very different with too much time being consumed by it and too many trainees being left "in limbo" at the end of training and left doing Fellowships and other pursuits passing the time waiting for a Consultant post to hopefully appear. Greg is my current Registrar and I have never seen him watch the clock. Last night (a Friday) I was still working away in the public hospital theatre at 8PM. It is a list I do on my own as the trainees are doing an outpatients clinic with one of my colleagues. When the outpatients was over, Greg came to join me in theatre to help with a case of a patient he was interested in following. He was off call and could have just gone home, but something else intervened and compelled him to theatre: a vocation. There are going to be times when the EWTD could interfere with that vocational ethos, and we need, in constructing safer hours for surgical trainees, to be mindful of that.
Without overstating it, I think we need to put a little more emphasis on "Vocation" rather than "Vacation". Having said all of that, I would never want anyone to go back to the past and work like my generation worked. I would, however, like to see more hands on operative teaching and a shortened and more focussed timeline for surgical training with a defined endpoint. I am also altruistically naive enough to want some emphasis on surgery being a Vocation.
A number of articles in the BJUI in the last two years have highlighted the role of technical skills training in Sim labs. The key messages are repetition, recording of progress using validated questionnaires and safe translation to real life.
The greater advance is the introduction of non-technical skills or human factors training. A survey of BAUS members showed that 90% had no knowledge of this whatsoever as the tools did not exist until recently.
I tell my robotic fellows that "50% of complications happen at the console, the rest outside it". Training in communication, team working, stress adaptation, decision making and even distraction from eye movements is now available.
Even more exciting is that technical skills and human factors can be combined inside a Distributed Simulation "igloo".
Life-long learning is imperative and goes far beyond restricted hours. The difference is it is now HOT NEWS. As a surgeon I am still learning.......
Are we really surprised by “a link between working long hours and fatigue” …?!
I think the real issue is the continuing conflict between service provision and training – which has become more important as the actual hours our trainees spend in hospital decreases. A “number of individuals reported having to undertake learning activities in their own time” is probably a reflection of having more time outside of work in which to do this. As far as I am aware all trainees who wish to succeed have always had to put in a lot of effort in their “spare” time (even when working much longer hours).
This report doesn’t actually seem to outline a way ahead out of this situation, whilst the success of the “end product” (a CCT’d Consultant) would appear only to be measured by the view of the trainees themselves (pages 73/74 of the main document) – and one could doubt the validity of this.
How is this to be reconciled by the view that some newly appointed Consultants aren’t experienced enough? I suppose this is where mentoring raises it’s head but (as we discussed in Council last year) mentoring is not really designed to be further “on the job” training for new appointees.
I see that there would seem to be a groundswell of opinion that 60-80 hours (but of more directed and focused training) is about right for surgical specialites.
I would imagine certain specialities could manage to train in much shorter hours over less years, but that is another matter.
Just a few thoughts
Duncan
Just as it is with other young guns having fun (steady on O'Brien, I feel a wham rap coming on...) and acquiring skills. Young associates at Freshfields work hard; young associates in banks work hard; and young surgeons work hard .... and all play hard.
48 hours is ludicrous. 120 hours (which we did) was ludicrous.
Split the difference...?
http://www.channel4.com/programmes/dispatches/articles/video-junior-doctors
Regards,
Amrith