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EWTD: Quantity or Quality?

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.

 

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31 replies
  1. John W. Davis
    John W. Davis says:

    The US mandates <80 hour work week for residents in all specialties. By now its accepted, but does reduce training opportunities. It may lead to more residents needing to pursue fellowships in more advanced surgery techniques. Programs may have to use more mid-level providers to assist in the OR on days where the post-call residents has to go home.

  2. Prokar Dasgupta
    Prokar Dasgupta says:

    While it suits emergency medicine to follow the EWTD, this is far from ideal for surgical training. Our French colleagues have shrugged their shoulders and said “boff” – we find it more difficult to do that. Perhaps 64 hours may be just right for surgeons? In the UK this issue continues to be debated in Parliament. A solution to safe training may be to supplement traditional surgical education with high quality simulation, both technical and non-technical.

  3. Ben Grey
    Ben Grey says:

    In the UK, the Specialist Urology Registrars’ Group (SURG), of which I am Chair, have represented trainees at a parliamentary level on this issue. I suspect many trainees, like myself, would prefer the 64 or 80 hour limits mentioned. My personal views are that, in addition to the points already made, the 48 hour limit severely fragments service delivery by disrupting continuity of patient care. Furthermore, in addition to the decrease in exposure to procedures, such fragmentation to the clinical team harms the educational experience of trainees and the ability of trainers to supervise effectively. Whilst the number of hours is less, I would question whether surgical trainees’ quality of life is better as a consequence (night shifts etc). Ultimately, many trainees adopt the “French” attitutude and opt out to ensure their own education doesn’t suffer and suspect (though cannot provide hard data) Trusts turn a blind eye as breaching limits is beneficial (more work without having to pay inflated on call supplements). Perhaps the latter point is a little cynical!

  4. Jake Patterson
    Jake Patterson says:

    I think that Ben’s point above is they key if we are to change things for UK trainees in surgical specialities. Although with properly designed training programmes, and an adoption of more simulation (as the technology becomes more freely available) I have no doubt that we could be trained in 48h per week, my concern is the disastrous effect this has on continuity of patient care. This is even more likely to be pertinent in light of the Francis report. In addition, if we do move towards 7 day consultant delivered care, I am sure that training continuity will also suffer as consultants are required to have rest days and their working timetables become more “flexible” or even annualised, thus spending less time with a single trainee.

    I would support a return to a 60h week, but in addition we must keep the ideal of better quality teaching.

  5. James Brewin
    James Brewin says:

    I agree with Jake’s point that reduced traing hours has implications for continuity of care and additionally continuity of training – it is hard to get outpatient and theatre experience when working night shifts.

    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.

  6. Miles Goldstraw
    Miles Goldstraw says:

    The debate on the EWTD continues: the situation in the UK is less than ideal. While some countries blatantly disregard the ruling others simply provide ‘opt-out’ clauses. The current trend in the UK to produce Specialists in a shorter period of time alongside the significant reduction in the number of hours worked does not compute. Patients deserve the highest standard of surgery performed by the most competent and experienced doctors.

    The current economic downturn can only place more pressure on this system.
    The EWTD needs updating with a more balanced and realistic approach.

  7. Oussama Elhage
    Oussama Elhage says:

    Although Temple reported that high quality training can be achieved in 48-hour week; the reality for surgical trainees is quite different. Many stay on after their night shift to get involved in an interesting case, and most will not drop everything and leave at 5 like office workers.

    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.

  8. Ben Jackson
    Ben Jackson says:

    The EWTD adversely affects training by reducing the experience gained by each trainee during a 5 year training programme, but that is not the full extent of the problem. With each trainee limited to 48hrs/week, the number of trainees required to maintain service delivery (especially oncall rotas) is likely, in the long-run at least, to exceed the number of consultant posts available for them to go into. Solving this equation requires that either: 1. We increase the amount of the service that is consultant delivered and increase the consultant workforce accordingly. This is fine but will be expensive, and will require some consultants to focus on core and emergency urology. 2. We accept that some trainees will not enter consultant posts and will enter staff grade/associate spec posts and then continue to contribute to delivery of middle-grade rotas in that capacity. 3. We get rid of the EWTD, each trainee then is able to increase their hours to maintain an oncall service with smaller number of trainees overall. This would mean that each trainee would get greater overall experience and the quality of training would increase with fewer trainees to divide available operative experience by.

    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.

  9. Kathy Duong
    Kathy Duong says:

    As a junior doctor who has recently completed core (basic) surgical training, I have not adhered to the 48 hour working week. Surgical trainees at more junior levels (CT1/CT2/SHO) work extremely hard to compete for operating time in order to ready themselves for recruitment and progression to higher surgical training. Most trainees use their ‘zero hours’ or compensatory rest time to attend theatre in order to get the required case load for progression since their ‘normal’ working hours are often spent covering an on-call for their specialty when they are not permitted, according to many hospitals, to scrub-in.

    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.

  10. Paul Hughes
    Paul Hughes says:

    We are not robots! We are not technicians. We are surgeons. Training is operative experience – Yes. But training is also the acquisition of experience and exposure to patients in clinic, on-call and on the ward. It’s involvement in the running of departments with consultant colleagues. It’s the overall maturation of an SHO surgical trainee, through SpR years, to grow in confidence and develop sensible safe clinical judgement.

    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.

  11. Paul Sturch
    Paul Sturch says:

    I agree with the points that Ben and Jake have made. Alongside a reduction in working hours, the EWTD brought with it an increase in shift work and cross-cover of specialities out of hours. This has led to multiple handovers each day and reduced continuity of care for patients as well as a disruption to the educational experience of surgical trainees. Many surgical trainees use days off on the 48 hour rotas to gain operating time, a 60 hour week could improve the quality and quantity of surgical training if the extra hours are protected for education.

  12. Dr. Nigel Rajaretnam, MRCSI
    Dr. Nigel Rajaretnam, MRCSI says:

    As basic specialist trainee(BSpT) that left the Irish healthcare system for New Zealand, I only know too well about the EWTD, how it still isn’t being adhered to and how, if managed well, time can be optimised to get the best out of the trainee.

    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.

  13. Professor Roger Kirby
    Professor Roger Kirby says:

    Good blog and well done Greg!
    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!

  14. Amrith Rao
    Amrith Rao says:

    I would like to add fuel to the fire by being on the minority side supporting the 48 hour Rota!

    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.
    ((https://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!

  15. Greg Nason
    Greg Nason says:

    Thank you Professor Kirby. I knew this topic would generate debate among Urological trainees. I find it very interesting to read the honest comments from Paul Hughes and Dr Rajaretnam. It is important that we as well as those directing the training programs and running the health services realises that we are not, as Paul puts it, robots.

    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.

  16. Dave
    Dave says:

    While I agree that the institution of this limitation on working hours will be challenging, there are a number of issues that have not been touched on here.

    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.

  17. Rahul Mistry
    Rahul Mistry says:

    Dear all, this is such an interesting debate… I thought I would enlighten you all to the round table debate that I attended at the House of Lords and my current experience whilst I am on Fellowship in the Christian Medical College, India.

    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.

  18. David Quinlan
    David Quinlan says:

    What a topic!

    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.

  19. Adam Landau
    Adam Landau says:

    Historically surgical trainees garnered significant experience and operative volume through the sheer number of hours spent at work, and on call. Globally this has been reduced, with the consequent reduction in experience.
    For the vast majority of trainees (myself included), the adage of ‘see one, do one, teach one’ does not ring true. We learn more slowly, and require guidance in how to do the operation well, not just reach its conclusion without catastophe. This is a product of experience, and that takes time.
    Does this mean that there is a minimum exposure required, below which trainee skill, patient care, quality of continuity, and efficiency of service provision will suffer? Most likely. What the magic number of hours is remains elusive. 48 seems low.
    That said, we do not live in the same era as our mentors, or our mentors mentors.
    We have access to technology not previously dreamt of.
    Utilization of this technology – simulation, modular training etc must be integrated with an appropriate number of hours.

  20. Prokar Dasgupta
    Prokar Dasgupta says:

    Recently I was at the RKMission Hospital in Kolkata, India where the trainees work about 80 hours/week. No one seems to know the “magic” number of hours needed.
    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…….

  21. Duncan Summerton
    Duncan Summerton says:

    GMC publishes research on the impact of the Working Time Regulations

    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

  22. Tim O'Brien
    Tim O'Brien says:

    Its not the work that tires out doctors in their 20s – its the partying.

    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…?

  23. Declan Murphy
    Declan Murphy says:

    Well said Tim! Spoken like the warrior you are with plenty of scars from medical socialising, high-end sporting prowess and hard surgical graft. It’s a great mix! Australian surgical trainees work about 60 hours per week – I think that’s about right.

  24. Adam Landau
    Adam Landau says:

    Although there have been changes to working hours – reductions following described trends, most Australian trainees would work between 55 – 60 hours a week.

  25. Prokar Dasgupta
    Prokar Dasgupta says:

    In South Africa you would not worry about training in trauma surgery. The volume is such that you would learn automatically. Trainees in India (see Rahul Mistry above) and the USA being in large nations, have the benefit of patient volume. In the UK and Ireland we live on small islands. Belgium and the Netherlands are similarly small nations. The number of hours of surgical training has to be reflected in part by the volume/nation. Thus the “volume-outcome relationship” does not apply just to individual surgeons but also to surgical training and the number of hours invested. I wish someone in the EU had considered this before imposing it on doctors in different nations.

  26. Muhammad Shamim Khan
    Muhammad Shamim Khan says:

    Debate on working hours is very interesting. Most feel that 48 hours is inadequate but a minority thinks that this is not the case. Our organisation (i.e NHS) employs surgeons. The new appointees are offered 10 PAs. Of these most spend 3 PAs operating and 7 PAs doing other activities. Of 3 PAs one is usually for day case procedures. That leaves one day of operating list in main theatres, i.e 8 hours. Out of these allocated 8 hours, at least 2 hours are lost are lost in patients’ delayed transportation, anaesthetics etc. Even if we assume that a surgeon has 40 lists a years, i.e 240 hours of operating, how well can he train a trainee considering the pressure of waiting lists etc. Trainee will also take annual and study leave and may be away for exams etc. Thus bottom line is that our system is not designed to deliver adequate training in 48 hours. Trainers need to be given more operating lists to allow adequate supervised training. Unless system changes we have to explore other options to address the inadequacy of surgical training, e.g. simulation or overseas fellowships.

  27. EAMON
    EAMON says:

    Interesting blog !
    Personally I believe that most trainee surgeons wouldn’t care if the work day or week was longer, providing it was productive. By this I don’t mean that doctors should be exhausted and hence a danger. But most devoted trainees would jump at the chance to clock up their number of procedures (providing they are being taught – and not just the retractor) Less of the administration/ bureaucracy workload and more operative “hands on”.

  28. Ian Willetts
    Ian Willetts says:

    As a consultant paediatric urologist and neonatal surgeon quality of training not quantity is essential to turn out a competent all-round clinician. If I had to do ’50 cases of …..’ annually to maintain my expertise I would have to give up doing circumcisions, orchidopexies, pyeloplasties, nephrectomies, major genital reconstruction, neonatal congenital surgery, etc ……………. – guess I could then do all those ‘non-operating tasks’ with the rest of the paediatric urology specialist consultant group. Optomising the training experience in a supportive environment (and crossing over the career boundaries between specialties occasionally) is vital.

  29. Jeremy Oates
    Jeremy Oates says:

    My personal feeling is that the EWTD is a bit of a red herring here. It’s all too easy to blame the Bureaucrats of Westminster and Brussels for the fact that trainees aren’t doing enough TURPs, RRPs or andrology procedures, but in reality my experiences as a trainee would suggest otherwise.

    In a speciality such as urology, the impact on individual trainees is far less significant than that of a speciality having to provide true 24hr shift cover such as general surgery. We don’t do night shifts, we don’t have countless ‘zero’ days after on call weekends and by and large, the vast majority of trainees don’t take the mandated half day after an on call shift. I, like the cast majority of registrars frequently worked three or four on call shifts back to back both for convenience of swaps but also to ensure patient safety, whilst at the same time being somewhat liberal with recording our hours for monitoring. I simply cannot see how elective operative numbers would increase significantly with the instigation of 56, 67 or even 100+ hr weeks without a significant change in the working practices of the trainees as most of the trainees already work 56+hr weeks but simply don’t record it. Rahul’s example of volume training in India is enlightening, but this level of operating could be achieved within a 48hr week. If we want to increase the amount of elective operating urology trainees are exposed to, they need to be in theatre more. To blame the trainees (which unfortunately happens frequently) for failing to make an effort to get to theatre is unfair; most trainees are only assigned 3-4 sessions a week, but they have few other free sessions during which they could attend due to the service provision requirements placed on them. Urology, in my opinion, has been very minimally impacted by the EWTD and I would certainly disagree with those who place the falling numbers of trainee procedures solely on the 48hr week.

  30. Anonymous Urologist
    Anonymous Urologist says:

    Wading in. In many hospitals in London where I train the 48 hour working week is not adhered to. I also do not think that urology trainees as a speciality suffers, primarily as registrars we do not do resident on-calls.

    I work in a large teaching hospital in London that will remain anonymous (as will I), and my timetable goes like this:

    I am there every day for ALL elective activity (on average I work from 0730 – 1830 every day = 11 hours/day) annual and study leave excepted.
    I work 1 in 6 nights (and work the day before and after – non-resident), and work one in 6 weekends (48 hours – with no time off before or after).

    This equates to 55 hours elective activity, plus 18 hours on call per week.

    This is 73 hours per week,

    I will reiterate that I am present for all elective activity, I rarely learn anything out of hours, it is hard to see how working more hours in the NHS would be helpful.

    I am therefore AGAINST scrapping the EWTD as I feel, that if I work 73 hours a week (sometimes more) when this regulation is in force, If it is increased to 60+ hours per week, we will probably find that trainees are back to working 100+ hours again – most of this will be covering emergency take. Hopefully that makes sense, but I rest assured that in the evenings I am not missing very much at all in the way of training opportunities, and therefore the training structure in the NHS would have to be reformed, not the working hours.

    It is my feeling that training is impeded by the consultant delivered care and targets, and time constraints rather than any real decrease in working times, furthermore the trainees should get 3 full days of operating per week, with a day of clinic and a day of ward rounds and on-call.

    There. I have said my bit, now I feel better.

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