Junior doctors' working hours: an unhealthy tradition?

Fundamental reform of hours worked by junior doctors is required

MJA 1998; 168: 587-588  

It has long been recognised that the rites of passage for junior doctors in public hospitals require extended hours of work with inadequate provision for rest and recovery. Not only are the junior doctors on a very demanding learning curve, but, at the same time, they are required to establish effective working relationships with patients, families and senior colleagues, and deal with the complexity of the modern hospital administration. Add to this a stressful workplace environment and, at times, the necessity to make critical decisions within a limited time frame and you have a situation no other professional group would be prepared to tolerate. Yet the research1 indicates that this is the situation most doctors face at the beginning of their careers. While Olson and Ambrogetti2 in this issue of the Journal present some criticisms of the methods of such research, there is considerable evidence to support the view that junior doctors' hours of work are, at times, excessive.3 The most recent Australian survey, undertaken as part of the current AMA Safe Hours Project, has produced further evidence to support this view.4 Why is this practice, which exerts a very heavy personal toll on the health and work performance of doctors, allowed to persist? No doubt there are respected members of the medical profession who argue that it is an essential component of the "toughening up" process. Clearly the hospital environment and the professional medical work ethic contribute to the excessive hours of work so ingrained in the hospital culture. The depth of this tradition was demonstrated recently in New York, where amendments to the Health Code5 were introduced in 1989 following the death of Libby Zion in a New York hospital. The circumstances of this unfortunate event are outlined by Nocera and Khursandi6 in this issue of the Journal. Libby's father, Sidney Zion, a newspaper columnist, was instrumental in launching a successful campaign restricting the hours of work of junior doctors working in hospital emergency departments. However, recent reports in the New York Times7 indicate there are still a large number of hospitals flouting this law. While legislative reform is one part of the solution, there is clearly a need to look at the attitudes which continue to support the practice. Until recently, little attention was given to the statutory responsibility of the employer to provide a safe system of work for doctors employed in hospitals.8 Currently, under occupational health and safety laws, there is increased emphasis on employers undertaking a hazard identification approach, followed by risk assessment and the application of risk controls. Applying this approach to the work regimen of junior doctors will present particular challenges to hospital administrators. An added consideration is the increasing recognition of the extent to which latent organisational failures may contribute by creating the circumstances leading to mishap.9 A hospital administration which fails to identify hazards and assess risks arising from extended hours of doctors' work could be in breach of a duty of care owed to doctors. Further, permitting a doctor to carry out duties while so fatigued that a patient's safety is endangered could be a breach of duty owed to the patient. The comments of the acting coroner in the recent inquest into the death of a New Zealand woman, the innocent party in a car crash, reinforce the importance of addressing the issue of fatigue.10 The patient survived the accident, but died following a mishap while in hospital. A significant issue for the coroner was the extent to which the fatigue of one of her doctors may have played a part in her demise. The coroner remarked that there was a growing level of concern, both nationally and internationally, over the hours of work of doctors in hospitals, and suggested that the medical professional bodies address the issue of extended periods of work. The hospital work practices of junior doctors appear to be common to many countries. Although the weekly hours worked by doctors in training are variable, it is reasonable to conclude that these routinely exceed 55 hours per week in many European countries.11 While the European Union originally excluded doctors in training from its 1993 Directive on Working Time,12 the Union's Council of Ministers indicated more recently that the directive should also apply to doctors in training.13 In 1990, the United Kingdom adopted an agreement, the New Deal, to phase in reduced hours for junior doctors.14 In March 1996, the AMA Federal Council adopted a policy to promote a safer workplace for junior doctors and patients in public hospitals.15 Part of the strategy involves the development of a national code of practice for the hours of work and rostering arrangements of junior doctors employed in hospitals. The Commonwealth Department of Health and Family Services has provided financial assistance to undertake a number of research projects to support the development of this national code. A draft of the code should be available for public comment in June/July 1998, to be followed by a national symposium in November 1998. Undoubtedly the major challenge is the professional medical culture, which, while it recognises the hazards and risks of excessive hours of work, appears to lack the collective will to resolve the problem. Nocera and Khursandi raise the question "Can the medical profession afford to let the courts decide what is reasonable?". In the absence of the medical profession's commitment to support fundamental reform of hours worked by junior doctors, where else can the victims turn? Gerry Holmes Manager, Occupational Health and Safety University of Wollongong Legal Advisor AMA Steering Committee, Safe Hours Project Swan, N. Juniors' Hours: International Overview. BMJ 1990; 301: 830-832. Olson LG, Ambrogetti A. Working harder -- working dangerously. Fatigue and performance in hospitals. Med J Aust 1998; 168: 614-616. Williamson A. The effects of workload and long hours of work on medical officers. Sydney: National Institute of Occupational Health and Safety (WorkSafe Australia), 1995. Australian Medical Association (AMA). Systems of work and overview of current arrangements. Canberra: Australian Medical Association, 1998. In press. New York State Health Code (10 NYCRR 405.4). New York: Department of Health, 1989. Nocera A, Khursandi DS. Doctors' working hours: can the medical profession afford to let the courts decide what is reasonable? Med J Aust 1998; 168: 616-618. Fein EB. Flouting law, hospitals overwork novice doctors. New York Times, 14 December 1997; 1. Holmes G. Hospital medical officers: hours of work and workloads, A strategic approach to occupational health and safety. Canberra: Australian Medical Association, 1995. Department of Transport. Investigation into the Kings Cross Underground Fire. London: HMSO, 1998. Coroner's Court. In the matter of the death of Patricia Margaret Ross. Rotorua, New Zealand: 15-17 October 1997; 18-20. Permanent Working Group of European Junior Hospital Doctors. Working conditions for doctors in training. Conference Proceedings, Executive Summary. Brussels: European Union Publications Office, December 1995. European Union. Directive on Working Time, 93/104. Brussels: European Union Publications Office, 1993. European Union. Sectors and activities excluded from working time directive. Brussels: European Union Publications Office, 1997. NHS Management Executive. Hours of work of doctors in training: guidance on regional task forces.London: Department of Health; 1991. Federal Council, Australian Medical Association. Executive minutes, 1-2 March 1996. Canberra: Australian Medical Association; 1996.