Jane McCredie: Working rites

MANY professions have their rites of passage and initiations that leave their survivors bloodied and bruised but confident of their admission to the tribe — perhaps none more so than medicine.

The trials of hospital residency — the 120-hour weeks, the procedures performed at the end of a 36-hour shift with little fuel other than a cup of instant coffee — provided war stories for generations of doctors.

In recent decades, much of that has changed, though many junior doctors still work shifts that would not be allowed for nearly every other profession or trade.

The focus on reducing long working hours has been driven by concern for both doctors’ wellbeing and patient safety.

A classic Australian study from the 1990s found performance impairment after 17 hours’ sustained wakefulness was equivalent to having a blood alcohol level above the legal driving limit of 0.05.

If we wouldn’t be happy to have a tipsy surgeon operating on us, why would we accept one who was equally impaired by fatigue?

But perhaps it isn’t that simple.

Brisbane liver surgeon Kellee Slater questions whether reductions in working hours could be compromising the training of junior surgeons.

“There was no such thing as ‘safe working hours’ for doctors during my training, and being awake for two consecutive days was worn like a badge of honour”, she writes in a new book.

“The sleeplessness was a difficult but vital part of my training, because the more hours I worked, the more cases I saw and the better I became … I really worry now that junior surgeons’ work hours have been severely restricted by well intentioned laws, as it will be difficult for them ever to get the experience they need to become really good.”

Dr Slater is not the only one to raise such concerns.

A US study in JAMA Surgery this month, and reported in MJA InSight, found the introduction of a 16-hour shift limit for general surgery interns was associated with a significant decrease in operative experience.

Broader implementation of such rules might mean junior surgeons needed additional years of training to ensure they acquired adequate experience, the authors suggested.

I doubt that would be a popular option for many young doctors.

Australia has generally been more active than the US in addressing excessive working hours. The AMA’s most recent Safe Hours Audit found hospital doctors worked 55 hours on average over the 2011 audit week, which doesn’t sound too bad.

However, the audit found 53% of hospital-based doctors were still working hours that could impair their performance, down from 78% a decade earlier.

Surgeons were by far the highest risk group at 77%, compared with just 33% for emergency physicians and 38% for anaesthetists.

The audit also found 21% of doctors did not have a day off during the audit week and the longest shift recorded was 43 hours.

“In any other industry or profession, these statistics would be cause for deep concern and immediate action”, the report said.

We don’t really know whether the gruelling regimes of the past did actually produce better doctors, although those who survived them often seem to believe that to be the case.

Nor do we have accurate data on the toll they exacted, in terms of either doctors’ health or the safety of patients.

The one thing we do know is that balancing the push for safer working hours with the need to provide junior doctors with adequate training and experience is never going to be easy.

Jane McCredie is a Sydney-based science and medicine writer.

COI: Jane McCredie commissioned Kellee Slater’s book in her former role as a publisher at NewSouth.