Rob Mitchell

THE negative effects of unsafe working hours in medicine cannot be disputed. A large body of evidence attests to the risks of fatigue for patient safety and the health and wellbeing of doctors.

Health care systems have responded in various ways. In certain regions, strict regulatory frameworks have been introduced to limit working hours, such as the European Working Time Directive and the US Accreditation Council of Graduate Medical Education’s duty-hour requirements.

Australia has adopted a less rigid and more iterative approach. Attitudinal shift, workforce expansion, improved rostering, dedicated clinical handover and industrial requirements have all enabled progress. Although unsafe practices persist, the overall working hours of Australian doctors are decreasing.

Much of the debate has now shifted to focus on the impact of restricted working hours on training. A systematic review published in the BMJ failed to determine an overall negative effect, but there is marked variation in the outcomes of individual studies.

Perspective articles recently published in JAMA and NEJM highlight ongoing concern that various fatigue management strategies might have a detrimental impact on the quality of clinical training. The JAMA article also contends that the development of a shiftwork mentality may undermine the one-on-one patient-doctor relationship and the culture of professional responsibility and accountability. It argues against further tightening of US restrictions to the extent of those imposed in Europe.

It is difficult to discern if the fears are well founded. Clearly, limiting working hours and introducing shift rostering can impact on training by reducing the amount of time trainees spend in the hospital. It can also affect continuity of care and access to supervisors.

However, this assumes that traditional training arrangements remain entrenched and do not evolve in concert with the shift to safe working hours. Innovative models of education and service delivery are clearly required to deliver the parallel objectives of high quality training and fatigue minimisation.

This was a key finding of a UK report by Professor Sir John Temple, which reviewed the impact of the European Working Time Directive on the quality of training of doctors and other health professional.

The one-size-fits-all approach is certainly unlikely to work and individualised solutions must be sought. Arrangements that function effectively in the emergency department may not work on the medical or surgical wards.

The perception that meaningful training can only occur Monday to Friday between the hours of 8 am and 5 pm is no longer valid. However, poor supervision and extensive out-of-hours service requirements compromise quality.

It is for this reason that the Temple report recommended widespread adoption of consultant-delivered service models. For example, senior clinicians might work extended hours and, as a consequence, provide valuable clinical training beyond “office hours”. It also suggested that hospital processes must be explicitly configured to support high-quality medical education. Outpatient clinics, for example, might be optimised to ensure sufficient time and space for teaching and learning. Differing levels of supervision could be provided for junior doctors, based on their stage of training.

Regardless of the concerns expressed in the recent JAMA and NEJM articles, safer working hours are here to stay. Fatigue impacts on both patients and doctors and the safety of both should not be compromised by inappropriate rostering and service arrangements.

Medical training must adapt and take advantage of this new paradigm.

Dr Rob Mitchell is an emergency registrar at Townsville Hospital and immediate past chair of the AMA Council of Doctors-in-Training. Dr Will Milford is a senior obstetrics and gynaecology registrar at the Mater Mothers Hospital in Brisbane and chair of the Council of Doctors-in-Training.

Posted 11 March 2013