Poorly designed shift rotas can have negative impacts on junior doctors’ professional performance and educational training, with implications for clinical practice, patient care, and the welfare of junior doctors.The impact of shift patterns on junior doctors’ perceptions of fatigue, training, work/life balance and the role of social support
Brown, Tucker, Rapport Et Al
As medical students, life is burdened only with the stress of studies and exams for a relatively long time, 4.5 years to be precise. After that, the stressors keep on compounding at a rate that is beyond the control of the doctors. Stress, anxiety, depression, burn-out, suicides, and change of profession is a commonplace in our profession.
There is no one specific reason. But one of the reasons for sure is the weird duty schedules. That too during the most productive years of life, the twenties. Sometimes it extends into the thirties and later years too.
When and Why Does it exist in our profession?
Since times immemorial, medical training is considered to be a rigorous exercise. The next step has to be in your reflexes because it can end up saving valuable time and lives in an emergency scenario. To induce such knowledge and make facts a part of our lives, it is considered medical training has to include long hours of work, continuous work hours and minimal holidays. That’s how the system has worked for years. In the hope to make better doctos.
My first >24 hour shift!
As an intern, I got exposed to this dark side of medicine. I was a young kid, excited about being in the hospital and putting my knowledge to some use. In my first week of the intern, I was told to do a 36-hour duty. I obviously did not know it means “36 continuous hours of staying up.” After almost 18 hours, at night I finally sneaked into a dark, dingy doctor’s room and managed to score a sofa to lie down. Around me, there were 2 beds, on which 5 residents were sleeping. The room had a typical ammonical whiff, the one you can relate to public washrooms in India. I crashed on the sofa and was dreaming of sleeping like a baby. I felt exhausted. 10 minutes later, my phone began to ring incessantly. I had to go to get blood for a patient. My entire night, I was running here and there, trying my best not to doze off next to the patient’s bed. Seeing the patients and attendants sleep, I genuinely felt jealous, a feeling which as a young doctor I did not like.
The next day was a struggle again. I was sitting in the OPD, half asleep, listening to patients blabber their histories, and me writing medications, mostly by reflex. I couldn’t articulate much or use my logic and reasoning to evaluate what the patient needed.
The long duty hours, the weird timings of sleep, and no leaves for 4-6 months at a stretch continued. As I became a resident it increased tremendously.
Who is a resident doctor?
A resident doctor or a Junior Resident is the one, who is pursuing his post-graduation in a particular medical specialization. The term “resident” comes from the fact that they spend most of their time during training in the “house” or the “hospital”.The aim of this program is to install knowdlegd and skill into these students so that they can save lives. In the name of inducing these skills, residents are made to work long shifts, do inhumane hours of work every week, and are made to feel guilty or unprofessional on asking for leaves.
Is it the same everywhere?
Almsot! Or rather it was!
In the USA, it took the death of a young female, Libby Zion, in 1984. Although the case is highly controversial, the family of this patient, sued the hospital over compromised care by an “overworked” resident doctors. And finally came the reform to resident work hours.
The USA has a uniform 80-hour workweek for residents whereas Europe has a 48-hour workweek. India also has a law, Uniform Central Residency Scheme, which states –
Continuous active duty for resident doctors will not normally exceed 12 hours per day. Subject to exigencies of work the resident doctors will be allowed one weekly holiday by rotation. The resident doctors will also require to be on call duty not exceeding 12 hours at a time. The junior Residents should ordinarily work for 48 hours per week and not more than 12 hours at a stretch subject to the condition that the working hours will be flexible as may be decided by the Medical Superintendents concerned keeping in view the workload and availability of doctors for clinical work.
This law was essentially built on line similar to the USA reforms. But implementation? As usual. FAR FAR FROM REALITY.
Residnets have a lot on stake – their thesis, degree, being patented as unprofessional, seniors not teaching them and whatnot. They have no other option but to mum their voices and keep working. That too at a meagre wage. Almost like bonded laborers. The brightest minds are turned into this.
One thing that commonly springs up about the hours of work is continuous care – Residents if not on duty continuously(24-48 hour shifts), do not get to observe the continuous care of the patient. How he is managed before surgery, during surgery, and what happens after the surgery. This creates a major lacuna in training. I feel that other workable methods, dummy cases, academic classes, or schedules to ensure continuous care should be made. This should not be used as an excuse to blatantly exploit these students of medicine.
A doctor must work 18 hours a day and seven days a week.
If you cannot console yourself to this, get out of the profession.”Dr. Martin H. Fischer, University of Cincinnati, professor of physiology 1910-1950
Does the long working hours affect how good a doctor one becomes? Or patient care?
Most of the scientific studies at present say NO. No such difference exists.
I personally feel I would learn more and serve the patient better if I am allowed to get adequate sleep. If I am working on a 48-hour shift, my chances of committing a mistake are much higher. And a mistake in our profession can cost someone their life or their limb.
Also, having a sound work: personal life balance is a must. Doctors mostly are engrossed in their profession. They barely get time when young to explore, and once they grow, they stop enjoying the pleasures of life.
Having a personal life, traveling, having a beer, or even wearing a bikini can be taken as unprofessionalism, as evidenced by the recent article in a reputed journal. The high burn our rates have always been a problem signifying the toxic nature of the profession and work culture.
In the aviation industry, pilots are responsible for lives and thus, their shift is fixed to 8 hours. It is mandatory to have the next 12 hours off. Similarly, even truck drivers have fixed shift hours of working, since the loss of attention due to lack of sleep can be fatal for the drivers as well as the business.
But are we okay to be treated by a doctor who hasn’t slept for the past 36 or 48 hours? Do we expect that he will not commit a mistake? Do we realize that a mistake by this sleep-deprived human can lead to loss of life for someone else?
The world has changed. The medical profession needs to change too. Doctors at the end of the day, are normal humans, who deserve to live a fulfilling life. They give life and happiness back to people. I wouldn’t want another generation of sad and frustrated doctors to exists ever again. How are the work schedules and environments in your professions? Drop-in your views on the same!