Safe and appropriate health care, especially in urgent or emergency situations, is the expectation of the public throughout the developed world. Achieving this goal requires appropriate levels of medical and other staff, appropriate training, and sensible working hours. Too often the brunt of such care, especially in out-of-hours situations, is borne by medical residents, who – to make matters worse – are frequently poorly supervised by more senior and experienced staff. Many jurisdictions have been alerted to this problem and are striving to correct it. However, the variation in attempts to restrict the actual hours worked by residents to “safe” levels is enormous, and all too often there is no consensus as to what should be put in place to achieve safe patient care. This paper sets out the current position for Europe, North America, and Australia.
The volume of hours worked by medical residents has been a concern for years. The realization that tired, inexperienced, and poorly supervised doctors make more mistakes than those who are fresh, alert, and closely guided has become apparent everywhere. And yet there remains a huge variation in the implementation of controls over the actual hours worked, the environment available for learning, and the degree of real supervision afforded to these young professionals.
Variation is seen both between countries with supposedly modern health care delivery systems and within the health systems of those countries themselves. What should be the role of medical residents? Should they be viewed as practitioners primarily, who provide service and attain further learning by clinical exposure (and, some would say, experience), or are they genuinely doctors in training, for whom every clinical event should be an appropriately supervised learning opportunity?
The former system has resulted in a random, unstructured, arbitrary, and often patron-dependant method of acquiring the necessary skills to be competent for independent clinical practice. The latter process, which has gained more recognition if not actual implementation in recent times, still has a long way to go before it becomes the accepted and quicker route to senior levels of service and care delivery. This paper reports on some of the systems and situations around the globe concerning the statutory regulation—or lack of it—as to what constitutes good practice leading to appropriate training of young doctors and, ultimately, safer patient care.
The case of Libby Zion, an 18-year-old woman who died while under the care of residents in a hospital emergency department in New York City in 1984, was the original stimulus to resident duty hour reform. The publicity that surrounded this case highlighted and subsequently influenced attempts to regulate the completely unrestricted hours worked by residents in hospital practice throughout the world. Subsequently, the lead in the journey of restricting hours was taken by Europe. The European Working Time Directive (EWTD), issued by the Council of Europe to protect the health and safety of all workers in the European Union, became law in 1998. It empowered a set of minimum requirements, including the following:
- a maximum work week of 48 hours
- a minimum rest period of 11 consecutive hours per 24-hour duty
- a minimum rest period of 24 hours per 7-day duty, or 48 hours of rest per 14-day duty
- a minimum of 4 weeks of paid annual leave
- a maximum of 8 hours’ work in any 24 hours for workers in stressful positions
- a minimum 20-minute rest period per 6 hours worked
The following section will review the outcome of the EWTD for medical residents since its implementation.
Official information remains extremely hard to gather or collate. An official European Union document reporting country-by-country compliance with the EWTD was due for publication in 2008 but has still not been released. The current situation of the 48-hour EWTD is as follows. There are beacons of achievement. Denmark has been compliant with the EWTD for many years and has a normal work week of 37 hours. Sweden and Germany indicate good compliance.
Finland is probably compliant. The Netherlands reached compliance during 2011. Norway, which is affiliated with the European Union but is not a full member, trains young doctors in a weekly average of 45 hours. The United Kingdom reports compliance now, but recent research suggests that up to 25% of junior doctors are still working beyond the 48-hour limit. Compliance figures are not available for 11 countries, namely Austria, Belgium, Bulgaria, Cyprus, Czech Republic, Italy, Luxembourg, Malta, Portugal, Slovakia, and Slovenia. There is anecdotal evidence that many doctors in Spain, Ireland, Greece, and France are working more than the regulation 48-hour week, often without additional pay.
Poor working conditions and excessive hours, but no hard data, are reported anecdotally in Estonia, Latvia, Lithuania, Poland, and Romania. However, many of this latter group joined the European Union relatively recently and were not previously subject to the EWTD. In the United Kingdom, the full implementation of the 48-hour EWTD in August 2009 led to widespread concern about the ability of the National Health Service (NHS) to continue to deliver both high-quality training for its staff and safe clinical service. In the health care sector, the EWTD was found to affect only doctors and, more specifically, only those in the secondary care sector.
The 2010 report Time for Training found that although “high quality training can be delivered in 48 hours” in the NHS, “this is precluded when trainees have a major role in out of hours service, are poorly supervised and access to learning is limited.” Thus, only 6 of the 27 European member states meet the prescribed standard, some 14 years after the EWTD became a legal requirement. In view of this lack of success, renegotiation of the 48-hour restriction, along with other factors, has been requested, but it will take a very long time for any revision to be agreed, let alone put into practice.