European Working Time Directive (2)
Editor – We note with interest the findings of McIntyre et al (Clin Med April 2010 pp 134–7), although we question the conclusions they reached regarding the role of the European Working Time Directive (EWTD) in increases in sickness absence among junior doctors. Not for the first time, the implementation of the EWTD has been linked to negative effects on junior doctors' fatigue and well-being.1 However, we believe that the heightened problems should not necessarily be blamed on the EWTD itself. It is our contention that many of the problems have arisen because of the way in which employers responded in their attempts to comply with the EWTD. While the new work schedules may conform to the EWTD's stipulations (eg a minimum daily rest period of 11 hours), they often fail to take into account other parameters which, although not covered by the EWTD, are nevertheless vital considerations in the management of fatigue.
We recently reported the findings of a large-scale survey of junior doctors in which we showed that such additional parameters are important determinants of the likely impact of EWTD-compliant work schedules on junior doctors' fatigue and well-being.2 For example, working more frequent on-calls (either at weekends or during the week) was associated with increased psychological strain and work–life interference, while being restricted to only one rest day after working nights was associated with greater fatigue. In support of the EWTD stipulations, we found that working >48 hours per week and short rest inter-shift intervals were both independently associated with increased fatigue. We also demonstrated that working seven consecutive nights was associated with greater accumulated fatigue and greater work–life interference, compared with working just three or four nights.
We would therefore argue that it is difficult to draw any firm conclusions from the study of McIntyre et al regarding the cause of increased sickness absence among doctors following the introduction of the EWTD-compliant working time arrangements, without knowing the way in which the new schedule was implemented and what changes in work schedule features were involved.
Footnotes
Please submit letters for the editor's consideration within three weeks of receipt of Clinical Medicine. Letters should ideally be limited to 350 words, and sent by email to: Clinicalmedicine{at}rcplondon.ac.uk
- © 2010 Royal College of Physicians
References
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- Murray A
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- Tucker P
European Working Time Directive (2)
In preparing our manuscript we found little formal research into junior doctor welfare. It seems paradoxical that the European Working Time Directive (EWTD) sought to improve this measure without a clear understanding of how this might best be attained. In the face of constant demand, a reduction in trainee hours without increase in numbers permits four scenarios that allow medical care to continue safely. The first is that prior to the reduction in hours there was large inefficiency (>10%). This has not, to our knowledge, been demonstrated. If such inefficiency were not present then, as Medford suggests, either work is being redistributed, omitted or compressed. Significant redistribution of medical work would be needed to cover the loss of nearly one seventh of the medical workforce. While nursing sickness rose during the period covering the introduction of the 48-hour week this finding is confounded by simultaneous alteration to bank staff remuneration which resulted in lesser bank usage. We do not have accurate data on consultant sick leave. Our finding that inpatient mortality and duration of hospital admission were not compromised supports the interpretation that work was not omitted. We may then speculate that work compression and task density must have increased. This effect will be amplified, as we indicated, with higher rates of sickness in a smaller group of trainees. Medford notes that the measurement of work compression and the impact of such compression upon trainees is difficult to assess, however, we found significant psychological stress in two of 15 trainees in a small (non-validated and unpublished) follow-up study. This merits further research.
We welcome the comments of Tucker and Folkar and note their contention that it is not the reduction in hours per se but the response of the employer, through rota design, that may be responsible for any negative effects. Underpinning this conclusion must be the fundamental assumption that that the same workload can safely be achieved, for both patients and staff, with reduced hours and less staff. Little guidance was available in meeting the 48-hour limit. We agree that enhanced rota design might improve the impact of EWTD implementation, but note that the authors refer to the ‘likely (our italics) impact of EWTD-compliant work schedules’. We are thus unclear if they were able to show that it is possible, without increasing staff numbers, to construct such a rota, meet full EWTD compliance and maintain workload and safe patient outcome? We would thus be concerned if attention were prematurely drawn away from the reduction in hours towards the responsibilities of the employer. We acknowledge that there are many uncertainties. Although our study has obvious limitations we sought to be as objective as possible in an attempt to lessen the speculation of ourselves and others. Contrary to the expectation of some, we did not find a reduction in standards of care. We did, however, find that sickness among trainees was markedly increased. This requires explanation. Surely trainees deserve more formal assessment of alternative ways of providing safe patient care while meeting EWTD compliance before it can be confidently stated that a working week of 48 hours is good for their welfare and training? We would hope such a view is shared by Tucker and Folkar and endorsed by all those with responsibility for junior doctors.
Footnotes
Please submit letters for the editor's consideration within three weeks of receipt of Clinical Medicine. Letters should ideally be limited to 350 words, and sent by email to: Clinicalmedicine{at}rcplondon.ac.uk
- © 2010 Royal College of Physicians
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