'Counterpoint' is an occasional feature presenting discussion of a topic that is currently under ... some things that can be done with the mixing of skills and.
International Journal for Quality in Health Care 2003; Volume 15, Number 2: pp. 109–110
10.1093/intqhc/mzg026
Counterpoint ‘Counterpoint’ is an occasional feature presenting discussion of a topic that is currently under debate in quality of care circles. We invite readers to submit Letters to the Editor adding their opinion to the topic.
Epimetheus’ responsibility: resident working hours and system redesign Pandora was a beautiful woman, sent to earth by Zeus with a box full of plagues and diseases to be used to maintain the existing power relationship between the Gods and mankind. If the title of the article on residents’ work hours is intended to suggest that the growing feminisation of the medical workforce in Western industrialised countries is the source of major quality problems, we want to object. It was Epimetheus—a man—who could not resist opening the box and therefore it seems only fair to call on all parties responsible for the design of our present health care systems to find a way to accommodate, for all professionals, implementation of work schedules that are societally acceptable and guarantee safety for our patients. In Western Europe the debate on the regulation of interns’ and residents’ work hours has been going on for several decades now. The 1980s witnessed several strikes and other forms of action through which junior doctors tried to reduce their work week that could exceed an average of 80–100 hours. As a result various European Union (EU) countries implemented national legislation. At the EU level, a major step was taken in November 1993 when the EU’s Council of Ministers adopted a directive to regulate certain aspects of the organisation of working time (93/104/EC). The basic objective of this directive was to safeguard the health and safety of workers against the adverse effects of being subjected to excessively long working hours, inadequate rest or disruptive work patterns. Despite recommendations of the European Parliament, the directive excluded doctors in training. In response, the Permanent Working Group of European Junior Doctors, representing the majority of national medical associations in the EU, has been instrumental in lobbying for adaptation of this directive, thus fulfilling a trade union function for all doctors in training who themselves are often in a very dependent situation towards their supervisors/ employers. In April 2000, after a long period of negotiations, the European Parliament and the Council of Ministers agreed that the ‘Work-time Directive’ should cover doctors in training. A 9-year transition period was agreed upon to limit working hours to a maximum of 58 hours effective from August 2004 to be reduced further to a maximum of 48 hours per week ultimately. In the meantime, a European Court of Justice ruling (the SIMAP case) implies that all employed doctors are covered under the Directive and an EU definition of working time has been established including all hours spent on on-call duty.
As in the US, the implementation of these working hour regulations raises problems in EU countries. These were nicely summarised by a representative of the British Medical Association during a meeting of the Permanent Working Group of European Junior Doctors during a meeting in Paris October 2001: ‘The reduction to a 48-hour working week is primarily a workforce issue in problem countries. There are some things that can be done with the mixing of skills and the elimination of non-medical tasks, but essentially, we need an expansion of the medical workforce. Implementing the rest period rules, however, is essentially about changing our patterns of work and this raises major work organisation issues’ [1]. The debate in the US related to the regulation of working hours of interns and residents is strongly linked to safety issues [2] and tends to focus on costs, liability and manpower issues [3,4]. The ‘Pandora paper’ takes a similar approach and brings in arguments of professional ethics (‘until recent years, the physician was committed to his patient and to his work in a different way’). The two solutions described (hiring of outside temporary staff and the loading of extra functions onto senior physicians) sound short-sighted and we therefore share the concerns of the author. Finding solutions, however, requires a broader view of the working hours problem. The problem is not the working time but the way we have designed our professional labour processes and the professional culture regarding teamwork. Of course, a first step will be to have realistic health manpower forecasts that include assumptions about regular working hours in accordance with the legal directives. There will be room in these forecasts for manpower substitution towards nurse practitioners and physician assistants, but this should be realistic and based on empirical data rather than political wishfulness. A parallel step that can be taken immediately is the redesign of the medical working processes. Here the starting point for hospitals is different in different countries. The structuring of hospital staffing structure, the role of consultants and the intertwining of clinical, emergency room, outpatient and daycare functions varies extensively by country. The number of hierarchical layers, structuring of nursing staff, involvement of physicians in hospital management, and employment or entrepreneurial status of medical specialists varies between countries and within countries. We agree with the author of the Pandora paper that more study is needed and we suggest
International Journal for Quality in Health Care 15(2) International Society for Quality in Health Care and Oxford University Press 2003; all rights reserved
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Counterpoint: Klazinga and van Bolderen
more thorough international comparative health services research to assess the various solutions to the redesign of the medical working processes that are already in place. A third step is the redesign of resident training programmes. A modular approach, with more exchange among training programmes of different specialities, can help to strengthen both the educational goals and training efficiency. The Dutch situation, with 60% of medical specialists organised in partnerships within the hospital context, with few hierarchical layers, and with several years of experience with management participation of specialists, can serve as a model. Reduction of working hours of residents is still a major challenge, but over the past decade we have been able to bring average working weeks from 70–80 hours down to 48–60 hours. This is also the case for medical specialists who are not covered by the Work-time Directive but for whom working times have been adjusted through changes in labour contracts. There is still more progress to be made, but overall the medical community has accepted the necessity of working time regulation and regulated working weeks have become part of the professional culture. Forces from within and outside the medical profession make a rethinking of the organisation of medical working processes necessary. The frustration is apparent but a more systematic focus on existing best practices might help us to face the common challenge of realising more acceptable working times for all doctors. By opening Pandora’s box, Epimetheus brought us plagues
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and diseases. The medical profession is specialised in fighting these very disasters; it should therefore be able to cure itself. Niek Klazinga Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands Alex van Bolderen Dutch Association of Employed Salaried Doctors Utrecht The Netherlands Alex van Bolderen is member delegate of the Permanent Working Group of European Junior Doctors
References 1. Coelho EG, Marques E. Proceedings PWG Seminar. Implementation of the European Working Time Directive. Paris, 11 October 2001. 2. Gaba DM, Howard SK Patient safety: fatigue among clinicians and the safety of patients. N Engl J Med 2002; 347: 1249–1255. 3. Lamberg L. Long hours, little sleep: bad medicine for physiciansin-training? J Am Med Assoc 2002; 287: 303–306. 4. Steinbrook R. The debate over residents’ work hours. N Engl J Med 2002; 347: 1296–1302.
