All junior staff in training in all specialities in the. Cardiff area were circulated. Three hundred and twenty-six questionnaires were sent out and 202 were returned ...
Journal of the Royal Society of Medicine Volume 87 June 1994
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Junior doctors' hours: what do they really think?
S West MBBS SHO S Weight MBBS SHO B J Jenkins MChir FRCS T P Stephenson MS FRCS Department of Urology, Cardiff Royal Infirmary, Newport Road, Cardiff CF2 15Z, Wales, UK
Keywords: quality of care; medical training; socio-economic factors
Summary Junior doctors' hours are one of the most controversial topics under debate in the health service today. We undertook a detailed postal questionnaire of hospital doctors in training within a major teaching unit in order to assess the awareness and perceived implications of the incipient changes and to elucidate how it was felt these changes would affect both the doctors and patients. The questionnaire focused specifically on the effect of the changes on quality and continuity of patient care, junior training and socio-economic factors relating to the medical staff. The questionnaire was entirely anonymous and carried only the first author name but provision was made to determine current grade, speciality, age, sex and career plans of the respondents. Importantly, space was included at the end for pertinent comments. All junior staff in training in all specialities in the Cardiff area were circulated. Three hundred and twenty-six questionnaires were sent out and 202 were returned of which 192 were properly completed (59%). Almost everyone was au fait with the proposed changes. There was a surprisingly high level of support for changes among non-surgical trainees, and half felt that quality of care would improve, though the more senior the trainee, the less enthusiastic they were in all aspects. Many felt that far too little consultation with junior staff had taken place and there was generalized criticism of general practitioner trainees by their specializing counterparts, partly because of a perceived lack of commitment and partly because of blame of this group for the inception of the changes. Most importantly, there was solid opposition among surgeons in training because of a perceived reduction in patient care, compromise in quality of training and a belief that the system is unworkable [only 9% of registrars and senior registrars and 25% of senior house officers (SHOs) and housemen planning a surgical career were in favour of change]. It is clear that different specialities need to be assessed separately. For example, the requirements for covering a partial shift system for special baby care, or anaesthetics are very different from the on call requirements of dermatology or urology. It is inappropriate to put every speciality under the same umbrella and this should be rethought before the introduction of the 72 h week results in unnecessary but predictable chaos.
Correspondence to: Mr T P Stephenson
Introduction Government requirements demand a reduction in junior doctors' hours to 83 per week by April 1993 and to 72 per week by December 1994. These guidelines were imposed after widespread committee consultation but inadequate assessment of the views of the majority. The instigation of these guidelines has led to the formation of regional task forces to ensure junior doctor posts will meet the new limitations by the required dates. Conflicts between clinicians and administrators over changes required; difficulties in achieving suitable rotas even to achieve an 83 h week; and a perception that it is inappropriate to treat every speciality in a similar way despite huge disparities of on call work commitments led us to conduct a survey to establish who felt changes were necessary and how doctors in training felt the changes would affect them.
Subjects and methods Cardiff has a fairly typical medical school and teaching hospital environment with three major acute hospitals, and satellites serving oncology, psychiatric and psychogeriatric specialities. A comprehensive questionnaire was circulated to all junior staff addressing most aspects of the proposed changes and the potential advantages and disadvantages (see Appendix). It assessed initially awareness of the changes, satisfaction or otherwise of the current hours; and which of the proposed rotas were preferred. Specific questions were asked about how the changes would affect quality and continuity of patient care, adequacy of post-graduate training, professional relationships with other staff, and the effect on overall income and social and domestic life. Although the questionnaire was entirely anonymous, provision was made to determine current grade and speciality, plus age, sex and long term career plans. At the end space was included for pertinent (often extremely pertinent) comments to be made, and whether he or she was in favour or against the changes, or neither. Results Three hundred and twenty-six questionnaires were distributed, and of 202 returned, 192 were properly completed (59%). All but 5% were aware ofthe planned changes (though not necessarily of the implications thereof). Throughout the replies, the more senior the trainee (and therefore the more committed to a specialist career) the greater was the likelihood of being satisfied with the current status, and this was overwhelmingly so among the surgeons. Thus, 69% of
Paper read to Section of Urology, 23-30 January 1993
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Journal of the Royal Society of Medicine Volume 87 June 1994
Table 1. Specific effect of changes Better Worse Unchanged Patient care Continuity of medical cover Adequacy of junior training Professional relationships with NHS staff Income Social life Domestic and family life
52% 13% 24% 42%
23% 56% 38% 19%
25% 31% 38% 39%
2% 75% 77%
88% 13% 14%
10% 12% 9%
NHS=National Health Service
senior registrars were satisfied with their current hours (though many of the non-surgical group were in favour of change), but only 36% of pre-registration house-officers. Across the board, most felt that 72 h was adequate to satisfy training requirements and provide adequate patient care, but very few at the time of the questionnaire (November 1992) had been involved in the difficulties of achieving rotas to reduce hours to even 83 h a week. Furthermore, of the 21% who felt that 83 h or more were required to satisfy patient care, all were surgical trainees. The majority of all grades favoured an on call system, but 28% were equally split between preference for the full and partial shift options (but again, at the time of completion of the questionnaire, virtually none of them had actually been involved with either). The more specific questions on patient care and socio-economic factors are shown in Table 1. The only really surprising aspect was so many believing that patient care would be improved, but details from the 'pertinent comments' section indicated that most felt that they would be less tired and therefore work better. Nobody seemed to mind much about the inevitable loss of income. Overall, despite so many being satisfied with their current hours 60% were broadly in favour of the changes. However, when these results were separated into surgical and medical specialities, the more senior surgical trainees were overwhelmingly against the changes - only five in favour (91% physicians and 9% surgeons in favour; 36% physicians and 64% surgeons against). Even at a more junior level where career commitment was less certain, there was still a heavy bias against the changes amongst the surgical trainees (75% physicians and 25% surgeons in favour; 36% physicians and 64% surgeons against).
Discussion Although there was an overall majority in favour of the changes (60%), the most striking result of the survey were the small number of surgeons in favour of the changes (9% at a senior level and 25% of the SHOs and housemen planning a surgical career) and, judged by their comments, the vehemence with which these views were held. Most of the other conclusions were fairly predictable, though one important aspect was that those who had actually worked partial or full shift systems disliked them and felt that failure of proper patient hand over led to poor continuity of care. This was also stressed by those involved in crosscover of other units where they knew neither the patients nor the work practices. Furthermore, the
difficulties involved in restructuring rotas to achieve an 83 h week, and the additional staff required where this cross-over is not possible (in anaesthetics for example) has indicated that further reduction to 72 h by the end of 1994 is probably impossible, because the additional manpower is unlikely to be available, and certainly clinically dangerous in some specialities, regardless of the effect on training. The following quotations from the 'pertinent comments' column was particularly illuminating and indicative of how strongly views are held: Changes do little to improve work enjoyment. The whole shambles has been organised by GP trainees and psychiatrists with no moral backbone or stamina and no intention of a hospital career [SHO] No experience=no experience ... The GP trainees have sold everyone who wants to do hospital medicine down the river [SHO] Fragmentation of the work load, poor continuity of care and greater intrusion into weekends [Registrar]
Perhaps the two most important comments, though, were less vitriolic and more thoughtful. Surely it is undemocratic to make it illegal to work after contracted hours - where is freedom of choice? [Senior registrar] Labelling all jobs the same is a bad move. All specialities should be looked at individually [Houseman]
Unsurprisingly these are carefully selected comments to support the premise to oppose further change at least in some specialities, and all were taken from surgical trainees. Nevertheless, if this survey is representative of the previously silent majority, it seems essential to assess different disciplines individually, and it appears questionable whether it is either desirable or legal to impose limitations on professional trainees. What other professional body has such rigid restrictions? Some major rethinking is required.
Appendix. Questionnaire on junior doctors' hours Please answer the following questions as accurately and as truthfully as possible. The answers that you provide will be treated with the strictest of confidence. They are intended to assess your understanding of the new laws with regard to junior doctors' hours. Please circle or tick the most appropriate answer in each case.
(1) Prior to this questionnaire were you aware ofthe changes to be implemented in junior doctors' hours? YES NO UNCERTAIN (2) Are you satisfied with the number of hours which you are presently required to work? YES NO (3) How many hours do you think you need to work in order to satisfy your training requirements and give adequate
patient care? >90 83 83 72
