The issue of whether it is possible to adequately train doctors in a 48 hour average week has long been the subject of discussion (some background here). A recent piece in the Guardian raised a number of eyebrows from those on either sides of the argument. The article, written by a healthcare software provider, was essentially saying longer individual shifts would be better for all involved. This point didn’t really resonate with those doing the shifts.
However whenever the EWTD (or technically EWTR) gets mentioned the debate re-opens.
— R. Hansen (@PaedsRH) August 30, 2013
As a member of the Temple report on working hours I was given the opportunity to hear from those of all those involved in training and being trained. As a result I was asked by the BMA (point of note I have never been a member of the Junior Doctors Committee) to write a short article on my personal perspectives. I was surprised to find, despite having written this in early 2010, I still stand by what I said then:
Reflections on the European Working Time Regulations
“In August 2002 I returned to the UK having spent a year in Perth (Western Australia) after my PRHO year (Foundation year one). I had spent it at a children’s hospital and had thoroughly enjoyed my clinical experiences there ; the 80 hour fortnights also helping take advantage of the sun, sea and surf. I retuned to a tertiary neonatal unit in the East Midlands with a degree of disappointment, worsened by the fact I knew I had to start getting my paediatric membership. The fact that the job was “Band 3” didn’t really mean much to me at the time except I knew it would help clear my substantial travelling debts. In practice “Band 3” meant a 4 and a half week run of shifts with only four days off. I look back at that period now with mixed feelings. Without a doubt I went from a neonatal novice to being able to make middle grade decisions within six months. The confidence felt by the end of the job certainly outweighted the utter panic of a first night shift spent peering through Perspex glass wondering how I would get a cannula into the minute bag of skin and bones in front of me. To say I enjoyed the experience would be looking back with rose tinted spectacles. During the runs of long days and evenings you resented every little bleep or request for fluids. The maternity theatre bleep was a clever device never going off when you were being grilled on a ward round but waiting until your hurried lunch break. They would be exhausting shifts whether you did them for 10, 40 or 60 hours a week. However having to do them for 50+ meant you were never truly on top of your game. Fortunately the camaraderie of the team of SHOs (specialist trainees) provided an outlet for times when you became utterly frustrated. I count myself lucky though I have experienced both sides of the EWTR coin and am convinced on which side I prefer it fall.
It is clear one size does not fit all but in paediatrics because of the high demands of out of hours working a suitably staffed rota does provide sufficient learning opportunities within the 48 hour framework. It is unfortunate however that many paediatric rotas are not suitably staffed! My experiences with EWTR have been favourable as I have always been rostered to allow exposure to elements in my training that are not just simply deciding whether a feverish child is ill or not. Others have not been so lucky and Out patient clinics, case conferences or governance meetings which all count as training are easily sacrificed if there is no-one available to clerk the next patient on the assessment unit. Without these opportunities the disadvantages of longer shifts, increased fatigue and less ability to unwind are irrelevant. As a trainee I want to be given the opportunity to train and want the system to flexible enough to allow me to take these opportunities. Ultimately though when frustrated that the systems fails I remember my neonatal job and am glad I don’t have to do it again. However as time progresses my memories will fade and the need to be effectively trained will remain. For paediatrics it is not the 48 hours that is the problem it is the delivery of training within it.”
I have always been clear that training is not one size fits all with the needs of the craft specialties different from the acute ones, and different again from community based services. I wonder as education and training changes over the next decade whether this problem will still persist, and whether I will still feel like this….