EWTD and Surgical Training

When the European Working Time Directive is implemented on August 1st this year the effect on the NHS and patient safety is likely to be catastrophic.

The immediate effects on patient care are potentially disastrous because there simply aren’t enough surgeons in the UK to fill the gaps in rotas when every doctor’s hours are cut to a 48 hour maximum.

This means that employers will be forced to find extra manpower to cover the unfilled shifts, which is being achieved either by employing their own doctors as “internal locums” or by forcing additional cross-cover between specialties. Neither solution is ideal, with the former making a mockery of the claimed need to reduce hours in order to eliminate fatigue and the latter leaving junior doctors covering specialties in which they may have had little or no training and experience.

A longer term problem is that junior doctors are telling us they can’t get enough experience in the operating theatre and clinics in order to progress on the shortened hours.

As far as the Association of Surgeons in Training (ASiT) is concerned the choice is clear; do we want patients to be treated by a group of highly skilled and experienced surgeons, or be passed around a wider group of lower skilled surgeons with less experience.

As the immediate past President of ASiT I agree that a complete opt-out of the directive for all surgical specialties is the only solution which will protect junior doctors’ training. We want junior doctors to be able to work up to and no more than 65 hours a week including on-call.

This will ensure that we are able to produce safe, properly trained doctors who are able to cover the workload required by hospitals. We simply cannot maintain safe surgery in the NHS on a 48 hour week.

65 hours is not a figure we have just plucked out of the air. Earlier this year, ASiT, along with the British Orthopaedic Trainees Association (BOTA) surveyed over a thousand of our members and concluded that 65 hours a week is the optimum number of hours required to gain the necessary training opportunities a trainee surgeon needs.

Of those surveyed more than 80 percent said they would support a complete opt-out of EWTD to protect their training.

71 percent of respondents reported that the reduction in working hours had not led to an improvement in their work life balance, while 68 percent reported a deterioration in the quality of their training and operative skills as a result of the shift working patterns that have been brought in to meet working time regulations.

This completely contradicts Department of Health propaganda that EWTD will mean less tired and safer doctors.

We know that shift working has been shown to lead to more fatigued doctors and increased medical errors when compared to 24 hour on-call rotas.

Because of the ludicrous shift patterns trainees often end up working through the night where they have very limited exposure to surgical training.

This is further compounded by the European Court ruling that time spent in a hospital must count as ‘work’.

If a trainee is asleep in an on-call room at night the time must be counted as work, and he or she must leave the hospital at the start of the next working day, missing out on that entire day’s opportunity both to treat patients and to gain valuable operative and clinical training experience. This is an absolute waste and utterly frustrating for trainees.

When doctors were allowed to work longer hours it was routine to work in teams who would carry out elective work as well as dealing with emergencies.

A 48 hour week means that there are not enough surgeons to provide a team to cover, and where there used to be two or three surgeons there is now only one on-call.

The irony is that the lone on-call surgeon will be so busy looking after the same number of patients that they will have no time to rest. Although they are technically working shorter hours, they will be rushed off their feet and constantly stressed – often without the tiers of support that their predecessors enjoyed.

Add to this a lack of training opportunities and being forced to work a system that is unsafe results in a law that, although intended to make life better, actually makes doctors more tired while ruining training and job satisfaction.

Regular monitoring of junior doctors training quality has shown that trainee surgeons are less and less able to get into the theatre to learn. Almost half of junior doctors in the first two years of surgical training go to theatre fewer than three times a week and one in 15 does not go at all.

Surgery is a craft specialty and requires significant exposure to hands-on training. One effect of the initial reduction in working hours to 56 per week in 2007 has been the number of logged index procedures performed by surgical trainees.

Studies have consistently shown a greater than 20% reduction in operative cases performed. A move to a 48 hour week from August 1st will inevitably reduce the number of procedures carried out even further.

Nobody wants to go back to the days of working over a hundred hours a week but we know that under the current rules and regulations junior doctors are not getting the opportunity to operate.

They know they’re not progressing as well as they should be, consultants know they are not progressing, and it is becoming apparent that today’s trainee surgeons are not going to be as experienced as in previous generations.

One trainee who spoke out recently said that in one 12 week period she had taken out three sets of tonsils, removed a cyst and drained two abscesses under supervision. In one week she made it into the operating theatre on just one day where she had three hours of supervised training. This isn’t enough.

As a comparison, during the earlier parts of my training, emergencies were covered by a team (or firm) of doctors who worked together on a daily basis. When their consultant was on-call the team was responsible for seeing, admitting and managing the emergency patients – usually for a 24 hour period. This meant that the same doctor could see and vitally, reassess a patient in order to detect subtle changes that would guide the very best management. As a bonus the regular team approach meant that there was always adequate cover and supervision and the relationships that developed meant that individuals got far more to do, with their seniors having an accurate impression of their abilities and level of competence.

Hospitals are so short of doctors that instead of gaining valuable training time junior doctors are undertake non-training service provision tasks such as covering clinics, doing ward rounds and admitting emergency patients.

It is also becoming commonplace for trainees to switch between different trainers, depending on which part of the week they are in the hospital, therefore eradicating the mutual build up of trust between trainee and trainer that should be at the very core of surgical training.

It has been suggested that we simply lengthen training time. This would not work in surgery as it would be impossible to obtain the requisite experience and intensity of training required to be a competent surgeon.

ASiT fully supports the Royal College of Surgeons who are completely opposed to lengthening training and whose strategy remains to have a complete opt-out of EWTD for surgeons.

It is totally negligent of the Department of Health to continue to push this directive through and I urge them to act now for the sake of patient safety and the future training of doctors.