Impact of reduction in working hours for doctors in training on postgraduate medical education and patients’ outcomes: systematic review
BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d1580 (Published 22 March 2011) Cite this as: BMJ 2011;342:d1580
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Dear Editor,
This interesting paper provides good insight about measures to know
the impact of reduced working hours on training of emergency care
specialists. The benchmarks identified to measure performance needs
further validation and comparison with outcomes prior to introduction of
reduced working hours.
Measures need to be implemented to improve education. Some of the
suggestions are listed below which will certainly help in this regard to
achieve competencies in better way.
- Teachers need to provide effecive education with good quality feed
back to improver performance of trainees
- Information technology use alog with use of simulators to perform
procedures of increasing complexities
- Gaining competencies as described in curriculum described for
various specialties e.g. ISCP curriculum for surgical training
- Regular assessment of achievement of learning goals by effective
learning and teaching
- Problem oriented learning with emphasis on critical thinking
- Establish supportive learning environment and increasing learning
opportunities in out of hours clinical practice
- Encourage active participation and increasing leadership role by
trainees in various clinical situations
- Encourage participation in journal clubs, teaching and audit
sessions
- Encourage self directed learning and development of didactic skills
- Awarness of own limitations
- Participation in grand rounds and procedural workshops
Following these tips will help to achieve our goal of better
education and skills in less working hours work pattern.
Competing interests: No competing interests
Moonesinghe and colleagues found that a reduction in working hours
probably has no tangible effect on postgraduate training or patient
outcome.1 Unfortunately, there may be more far reaching consequences to
postgraduate medicine in the UK that are not yet reviewable.
The erosion of the team structure by shift work is leading to a loss
of professional identity among junior doctors. Less and less time is spent
working in a 'firm' with consequent loss of the benefits of this
structure. These include mentoring, education and performance feedback
which are known to decrease stress and increase job satisfaction.2;3
Consultants too are finding themselves with few or no team members
and are increasingly working in isolation. This could easily damage
patient outcome in addition to generating disillusionment which will
filter through to juniors already being put off postgraduate hospital
careers.
Historically, hours were long but satisfaction was higher.4 Reducing
hours with shift work within the current system risks disillusioning a
generation who will not work with the same team structure or professional
satisfaction of their forbearers. This could damage both medical education
and patient outcome. By the time the effect is systematically reviewable,
it may be too late.
(1) Moonesinghe SR, Lowery J, Shahi N, Millen A, Beard JD. Impact of
reduction in working hours for doctors in training on postgraduate medical
education and patients' outcomes: systematic review. BMJ 2011; 342:d1580.
2) Joyce CM, Schurer S, Scott A, Humphreys J, Kalb G. Australian
doctors' satisfaction with their work: results from the MABEL longitudinal
survey of doctors. Med J Aust 2011; 194(1):30-33.
(3) Jaffer U, Pennell A, Musonda P. General surgical trainee
experiences of mentoring: a UK regional audit. J Surg Educ 2010; 67(1):19-
24.
(4) Taylor K, Lambert T, Goldacre M. Career destinations, views and
future plans of the UK medical qualifiers of 1988. J R Soc Med 2010;
103(1):21-30.
Competing interests: No competing interests
Dear Editor
The paper by Moonesinghe et al raised a number of important issues.
In the UK the European working time directive has caused a detrimental
impact to the exposure of juniors, probably more so than our American
counterparts whose working hours are still comparatively long.
In the setting of a stretched NHS, consultants are under increasing
pressure to give preference to patient provision and 'productivity'
targets over educational supervision.1 This together with shortening of
training programmes, reduction of working hours, ethical imperatives to
protect patients from harm, and the fact that opportunities for training
within a clinical setting are unpredictable, have a profound effect upon
traditional approaches to training.2 In the UK there has been a move to
focus upon the quality of training experiences and the use of work placed
based assessments and reflective practice. This may produce acceptable
outcomes in some specialties, but in skill based e.g. surgery, the
reduction in hours will undoubtedly lead to less clinical exposure.
Consequently this can lead to a mismatch between the expectations about
what educational objectives can be achieved and what the actual clinical
teaching environment can provide,3 meaning juniors have the potential to
be short changed in their training. However the current situation offers
an opportunity to modernise and focus training programs through
optimisation of learning environments.
Emphasis needs to be placed on changing attitudes to that of
promoting teaching at all times in the clinical setting. Trusts need to be
mindful of this rapidly changing environment and the responsibility they
have to their junior doctors.4 It is essential for the future of the NHS
that consultants can facilitate trainees to be interactive, work
collaboratively and learn through exploration. This may require steps such
as devising job plans to ensure that adequate supporting professional
activities (SPAs) are designated to medical education and allowing shorter
procedural and outpatients lists to ensure more training time. This is
again an opportunity to empower trainees to have personal responsibility
for focusing their training opportunities to what they feel is their
deficiencies, which would undoubtedly stand them in good stead in their
continuing professional development.
Failure to recognise the clinical area as the learning environment
will give rise to two problems. Firstly there will be an increased
reliance on non clinical learning environments, such as the use of
simulation, which can undermine the development of 'real life' and
interpersonal skills.5 Secondly future consultants may not be of the same
standard as their predecessors, whose training was more extensive and not
subject to restrictions, which ultimately may have a detrimental impact on
the quality of patients' care.
1. O'Neill PA, Owen CA, McArdle PJ, Duffy KA. Views, behaviours and
perceived staff development needs of doctors and surgeons regarding
learners in outpatient clinics. Medical Education. 2006;40:348-354.
2. Kneebone R, Nestel D, Wetzel C, Black S. The Human Face of Simulation:
Patient-Focused Simulation Training. Academic Medicine. 2006;81(10):919-
924.
3. Jolly B, Harris D, Peyton R. Teaching with Patients. In:Peyton RJ.
Teaching & Learning in medical practice. Guildford: Manticore; 1998.
4. Lesky LG. The Ever-Widening Training-Practice Gap. Academic Medicine.
2007;82(3):219-221.
5. Hanna M, Fins JJ. Viewpoint: Power and Communication: Why Simulation
Training Ought to Be Complemented by Experiential and Humanist Learning.
Academic Medicine. 2006;81(3):265-270.
Competing interests: No competing interests
Dear Sir,
I read this article with interest. As a Senior Faculty Attending
Physician at one of the leading teaching medical institutions in the
United States, I have had close interactions with the trainees (residents
and fellows). My impression may sound anecdotal but other Attending
Clinicians have also voiced their findings.
Contrary to the authors, I do not believe in any of the results of
the published studies performed in the United States after 2003. The truth
may never come out. The recommendations set forth by the Accreditation
Council for Graduate Medical Education (ACGME) have put us (Faculty
Members) and the trainees in a very difficult position.
We, the trainers, have the moral duties and obligations to train the
trainees to achieve independent practitioner status (either specialists or
primary care providers) after the completion of their residencies. This
aim must be achieved at all costs while maintaining patients' safety and
improving their outcomes. The trainees also have the moral
responsibilities to learn, to train and to take care of patients. Some
specialties, especially surgical specialties, are very demanding. The
ACGME's recommendation not to let first-year resident work more than 16
hours continuously, may not just be practical, for some neurosurgical
procedures take more than 24 hours. Therefore, at the end of the day, many
residents underreport their duty hours to their program directors at many
institutions. They have even created a term "working under the table". On
paper, everything looks alright.
Pilot studies were performed at some teaching institutions to see if
residents were accurately reporting their work hours. MacGregor, et al,
also concluded that surgical residents did not always record their work
hours accurately and many have concerns about further work hour
restrictions and that the majority (52%) under-reported work hours and
felt that further work hour restriction would be detrimental to their
training[1]. Carpenter et al, also concluded that the ACGME work-hour
restriction have created ethical dilemma for residents and that many
residents (49%) felt compelled to exceed work-hour regulations and report
those hours falsely [2]
References:
1.MacGregor JM, Sticca R. General surgery residents' views on work
hour regulations. J Surg Educ 2010;67:376-80. Epub 2010 Nov 5
2.Carpenter RO, Austin MT, Tarpley JL, et al. Work-hour restrictions
as an ethical dilemma for residents. Am J Surg 2006;191:527-32
Competing interests: I am a Faculty Attending Physician.
Re: Impact of reduction in working hours for doctors in training on postgraduate medical education and patients’ outcomes: systematic review
National Service for the NHS.
The cost of training a medical student is at least £250,000 so it behoves the country to make this investment wisely. We should be ensuring that less students drop out, less emigrate and more work longer in the NHS. It is suggested that a greater percentage of bright school leavers are dropping out than those entering at graduate level and one might surmise that the graduates had thought more about the course independently than the school leavers being pushed by parents and schools.
This current recruitment shortfall is being compounded by increasing numbers of trained GPs leaving the workforce, most significantly GPs approaching retirement, but perhaps more worryingly women in their 30s. It really should be a burning imperative to facilitate women getting back to work after children. Retainers and returners should be the norm and not the occasional. The other reality to be tackled is junior doctors emigrating or having long stretches working abroad. This has become increasingly fashionable recently and certainly has its merits - but also its costs to the Nation.
I would suggest a couple of radical changes so that team GB can get more value out of its doctors. Firstly I would stop medical school entry before 21 to ensure greater commitment from the students the country is investing in. Secondly I would make the grant and maintenance fees an NHS loan which is completely free if the male student does 21 years working for the NHS and maybe women should have a year reduction for every child – in respect of real ‘labour’! If less years are served then I would suggest a pro rata reduction but this loan would be real with the 'get out of gaol' promise once the NHS sentence had been served! Maybe this sounds like a serfdom but it seems fairer that graduates should be making balanced work/financial decisions rather that potential applicants being scared off by frightening training costs. Of course the NHS can recognise jobs abroad as affiliated if it so chooses but the fundamental concept is to get doctors to realise just how much their country has invested in them and paying this back through working for the NHS seems only fair. If you join the forces then in order to get the best training opportunities you sign a Contract for up to 21 years. This makes the investment in training worthwhile and leaving early incurs a financial penalty - why should doctors be different when they cost us all so much more?
Yours sincerely,
Dr John Havard
Saxmundham Health
Lambsale Meadow
Saxmundham
Suffolk IP17 1AS
01728 602022
01728 602083
John.Havard@gp-d83053.nhs.uk
www.saxquax.co.uk
Competing interests: No competing interests