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British orthopaedists face roadblocks for training times
The impending introduction of the final phase of the European Working Time Directive has caused increasing concern for the maintenance of surgical practice and training in the United Kingdom.
In August, British legislation will reduce the maximum working week for all doctors in the National Health Service (NHS) to 48 hours. The previous reduction from 72 to 56 hours in 2007 coincided with the introduction of a new shortened training scheme to replace Calman specialist training that took a minimum of 6 years. The result was predictable in light of an apparent need to move away from the old “on-call” work patterns, where junior staff worked with the same seniors to provide continuity of acute care in an apprentice-style system.
In their place, rotas were designed on a shift system to provide physicians with the necessary days and nights off and to protect the new formalized education programs. These rotas incorporated a structured curriculum designed for the instruction of trainees in their chosen specialty, which improved their theoretical knowledge but at the expense of hands-on practical operative experience under the supervision of a consultant.
Filling in the gaps
The resultant gaps in the out-of-hours junior have been filled by additional non-training-grade medical posts or nurse practitioners. Unfortunately, we cannot sustain this solution any longer with the decreasing number of doctors from overseas prepared to take such posts and the increasing criticism of the standards and continuity of patient care.
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At the time these radical changes to training and work patterns for junior staff were being introduced, the British government made increasing demands on senior staff in the NHS to provide a consultant-delivered service for both emergency and elective surgery.
The necessary expansion of the consultant workforce has not kept pace with this requirement, however, and the difficulties have been compounded by patient “throughput” targets that allow little time for supervising trainee operations. The potential threat to surgical practice in the medium term is that this care will be provided by younger surgeons who lack the broader operative experience necessary for independent practice.
The potential crisis has been highlighted by John Black, president of the Royal College of Surgeons of England, in his monthly newsletter. In it, he warned, “With nobody able to work more than 48 hours a week, the effects on patient care are potentially disastrous.”
Trainees want instruction
Perhaps what is most surprising, the surgical trainees themselves have been openly critical of these new working conditions designed to protect their family and leisure time, but which they see as limiting their opportunities to obtain practical operative and procedural experience. A large majority of them advocate a return to a working week of around 65 hours based on an on-call system.
Theoretically, this should be a problem affecting all of Europe, but other countries do not seem to be experiencing the same difficulties. Is this because their health care systems are different, supporting a greater use of post-training specialist fellowships, or does it reflect a policy of non-compliance?
What can the United Kingdom learn from them? I invite feedback from our readers in other countries as to how they see a resolution to this difficult problem.
For more information:
- David L. Hamblen, PhD, FRCS, is professor emeritus at the University of Glasgow and is the consulting editor for Orthopaedics Today Europe. He can be reached at ote@slackinc.com.