Residents' work hour restrictions being debated, set worldwide

In August, working hours for residents and junior staff in Europe were limited to 58 hours per week.

Issue: Issue 5 2004

Governments, medical organizations and hospital officials worldwide have become increasingly concerned about the long hours that residents spend working and training to be orthopaedic surgeons.

Although few good studies exist that prove exactly how being overtired after working consecutive shifts without adequate rest impacts young residents, many researchers argue that a resident’s performance, competency and judgment can be significantly affected. There are well-documented cases of individuals being too tired to drive home safely after a night shift or so fatigued that their ability to operate and perform other procedures is severely impaired.

To combat some of these problems, a movement is underway in several countries to decrease residents’ work hours. For example, changes governing residents’ work hours went into effect in the United States on July 1, 2003. Medical residents there are now limited to working an average of 80 hours per week over a four-week period, and are required to be off for one 24-hour period per week.

On Aug. 1, European health care systems limited the number of hours junior medical staff can work to 58 hours per week, as defined by the European Working Time Directive (EWTD). According to the EWTD, those hours will drop to 56 per week in 2007 and eventually to 48 hours a week starting in 2009.

Impact on surgery

“The problem of junior staff work hours is a very real one in the United Kingdom and is particularly impacting on surgery, where there has always been a tension because of the mismatch between service commitments and training time requirements,” said David L. Hamblen, PhD, FRCS, medical editor of Orthopaedics Today.

The August 1 deadline for reduced hours passed without incident in the United Kingdom.

For years, medical residents in Europe were trained using a 72-hour workweek. However, several countries have joined the movement to cut back residents’ work hours, something many residents say they want and need in order to devote more time to the training aspect of their residency and to have a little more personal time.

Such contention about working hours may ultimately result in changes to shorten or condense the residency training system, which raises other issues.

“There is real concern that the trainees will lack the broad in-depth operative experience obtained by their seniors and will no longer be able to provide such a wide range of generalist care,” said Hamblen, who is an emeritus professor of orthopaedic surgery at the University of Glasgow.

Japan’s 40-hour work week

Similar trends can now be seen elsewhere in the world. Shinji Ogura, MD, PhD, whose hospital — Gifu University Medical Center — has the largest emergency care center in Japan, is responsible for scheduling physician coverage of the emergency room and the intensive care and critical care units.

He told Orthopaedics Today that his job as president of the advanced critical center and chair of the department of emergency and disaster medicine at the hospital is not easy. Furthermore, it is now more challenging than ever “to shift appropriate doctors to appropriate places,” he said.

In April, Japan’s social insurance agency restricted doctors to working fewer than 40 hours each week — the standard work time for all laborers in Japan, Ogura said.

Aware of the staffing shortages faced by his counterparts at other centers in Japan, Ogura feels fortunate that he has 27 doctors, including residents, who he can place for adequate coverage of day and evening shifts.

“Shifts are set with 14 doctors in the daytime and seven doctors at night. … I have to [do] my best to [schedule shifts] with our doctors,” he said.

Pros and cons

Among the benefits of such work hour limits are a better quality of life outside of work for those in training, as well as for senior physicians, Ogura said. Overall patient safety is improved, and fewer situations arise where physicians need to drive or perform other activities when they are overtired, thus greatly reducing the risk for an accident or error to occur.

“A 40-hour workweek is the fundamental right of all laborers,” Ogura told Orthopaedics Today.

Restricted hours for French residents went into force in January. After residents work night duty for one evening a week, they may not schedule clinics or work in the operating rooms for 24 hours, but “other days they can work without limitation,” said Jacques Y. Nordin, MD, of Paris, chairman of the Orthopaedics Today Editorial Advisory Board. In addition, residents must spend one day out of the department to attend lectures and instructional courses or to perform research.

The rules differ slightly for senior orthopaedic attendants in France, who are restricted to working a 48-hour week, which includes one night of being on call. However, the following day they are not allowed to conduct clinics or perform surgeries, said Nordin, professor of orthopaedic surgery and traumatology at the University Hospital of Paris.

Too few doctors

Although work hour restrictions imposed by the EWTD may be welcomed in some areas of Europe, many French senior physicians are concerned about their severe staffing shortages.

“Theoretically we should have more positions to do the same work than before,” Nordin said, but fewer French students are choosing surgical careers due to greater legal risks, lower levels of pay and more medicolegal prosecutions, he said.

In the United Kingdom, coverage of shifts has been equally difficult because the ratio of junior to senior staff is 1.4-to-1, compared with the average in the rest of Europe of 1-to-4, Hamblen noted.

While U.K. staffing problems have existed for years, they have been managed fairly well by having senior trainees work many of the overtime hours, he told Orthopaedics Today. Unfortunately, the British government has only gradually increased the number of medical students in training to make up the shortfall. “They continue to rely on overseas doctors.”

Implementing reduced work hours while maintaining the quality of physician training programs remains an ongoing challenge for everyone.

In a 2001 editorial in the British Medical Journal, Trevor Pickersgill, who chaired the British Medical Association’s junior doctors committee, wrote: “Given the will and the investment, training can be improved and the working hours of doctors reduced. We will, however, need more doctors, better organization of services, and improved training opportunities to expand the number of consultants."

For more information:

Pickersgill T. The European working time directive for doctors in training. Brit Med J, 2001;323:1266.