SECOND OPINION Paul Finucane and Michael ShanahanThe European Working Time Directive (EWTD) aims to reduce working hours for Non-Consultant Hospital Doctors (NCHDs) to an average of 58 hours per week initially and ultimately to 48 hours per week.
To date, implementation has proved difficult, at least in part due to a lack of acceptance by various professional bodies. There are particular concerns about the feasibility of the EWTD and its impact on patient care and on postgraduate training. We worked in the Australian healthcare system in the early 1990s when plans to reduce the working hours of junior doctors generated similar concerns. We believe that Ireland can take heart from the Australian experience.
Before 1990, working conditions for junior doctors in Australia were similar to Ireland today. Shifts of 34 hours or longer were standard when a night on call, often without any sleep or adequate meal breaks, would be followed by a "normal" working day. On-call rotations of one in four or worse and few free days resulted in working weeks of more than 80 hours and sometimes more than 100 hours. There were concerns about fatigue-related medical errors as well as some high-profile fatal accidents involving exhausted doctors coming from work. Outside of work, junior doctors dealt with sleep deprivation, studied for examinations, formed relationships and raised families. It was realised that such stressful lifestyles were intrinsically bad and, in time, would make medicine a less attractive career option.
Strategies to reduce working hours were successfully implemented and Australian junior doctors now work a standard 37.5-hour week with an additional 10 to 15 hours overtime. Most have at least one day off each week and for most of the year, have no night work. Instead, doctors work a block of nights, generally for three weeks each year. Night work tends to be popular, particularly as each working week is followed by a rest week. The workplace is generally busier as there are fewer doctors on duty at any given time to share the load. However, much non-medical work (e.g. phlebotomy, searching for X-rays, etc.) has been taken over by others, allowing doctors to focus on direct patient care.
In Australia, specific strategies have been developed to deal with the potential effect of reduced working hours on the continuity of patient care. For example, greater attention is paid to the maintenance of good clinical records and most hospitals now have formal processes for patient hand-over. Indeed, the process of patient hand-over provides an excellent educational opportunity. For example, many hospitals have a morning report when the medical staff going off duty meet those coming on duty to discuss the overnight admissions and the patients giving cause for concern. With an effective chairperson, a report on a specific problem in a specific patient easily leads to a broader discussion on diagnosis, management and other clinical issues.
Concerns about the impact of reduced working hours on postgraduate training have also been dispelled, in part due to specific strategies to enhance training quality. Postgraduate training in Australia has become more focused with defined training objectives and strategies in place (e.g. logbooks, portfolios, etc.) to ensure that these are met. Furthermore, it has long been accepted that medical practice involves lifelong learning of which postgraduate training is just one, albeit vital, component. If postgraduate training is regarded as part of a continuum of education, it is arguably less crucial to have a long and intensive exposure to a clinical speciality prior to being considered fit for independent practice.
While people in Ireland seem keen to downplay the financial implications of the EWTD to junior doctors, this was certainly an issue in Australia at the time of reform in the early 1990s. Reduced hours did lead to reduced income and caused real concerns for those with ongoing financial commitments.
However, these concerns were short-lived as doctors realised that leisure time also contributes to their "wealth".
For Australian junior doctors who want to earn extra money, there is ample opportunity (and now the time) for lucrative additional work in public and private hospitals and in general practice. Not only is it possible to earn extra money with less effort than previously, there is also greater flexibility. Doctors might choose to do extra work when saving for a new car but not in the lead-up to an important examination.
We believe that the introduction of the EWTD and the demise of the bleary-eyed doctor at the end of a 30-hour shift are positive developments for doctors and patients alike. It is an opportunity to further improve the living and working conditions of medical practitioners in Ireland without necessarily sacrificing their training experience or the medical care of their patients.
Prof Paul Finucane is an Irish medical graduate who worked in academic geriatric medicine in Australia for 10 years between 1991 and 2001. He has also worked for extended periods in Cork, Dublin, Waterford, the UK and the Middle East. Currently, he is director of the Graduate Medical School Development at the University of Limerick and also works as a locum consultant physician.
Dr Michael Shanahan is an Australian rheumatologist and occupational physician who has worked for many years in internal medicine in several Australian hospitals.
He is a frequent visitor to Ireland and over the years has worked in a number of Irish Hospitals as an SHO, registrar and locum consultant.