Appropriate working hours for surgical training according to Australasian trainees

Resident Physicians Have an Increased Risk of Adverse Driving Events Following Extended-Duration Work Shifts: A Systematic Review

Resident physicians often work extended-duration work shifts (EDWSs) exceeding 16 hours. EDWSs are associated with fatigue, workplace errors, mental health problems, and motor vehicle incidents. A 2019 systematic review reported that resident physicians had an increased risk of motor vehicle collisions (MVCs) and of falling asleep at the wheel after EDWSs. This systematic review updates those findings with recent literature. Embase, PubMed, Cochrane Database, and Ovid Medline were searched for original research articles studying resident physician driving safety following EDWS. Two authors independently reviewed articles for inclusion. Both reviewers performed data extraction and quality appraisal for each included article. Six articles met the inclusion criteria. Three articles found associations between EDWS and increased sleepiness in resident physicians. Self-reported sleepiness was increased by 46% following an EDWS compared to a normal-length shift. Objective measures of sleepiness were also increased following an EDWS. Similarly, there was a three-fold increase in adverse driving events following an EDWS compared to pre-EDWS. One study found 3.90 higher odds of an adverse driving incident following an EDWS compared to a day shift. EDWS are associated with an increased risk of adverse driving incidents, including collisions and falling asleep while driving, in resident physicians. Possible solutions including compensation for ride-share and taxi services, scheduled breaks, education on risks of driving while fatigued, and the use of caffeine may lower the risk of adverse driving incidents post-EDWSs. Further research is needed to assess the impact of possible solutions.

Overtime claiming among Australian doctors-in-training

ObjectiveTo quantify patterns of overtime among doctors-in-training in New South Wales and to explore the reasons doctors-in-training cite for not claiming overtime worked.MethodsA confidential online self-reporting survey was conducted of post-graduate doctors-in-training, working in hospitals in NSW, from post-graduate year 1 through to completion of specialist training. Questions sought to determine the average amount of overtime worked, overtime claiming patterns, and reasons why overtime was not claimed. Comparisons were made by level of training and specialty training pathway.ResultsA total of 1351 valid responses were received. Unrostered overtime was extremely common, as was underpayment for work completed. Though 73.5% of respondents reported working at least 5 h of unrostered overtime per fortnight, only 15.6% of respondents reported claiming all their unrostered overtime, and among those who did claim overtime, only 45.5% reported being paid the amount in full. Common reasons for not claiming overtime included workplace cultural expectations (37.0%), and overtime not falling under approved reasons (32.6%). There were statistically significant differences (P < 0.001) in all response categories between critical care, physician and surgical training pathways.ConclusionsThe survey data demonstrated a significant disconnect between expectations and reality of working hours among doctors-in-training. This is indicative of concerns regarding loss of income, impaired ability to plan workforce allocation due to hidden workload, and possibly impaired wellbeing.

COVID-19 impact on junior doctor education and training: a scoping review

COVID-19 has had a significant impact on healthcare resources and the medical workforce. Clinically-based medical education is the principal source of learning, and this has been profoundly impacted by restrictions due to COVID-19. It follows that junior medical staff and their education would be significantly impacted due to the altered volume and breadth of their clinical exposure. Some literature has been published regarding the impact to medical training during COVID-19. This study sought to review junior medical staff perceptions and their reported impact of the COVID-19 pandemic on their education and training.Nine databases (three Ovid MEDLINE databases, Embase, Web of Science, Scopus, Cumulative Index to Nursing and Allied Health Literature, Educational Resources Information Centre and PsychINFO) were searched for studies published in 1 January 2020 through 24 August 2020. Via a scoping review protocol, an iterative process was used to perform the identification, review and charting analysis of the reported outcomes and themes. Descriptive analysis was performed using quantitative and qualitative methods.Of the 25 343 sources identified, 32 were included in the review. There were studies published from nearly all continents, predominantly in surgical journals, with a wide spread of specialties. Themes identified included the current impact of the pandemic in relation to continuation of and modifications to training programmes, as well as the future impact due to training requirements and career progression.Junior medical staff report that the COVID-19 pandemic has had a significant impact on their education and training. Whether the changes imposed by the pandemic on education are temporary measures or permanent fixtures, and whether standards of competence may be impacted, is not yet known. This scoping review forms a basis for further investigation in the field.

Working hours, common mental disorder and suicidal ideation among junior doctors in Australia: a cross-sectional survey

OBJECTIVE

Despite concern regarding high rates of mental illness and suicide amongst the medical profession, the link between working hours and doctors' mental health remains unclear. This study examines the relationship between average weekly working hours and junior doctors' (JDs') mental health in Australia.

DESIGN AND PARTICIPANTS

A randomly selected sample of 42 942 Australian doctors were invited to take part in an anonymous Beyondblue National Mental Health Survey in 2013, of whom 12 252 doctors provided valid data (response rate approximately 27%). The sample of interest comprised 2706 full-time graduate medical trainees in various specialties, at either intern, prevocational or vocational training stage. Consultants and retired doctors were excluded.

OUTCOME MEASURES

Main outcomes of interest were caseness of common mental disorder (CMD) (assessed using a cut-off of 4 as a threshold on total General Health Questionnaire-28 score), presence of suicidal ideation (SI) (assessed with a single item) and average weekly working hours. Logistic regression modelling was used to account for the impact of age, gender, stage of training, location of work, specialty, marital status and whether JDs had trained outside Australia.

RESULTS

JDs reported working an average of 50.1 hours per week (SD=13.4). JDs who worked over 55 hours a week were more than twice as likely to report CMD (adjusted OR=2.05; 95% CI 1.62 to 2.59, p<0.001) and SI (adjusted OR=2.00; 95% CI 1.42 to 2.81, p<0.001) compared to those working 40-44 hours per week.

CONCLUSIONS

Our results show that around one in four JDs are currently working hours that are associated with a doubling of their risk of common mental health problems and SI. These findings suggest that management of working hours represents an important focus for workplaces to improve the mental health of medical trainees.

Resident Physicians are at Increased Risk for Dangerous Driving after Extended-duration Work Shifts: A Systematic Review

BACKGROUND

Resident physicians often work longer than 24 consecutive hours with little or no sleep. A systematic review of the literature was conducted to investigate the risk of resident physician motor vehicle collisions (MVC), and dangerous driving, after extended-duration work shifts (EDWS).

MATERIAL AND METHODS

A keyword search was performed for original research articles evaluating any aspect of driving safety following EDWS for the resident physician population. Two authors independently reviewed articles for inclusion. Subsequent independent data abstraction and quality appraisal were carried out. Five articles met the study inclusion criteria.

RESULTS

The quality of the evidence was low to very low. Results were not pooled due to study heterogeneity. Residents reported between 2.3 to 3.8 hours of sleep during EDWS. Three survey-based studies identified an increased risk of MVCs and falling asleep at the wheel after EDWS. One study associated weekly cumulative sleep hours lost with the risk of falling asleep while driving. Both driving simulation and survey studies linked EDWS with MVCs. Notably, a driving simulation study found an increase in crash frequency in male residents post-EDWS. Additionally, a survey reported that the risk of an MVC post-EDWS increased by 16.2% per shift worked in a month.

CONCLUSION

The period following EDWS is associated with an increased risk of potentially life-threatening driving safety risks for resident physicians. These observations warrant careful consideration. They suggest that there is a need for greater awareness and action in order to avoid the occupational and public health risks of driving after EDWS.

Fatigue and training of obstetrics and gynaecology trainees in Australia and New Zealand

BACKGROUND

Several studies have linked doctor fatigue with adverse patient events and an increase in risk to doctors' personal safety and wellbeing. The present study assesses the rostering structure of Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) trainees and its association with trainees' reported fatigue levels, training opportunities and wellbeing, which were secondary outcomes of a larger study of trainee working hours which has been separately reported.

METHODS

An anonymous, online survey of RANZCOG trainees was conducted. Demographic data collected included: age, gender, level of training and current rotation. Data were also collected on hours worked per week, long shifts (>12 h), self-reported fatigue levels, and opinions regarding current rostering and training.

RESULTS

A majority (72.9%) of respondents regularly felt fatigued, with higher fatigue levels being associated with more hours worked per week (P = <0.001) and working long shifts (>12 h) (P = 0.007). Fatigue was associated with an increased risk of dozing while driving (P = 0.028), with 56.1% of respondents reporting that this occurs. Trainees appeared to be less confident in achieving their technical skill requirements, with increasing hours not increasing confidence in achieving these skills (P = 0.594). Trainees who worked under 50 h per week were less likely to report fatigue (P = <0.001) and more likely to report greater work enjoyment (P = 0.043), and working hours being conducive to learning (P = 0.015).

CONCLUSION

Fatigue was frequently reported by RANZCOG trainees with increased working hours and long shifts being significant factors in fatigue levels. Strategies should be developed and trialled to enable trainees to obtain adequate case exposure and teaching without compromising patient and doctor safety.

Perspectives on the working hours of Australian junior doctors

The working hours of junior doctors have been a focus of discussion in Australia since the mid-1990s. Several national organizations, including the Australian Medical Association (AMA), have been prominent in advancing this agenda and have collected data (most of which is self-reported) on the working hours of junior doctors over the last 15 years. Overall, the available data indicate that working hours have fallen in a step-wise fashion, and AMA data suggest that the proportion of doctors at high risk of fatigue may be declining. It is likely that these changes reflect significant growth in the number of medical graduates, more detailed specifications regarding working hours in industrial agreements, and a greater focus on achieving a healthy work-life balance. It is notable that reductions in junior doctors' working hours have occurred despite the absence of a national regulatory framework for working hours. Informed by a growing international literature on working hours and their relation to patient and practitioner safety, accreditation bodies such as the Australian Commission on Safety and Quality in Health Care (ACSQHC) and the Australian Medical Council (AMC) are adjusting their standards to encourage improved work and training practices.

Provision of acute general surgery: a systematic review of models of care

BACKGROUND

This article systematically reviews currently available models in Europe, the United Kingdom, Australia and New Zealand for the provision of acute general surgical service and acute care surgery.

METHOD

Four hundred and thirty eight articles were identified in a literature search. Of these, 13 were included within the systematic review.

RESULTS

Each acute care model is unique to its local and regional setting but all models have common goals. These include being consultant led, adequate resourcing with junior medical staff, theatre space and anaesthetic support and no competing elective surgical or out-patient commitments. All models require an individual, service and institutional commitment to prioritising the assessment and treatment of acute surgical patients and are characterised by uninterrupted periods of work focussed on the care of acute surgical patients supported by comprehensive patient handover to maintain safe staff working hours.

CONCLUSION

The provision of acute care for surgical patients is a fundamental role of general surgeons. With the diverse demands on surgeons of teaching, research, elective surgery and patient assessments as well as a family and lifestyle obligations newer systems of service provision based on collective, rather than individualised service commitment, are being developed. These systems emphasise discrete periods of defined service without elective surgical commitments with formal and structured surgeon to surgeon handover. Initial experience indicates that patient care is satisfactory, continuity of care is maintained, and acute care pathways function efficiently.

LEVEL OF EVIDENCE

Systematic review, level IV.

The impact of the European Working Time Regulations on Ophthalmic Specialist Training--a national trainee survey

SUMMARY AND INTRODUCTION

To assess ophthalmic trainees' perspective of the impact of the European Working Time Regulations (EWTR) on their training.

METHODS

All trainees in ophthalmology in the UK were emailed a link to an electronic survey asking about their experiences of the EWTR.

RESULTS

324 trainees (46% of those invited) responded to the survey. 44.4% of trainees reported that their posts were compliant with the EWTR. 40.7% felt that training had been adversely affected. 49.1% thought that ophthalmic trainees should opt out of the EWTR to work more than 48 h per week, with 57 the mean number of hours suggested appropriate.

DISCUSSION

Many ophthalmic trainees in the United Kingdom are working in rotas which are not compliant with the European Working Time Directive. Many trainees feel that implementation of the EWTD has had a negative effect on training and feel it would be acceptable to work a higher number of hours per week.