Hours, volume, and type of work of preregistration house officers

THE IDEAL HOUSE OFFICER: TRAINEE'S PERSPECTIVES

Background

The housemanship period is a peculiar time in a doctor's career, and some have described it as a "Nuisance year" during which the junior doctor assumes many roles at the same time - as a doctor of his patients, a student of his trainers (Resident doctors and Consultants) and a teacher of medical students. He is also at the same time undergoing training and research to practice as a professional in an increasingly competitive society-https://youtu.be/SaaQmMHy_qI.

Nigerian perspective

A typical House officer is seen neatly dressed with black circles around the eyes depicting tiredness, ward coat pockets stuffed with enough materials to start up a new ward; ranging from continuation sheets, syringes, water for injection, capillary tubes, hand gloves, investigation forms, commonly used drugs, cannula, tourniquet et cetera, smart shoes and feet ready to move on large doses of caffeine, and with carbonated drinks at arm's reach for a quick glucose rush for the day.He or she is faced with institutional problems, staff and workplace disharmony ranging from lack of adequate residential apartment for interns, early daily resumption and retires much later than the team to effectively carry out the work plan among acute shortage of staff. Majority of interns also try to adapt to the internship workings because they are new to the system, and some health workers typically try to take advantage of them which sometimes interfere with their work and the intern struggles to give the patients his best. Despite all these, the house officer interacts with the patient and relatives more often than the rest of the team. He builds the trust, respect, and confidence the patient has for the team as he represents not only himself but also the team.

Conclusion

As once said by Sir William Osler - the great physician whose name is still being invoked in modern day medicine - that "his time was ripe for him, and he was ripe for his time". Trainees must always make themselves "ripe for their time", and the relevant authorities must also make time "ripe for trainees". The ideal scenario will then be a nexus of an ideal trainee and an ideal work environment.

The work environment of junior doctors: their perspectives and coping strategies

OBJECTIVE

This study explores the associations between psychological distress in junior doctors and their work environment and how they cope with work stressors.

METHODS

A cross-sectional survey designed by Health Education and Training Institute was delivered in 2014 to over 1900 junior doctors across 15 hospital networks through Australian Capital Territory and New South Wales. Psychological distress was evaluated using the Kessler Psychological Distress Scale-10 (K10). Numerous variables were assessed for associations with psychological distress to identify the strongest relationships and the coping strategies used. Potential associations between work demands, coping strategies and psychological distress were explored.

RESULTS

540 responses were analysed. 414 (81%) thought their workload was reasonable, 376 (75%) were enjoying their current job and 446 (82.6%) were content with their work life. However, 85 (15.7%) reported that they would not study medicine if given their time again, and 146 (27%) reported workplace bullying. The mean K10 score was 17.2 (σ=6.3) and the prevalence of elevated psychological distress was between 63% and 80% higher than the general community. Variables most strongly associated with distress were: being discontented with workload, lack of enjoyment from current job, taking time off work and having experienced workplace bullying. There was a preference to use social activities as a method of coping but at higher levels of psychological distress there is a greater proportion who took time off work.

CONCLUSIONS

Psychologically distressed junior doctors need recognition, support and treatment. Future interventions should focus on improving work environment, job satisfaction, provision of supports, use of healthy coping strategies and improving work-related relationships. This could potentially reduce levels of psychological distress in junior doctors, optimise delivery of healthcare to patients and maximise workforce potential.

Time-motion studies of internal medicine residents' duty hours: a systematic review and meta-analysis

BACKGROUND

Since the mid-1980s, medical residents' long duty hours have been under scrutiny as a factor affecting patient safety and the work environment for the residents. After several mandated changes in duty hours, it is important to understand how residents spend their time before proposing and implementing future changes. Time-motion methodology may provide reliable information on what residents do while on duty.

PURPOSE

The purpose of this study is to review all available literature pertaining to time-motion studies of internal medicine residents while on a medicine service and to understand how much of their time is apportioned to various categories of tasks, and also to determine the effects of the Accreditation Council for Graduate Medical Education (ACGME)-mandated duty hour changes on resident workflow in North America.

METHODS

Electronic bibliographic databases were searched for articles in English between 1941 and April 2013 reporting time-motion studies of internal medicine residents rotating through a general medicine service.

RESULTS

Eight articles were included. Residents spent 41.8% of time in patient care activities, 18.1% communicating, 13.8% in educational activities, 19.7% in personal/other, and 6.6% in transit. North American data showed the following changes after the implementation of the ACGME 2003 duty hours standard: patient care activities from 41.8% to 40.8%, communication activities from 19.0% to 22.3%, educational activities from 17.7% to 11.6%, and personal/other activities from 21.5% to 17.1%.

CONCLUSION

There was a paucity of time-motion data. There was great variability in the operational definitions of task categories reported in the studies. Implementation of the ACGME duty hour standards did not have a significant effect on the percentage of time spent in particular tasks. There are conflicting reports on how duty hour changes have affected patient safety. A low proportion of time spent in educational activities deserves further study and may point to a review of the educational models used.

Foundation doctors working at night: what training opportunities exist?

INTRODUCTION

Foundation Training is designed for doctors in their first two years of post-graduation. The number of foundation doctors (FD) in the UK working nights has reduced because of a perception that clinical supervision at night is unsatisfactory and that minimal training opportunities exist. We aimed to assess the value of night shifts to FDs and hypothesised that removing FDs from nights may be detrimental to training.

METHODS

Using a survey, we assessed the number of FDs working nights in London, FDs views on working nights and their supervision at night. We evaluated whether working at night, compared to daytime working provided opportunities to achieve foundation competencies.

RESULTS

83% (N = 2157/2593) of FDs completed the survey. Over 90% of FDs who worked nights felt that the experience they gained improved their ability to prioritise, make decisions and plan. FDs who worked nights reported higher scores for achieving competencies in history taking (2.67 vs. 2.51; p = 0.00), examination (2.72 vs. 2.59; p = 0.01) and resuscitation (2.27 vs. 1.96; p = 0.00). The majority (65%) felt adequately supervised.

CONCLUSIONS

Our survey has demonstrated that FDs find working nights a valuable experience, providing important training opportunities, which are additional to those encountered during daytime working.

Education and the working patterns of junior doctors in the UK: a review of the literature

OBJECTIVE

To identify and review UK research relating to the effects of patterns of work on the education of junior doctors, describe the trends in the research, contextualise the progress of the UK in reducing the number of hours worked by junior doctors alongside that of other countries and identify areas for future research.

METHOD

A total of 77 research studies, mostly written after 1995, were identified as relevant from approximately 900 references generated by searching Medline and using a 'snowball' technique. The articles identified were qualitatively reviewed to identify their key research conclusions and/or the main points of argument. These were collated and presented in a qualitative review.

RESULTS

Research in the UK is contradictory regarding the effects of working patterns and the views of doctors towards them. Further research is needed to examine in depth the differences in the effects of working patterns on education between hard-pressed and non hard-pressed specialties, hospitals and regions. When viewed in an international context, the UK ranks among a number of countries with similar medical systems that are moving towards reducing the hours worked by doctors in training, all of which are at different points in the process.

CONCLUSION

The literature review has helped to identify the popular wisdom surrounding the debate on junior doctors' hours, the progress of the UK when compared to that of other countries and gaps in research. Further research is needed to refine understanding of this area.

Identifying appropriate tasks for the preregistration year: modified Delphi technique

OBJECTIVES

To identify the tasks that should constitute the work of preregistration house officers to provide the basis for the development of a self evaluation instrument.

DESIGN

Literature review and modified Delphi technique.

SETTING

Northern Deanery within the Northern and Yorkshire office NHS executive.

SUBJECTS

67 educational supervisors of preregistration house officers.

MAIN OUTCOME MEASURES

Percentage of agreement by educational supervisors to tasks identified from the literature.

RESULTS

Over 61% of communication items, 70% of on call patient care items, 75% of routine patient care items, 45% of practical procedure items, and over 63% of self management items achieved over 95% agreement that they should be part of the house job of preregistration house officers. Poor agreement was found for the laboratory and clinical investigations that house officers could perform with or without supervision.

CONCLUSIONS

The tasks of house officers were identified but issues in using this method and in devising a universally acceptable list of tasks for preregistration house officers were apparent.

Working patterns and the quality of training of medical house officers: evaluating the effect of the 'new deal'

The 'new deal' on junior doctors' hours of work has led to the widespread introduction of working patterns such as full shifts and partial shifts in the United Kingdom. The impact of these changes on the training of medical staff is unclear. The subjects of the current study were 36 pre-registration medical house officers working shift rotas and on-call rotas at a teaching hospital in the north of England. They were studied over a 12-month period using a self-report questionnaire seeking their views on the quality of their training experience and their satisfaction with the in-service training they received. Nursing staff, consultant and medical student opinion was also sought. Partial-shift and full-shift systems led to reduced hours of work when compared to on-call rotas (mean hours: partial shift 65.0; full shift 59.8; on-call 72.7), but they were associated with significantly lower training experience and training satisfaction scores for the house officers than were on-call systems (P < 0.01). Shift systems were unpopular among consultants and medical students but not nursing staff. Despite reducing excessive hours of work, shifts may be detrimental to the training of medical house officers. The further imposition of shift working should be suspended until such time as the impact of new working patterns on the training of medical staff has been determined.

Senior house officers' work activities in an accident and emergency department

A study of senior house officers' daytime work activities was conducted in the accident and emergency department of the Cardiff Royal Infirmary. Activities were timed every 15 seconds by a single observer and were subdivided into working periods, meal periods and periods when no patient was waiting to be seen. A total of 96.1 h was analysed. The SHOs were found to be working for 78% of their time, of which 18.5% was taken up by non-doctor tasks. The SHOs took an average of 10.4 min for each walking wounded patient, 10.6 min for each paediatric patient and 27.3 min for a trolley patient. Each patient required an average of 14.2 min for assessment and treatment, which meant that 3.3 patients were seen each hour. However, considering that SHOs worked for 78% of their time, the actual rate of work was 4.2 patients for each working hour. The implications for staffing are discussed.

The pre-registration year. It's time for job reprofiling

The pre-registration house officers' year has a dual purpose. On the one hand, there is the basic service requirement for long hours of routine assistance to senior medical staff. On the other hand, there is the educational component of the job as seen in the GMC and post-graduate deans' objectives. Reports on a study which shows there is considerable tension between these two objectives. Examines the extent and nature of this divergence. Suggests that there are two problems to be addressed: how best to generate a sense of ownership and affinity to the trust hospital, and even more fundamental, requires a strategic audit and reappraisal of the purpose of the pre-registration year and strongly suggests the desirability of reprofiling it in order to provide a rich working experience and learning environment.

The preregistration year

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Twenty-four-hour blood pressure in junior medical staff

Circadian variations in blood pressure in junior medical staff were compared during routine working days and days receiving medical emergencies. The overnight work commitment of junior medical staff when receiving medical emergencies causes a loss in the normal circadian blood pressure rhythm, with overnight blood pressure falling 10/11 mmHg less than on routine working days. This supports the hypothesis that circadian blood-pressure changes are activity related rather than dependent upon hormonal variation. Long-term health effects of abolishing such normal circadian rhythms are not known.

Educational supervision of pre-registration house officers

An annual survey of the educational supervision of pre-registration house officers has been carried out since 1987 by the Northern Ireland Council for Postgraduate Medical Education and the Queen's University of Belfast. Educational supervision was considered by house officers to be unsatisfactory in 27% of medical posts and 52% of surgical posts. Regular teaching was provided at least weekly in 77% of the posts, but 50% of house officers wanted mor experience of managing common medical emergencies. Over one-third felt administrative duties were excessive. There is a strong argument that hospitals should designate within clinical units a consultant with responsibility for educational supervision of the pre-registration house officers. Creation of the hospital counterpart of the General Practitioner trainer--the educational supervisor--would enhance the educational value of the pre-registration year. This might avoid withdrawal of approval for training purposes from some pre-registration posts.

Does the current use of junior doctors in the United Kingdom affect the quality of medical care?

Current proposals in the U.K. envisage a reduction in both junior staff numbers and the hours which they work. The proponents of change argue that this will improve patient care, although there are also opposing arguments, based mainly on the need to maintain continuity of care and ensure juniors gain sufficient clinical experience. By means of a literature review and interviews with junior doctors, this paper examines the effect of the existing system of hospital medical staffing on quality of care. There is evidence that the existing system reduces the quality of care, principally through mistakes associated with inadequate supervision, and lowered humanity of care due to tiredness. The training value of night-time and weekend work is low, and many doctors find it unsatisfying. In contrast, many doctors value providing continuity of care and a few appreciate the opportunity to gain unsupervised experience. Overall, the disadvantages of the existing system outweight the advantages, and change is required to improve the quality of care. There are, however, several obstacles to change, and there are doubts about the extent to which the current proposals will be implemented.

Reducing hours of work of preregistration house officers: report on a shift system

OBJECTIVE

To determine the advantages and disadvantages of a shift system of working compared with the conventional on call system for preregistration house officers.

DESIGN

A shift system of working was employed in the unit from 1 August 1989 to 31 July 1990. During attachments of three or six months four house officers rotated at intervals of one month among three daytime shifts and one night shift (Mondays to Fridays only). Weekends (48 hours) were worked on a one in three rota by the doctors working a day shift. The views of the house officers working this shift system were sought in writing and by direct interview.

SETTING

Professorial surgical unit, Royal Liverpool Hospital.

SUBJECTS

The 14 house officers who were attached to the unit for three or six months during their preregistration year.

RESULTS

The shift system was preferred to conventional on call without exception. The incidence of chronic tiredness was reduced and formal hand-over between shifts resulted in more informed decision making by doctors while on call. During annual leave it was sometimes necessary to revert to the conventional one in three on call system to ensure that daytime work was completed. Other disadvantages were the long weekend shift and an inequitable distribution of the night shift. The house officers recommended extending the shifts to weekends and working the night shift one week in four.

CONCLUSION

A shift system of working was effective in reducing chronic tiredness among house officers, who found it preferable to conventional on call arrangements. Shift working is feasible only if the daytime duties of the doctor working at night can be completed by the other doctors on the rota.

Junior doctors' on call activities: differences in workload and work patterns among grades

OBJECTIVE

To examine the workload and work patterns of junior doctors of all grades while on call.

DESIGN

Pilot study of activity data self recorded by junior doctors, with the help of students during busy periods.

SETTING

A general surgical firm and a general medical firm based at University Hospital, Nottingham.

SUBJECTS

Four registrars, three senior house officers, and five preregistration house officers.

RESULTS

Senior house officers and preregistration house officers spent nearly half of all their on call duty time working, but less than half of that time was spent in direct contact with patients. Registrars were on call more often than the house officers but spent less than one fifth of their on call duty time working, and almost two thirds of that time was spent in direct contact with patients.

CONCLUSIONS

Workload while on duty is excessive for both senior and preregistration house officers. Changes in some administrative procedures and employment of more non-medical staff during on call periods might reduce the time spent on non-clinical activities, thereby reducing the overall workload and allowing more time for patient contact.