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Time for new priorities in safe hours campaign?

29 Jul 2013

Since the AMA embarked upon its safe working hours campaign in 2001, the medical training environment has evolved dramatically.

Rapid growth in prevocational and vocational training numbers has created a surplus of junior doctors in many hospitals and specialties, industrial agreements have been strengthened - particularly in regards to un-rostered overtime - and the political push for efficiency dividends has seen hospitals act to cut excessive expenditure.

It is in this context that last year’s AMA Safe Hours Audit recorded significant reductions in the number of doctors working in high fatigue risk categories. Since 2001, there has been a 16 per cent fall in the number of doctors doing shifts that exceed 14 hours per day, have no meal breaks, or have a break between shifts of less than 10 hours.

However, extremes are still prevalent, with some doctors reporting shifts of 43 hours duration or working weeks of greater than 120 hours.

Recent international developments have reflected a changing focus in fatigue management, with increasing concern for the potential adverse effects of safe hours regulations on medical training and the apparent lack of effect on patient safety.

In the United States, an 80-hour work week limit for all residents was introduced in 2003 and a 16-hour shift length restriction for interns was introduced in 2011.  Subsequent reports indicate that the changes to intern shift length have resulted in an improvement of quality of life for interns, but have also increased handover frequency and upped the workload for senior residents. Perceptions of patient safety, fatigue and the balance of service and education have remained unchanged. More recently, evidence has also been published that these regulations have resulted in a reduction in intern operative exposure.

Opposition to the duty hour regulations has been obvious throughout the medical literature, with unproven assumptions about the effect of fatigue, the inflexibility of the current regulations and the lack of evaluation, all cited as major flaws to the US approach to doctor fatigue.

Across the border in Canada, a different approach has been taken. In June this year, a report on this issue was published by the National Steering Committee on Resident Duty Hours.

The report confirmed a lack of clarity regarding the relationship between fatigue and patient safety, and reflected the concerns that this relationship is more complex than simple policy directives such as duty hour restrictions may infer.

Other conclusions included the lack of any clear evidence that resident duty hour regulations have had either a positive or negative affect on academic performance - although there were findings that educational outcomes in surgery were probably adversely affected.

The report’s recommendations were wide-ranging and high-level, and moved away from a regulatory response, concluding that accreditation could be the appropriate lever to enforce appropriate fatigue risk management activities.

Australia’s non-regulatory approach, using the AMA’s National Code of Practice, seems justified after considering the international evidence.

Not only has the approach seen a shift in workplace practice, with fewer doctors working in high fatigue risk categories, but it has not generated the concerns regarding a negative impact upon training that exist within the regulatory system in the US. 

The impact of other factors on the Australian environment cannot be understated.

While the Code of Practice has produced improvements, increasing numbers of medical staff and the reluctance of health jurisdictions to pay overtime must also be credited with producing improvements in doctor fatigue.

Similarly, if the Safe Hours campaign is to be condemned for a perceived negative impact on medical training, than so must these other significant factors.

As the evidence regarding doctor fatigue and patient safety matures, it is clear that the problem is multifaceted and will require complex solutions beyond a simple restriction on working hours. Possible risks, such as a detrimental effect on training, need to be measured, considered and mitigated.

Patient safety should always remain the paramount priority, and maintaining this while maximising training opportunities should be the goal of future campaigns to reduce doctor fatigue.

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Published: 29 Jul 2013