The findings of a survey of trainee surgeons carried out by the Royal College of Surgeons (RCSEng), in collaboration with sister surgical Royal Colleges, the Association of Surgeons in Training (AsiT) and the British Orthopaedic Trainees’ Association (BOTA) to find out the effect the European Working Time Directive (EWTD) has had on their training, their care of patients and the quality of their own lives reveals that the introduction of the European Working Time Directive has seriously compromised surgical training. The implementation of shorter hours has meant that training time in the operating theatre and contact with surgeon trainers have both diminished significantly.
Nearly 90% of SHOs felt that the revised working patterns had diminished their training; 84% felt that continuity of care had suffered; 58% considered that the quality of care had worsened; and 47% felt that their quality of life had deteriorated. Almost 75% considered that their direct contact time with their trainer(s) had decreased; 82% felt that their theatre training time had decreased; and 58% felt that out-patient clinic training time had also decreased.
‘Surgery is a craft specialty and while the Royal College of Surgeons supports the need for team-working, the skills that ensure patient safety cannot be acquired without a long period of experience and one-to-one teaching from consultants,’ said Professor John Lowry, chairman of the Royal College of Surgeons’ EWTD Working Party. ‘This survey suggests that even the first stage of implementation of EWTD has reduced trainees’ contact time with their trainers to a significant degree. The situation will be exacerbated unless training is properly funded. Training a surgeon takes time and that time must be spent in theatre, in out-patient clinics and on the ward.’
The survey was carried out on-line over a period of five weeks in December 2004/January 2005. 1323 responses were received, of whom 577 (44%) were SpRs, 681 (51%) were SHOs and 65 (5%) were ‘other’, comprising clinical fellows, PRHOs and research fellows. 84% of them were working in England, 8% in Scotland, 3% in Ireland and 5% in Wales.
The European Working Time Directive (EWTD) became law for junior doctors in August 2004. It reduced the working week to a maximum of 58 hours. In 2007 the working week will be further reduced to 56 hours, and possibly to 48 hours by 2009 (this could be extended to 2012).
Before the introduction of the EWTD, most SHOs were either resident on-call (ie they could rest at the hospital in between periods of activity) or non-resident on-call (ie on call from home and only called in to the hospital for emergencies). Now, more than half of them (57%) are working shifts of up to 13 hours, followed by 11 hours’ continuous rest in every 24-hour period. Of those, almost half are working one week in seven (1:7) in this pattern, or more frequently.
In this working period, SHOs are largely providing service work in hospitals rather than receiving the direct training which is vital to their career progression. Little surgical activity takes place at night and so SHOs working full shifts lack training opportunities. In addition, they miss out on daytime training (when most surgery is carried out) because they have to take compensatory rest after night work. This results in them spending less time with their trainer(s) and having less training time in theatre. Many Trusts use their SHOs for service work, especially at night.
Although the RCS and the Academy of Medical Royal Colleges recommend that a 1:8 rota should be the minimum, ie a trainee surgeon should not be on call more than one block of nights in eight (including working a full day either side), 45% of SHO respondents were working full shifts on a 1:7 rota or more frequently. Only 5.3% of SpRs were working a 1:9 shift or less frequently - for most of them the frequency of the shift pattern was between 1:5 and 1:8. Nearly 90% of SHOs felt that the revised working pattern had diminished their training time and almost 75% of them felt they had less direct time with their trainer(s). Just over half of the SpRs reported that the quality of their training had ‘severely or slightly worsened’.
In July 2003, the RCS said that additional funding was required to increase the number of doctors in higher specialist training, and pointed out to the Department of Health that the EWTD would require more consultant surgeons to provide a safe and effective acute service. Last March, the College said that the job plans of consultant surgeons had to allow protected teaching time – in out-patient departments, at the bedside, and in the operating theatre.*
Last week, Mr Hugh Phillips, the President of the RCS, drew attention to the shortfall of surgeons and the need for more consultant posts to carry out the necessary surgical work and to train their successors. ‘Surgical trainees are working to keep hospitals safe at night but are not getting enough training because of shift work. Trainees should not be used to provide service cover unsupervised, particularly at night, to the detriment of their training,’ Mr Phillips said.
‘Trusts must fund and resource training,’ said Mr Phillips. ‘Surgical trainees must insist on being trained. Trainers must insist on the opportunity to train. Surgery is a craft that is learned at the elbow of the trainer, not by doing unsupervised service work.’
Through its EWTD Working Party, chaired by Professor John Lowry, the RCS will continue to lobby the government and the Department of Health to ensure that Trusts adequately resource and protect surgical training time and maximise training opportunities for junior surgeons.