Improving Doctors' Working Lives

The BMJ editorial Junior doctors' shifts and sleep deprivation was all over the papers at the end of last week. The group of writers, who include Dame Carol Black and Professor Roy Pounder of the RCP, argue that weeks of nights are dangerous and that single night shifts, or at most three nights in a row, should be used.

The thrust of the article is that while average hours have come down, the move to full shifts with weeks of nights means that on certain weeks doctors will be working up to 91 hours. The negative effects of this have been shown in the RCP survey Working the Night Shift and the authors make a good point. Their use of the Landrigan study, the main study linking hours to medical errors, is slightly less compelling as that study is technically about average hours over a 4-week period, not hours worked in a single week of continuous shifts. However, they do list some important research and anecdotal evidence to suggest that a 91-hour week of nights is not a good working pattern for doctors or patients.

The article also suggests that single nights cause least distortion to circadian rhythms. There is evidence for this, though it is equally beneficial to put people onto several weeks of night shifts at a time (not very good for their family life, of course). On the other hand, the article doesn't go into the risks associated with decreased continuity of care, the implications for organising the medical take, or the fact that single nights do often mean more days off which may further restrict training opportunities (the authors feel this would have a limited additional effect). These points are raised in the Rapid Responses to the article, though the responses are so far mostly supportive.

The authors also make the extremely contentious point that doctors should be required to have 2 hours sleep on a night shift. This appears to be drawn from the finding in the RCP survey that night shift doctors tend to sleep for 2 hours during the night and have problems sleeping during the day. However, since it's more than possible that those two things are linked - ie if you are sleeping for two hours during the night, you will have problems sleeping during the day - perhaps the 2-hour sleep should actually be discouraged! Naps of 20-40 minutes, though, have certainly been shown to have a beneficial effect. (NB The "this is really a partial shift, we should all be getting 3 hours sleep and everyone is really non-compliant" argument resurfaces in one of the rapid responses - bear in mind that an employment tribunal ruled against this argument last year.)

This is an important editorial which highlights a genuine difficulty within the shift sytem. It also makes some good suggestions about how to promote sleep during the day. Unfortunately, like most similar articles, it does not engage with the experiences of other night shift staff, most importantly nurses, who have to work continuous night shifts and are forbidden to rest at night. The issue of night shift work affects more than just doctors and needs to be addressed in a multiprofessional way.

This article has been featured in a number of newspapers, notably the Daily Mail. This also quotes the BMA JDC Chair, Simon Eccles, who agrees with the principle but also encourages hospitals to pursue Hospital at Night solutions and keep on call rooms available for full shift doctors.

New poll: Should weeks of nights be phased out?
Oh, and 83% of you thought that Nestle had lost the plot by getting rid of the foil wrappers on KitKats. So not all change is good, eh?

Discussion forum
Brian Jones has posted a question about DRS calculations for natural breaks on study leave days - comments please!

In other news:
Hospital doctors need a new career structure (BMJ)
How to teach and learn under the EWTD (BMJCF)
Computer access for hospital doctors poor, says BMA (E-Health Insider)
Doctors and the art of timewasting (BMJCF)
Replace doctors with robots! (BMJCF)

DRS news
The rollout of version 2 of DRS, the doctors' rostering and monitoring software, is continuing - the SHAs have details of this. A version of DRS including new flexible trainee calculations will be available soon.

Ian Rothwell has joined the DRS team as the DRS Support Worker. Ian will be handling all support calls and regularly monitoring the DRS forums. He can be contacted at ian@drsusers.com or on 07768 640374.

Diary cards and other templates
I'm also in the process of uploading templates for diary cards and fraud forms, etc, so people can see what's happening in other Trusts and adapt for their own use. These can be found in the Downloadable Documents section.