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Can doctors be trained in a 48-hour working week?

Since August 2009 all UK trainee doctors have been restricted to a 48-hour week, but some say this has had negative effects on the quantity and quality of medical training. Is there any evidence to substantiate these fears?

BMJ

Since August 2009 all UK trainee doctors have been restricted to a 48 hour week, but some say this has had negative effects on the quantity and quality of medical training. Is there any evidence to substantiate these fears? Doctors discuss the issue in The BMJ this week.

Andrew Hartle and Sarah Gibb of the Association of Anaesthetists of Great Britain and Ireland find no evidence that implementation of the European Working Time Directive has led to a decline in the quality of training.

They point out that several reviews on the impact of restricting working time have concluded that high quality training can be delivered in a 48 hour working week, and that trainees for all grades and specialties are increasingly satisfied with training. The BMA could also find no evidence that fewer doctors have reached the specialist register grade since the working time regulations were implemented.

What is concerning, they say, is the government's acceptance of the recommendation to encourage more widespread use of the voluntary opt-out from the restrictions on working hours. This would allow (or even require) trainees to choose to work more than the average 48 hours (but no more than 56).

"To recommend opt-out as a solution risks patient safety from tired doctors and stifles attempts to reconfigure services and delivery of training," they argue. "Far better to do fewer procedures well, under supervision, than be left to get on with more, without."

They point out that consultant delivered care is seen as imperative for many reasons. "By doing this we will continue to train doctors who provide excellent patient care within the confines of a 48 hour week," they conclude.

But Andrew Goddard of the Royal College of Physicians, London argues that not all doctors can be trained in a 48 hour working week.

"It may well be that we can train many types of doctor within the current system but for hospital medicine this is not the case," he says.

He points to evidence collected by the Royal College of Physicians over the past decade that supports this. For example, more than 50% of consultants and trainees are clear that the 48 hour working week has reduced the quality of training, while 44% of doctors completing core medical training report that they are not sufficiently trained to be a higher specialist trainee.

The situation for medical registrars is better and has improved in the past five years, writes Goddard. However, 18% described themselves as "adequately" trained and 30% as "fairly well" trained - not exactly a ringing endorsement.

Much evidence indicates that service pressures currently affect the ability of trainees to attend formal training, gain feedback (a crucial and under-championed part of clinical training), and feel part of a team, says Goddard. Furthermore, there are no plans to increase the total numbers of doctors on the ground to release more time for training.

"It seems unlikely that the working week will increase from 48 hours or that service pressures will relent. Given the evidence, hospital doctors will need a lot of convincing that shorter training time will produce better doctors," he concludes.

A linked article published by BMJ Careers today, says doctors in Norway have shorter working hours than many of their counterparts in Europe - and asks could the UK follow suit?

Johan Torgersen, who chairs Norway's junior doctors' association, says there is a general view that doctors in technical specialties "work more than others, often motivated by the need to develop their technical skills." He believes that making national agreements on extended working hours "would make working hours more transparent, easier to control and plan working time better."

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