On June 3 a recently graduated doctor and
classmate of mine died in a motor vehicle
accident. The night before, she had worked
for more than 24 hours at Paarl Hospital
in the Western Cape, where she was doing
her internship. She was, like many interns around South
She is not the first of my classmates to be involved in a
serious car accident while "post-call" in the six months
since we started working.
Every time one of these fatigued doctors go home, the
odds are stacked against them arriving home safely.
Every time, they have been caring for patients until
moments before they departed.
Safe Working Hours and the Junior Doctors
Association of South Africa (Judasa) have been collecting
information from doctors about their experiences during
and after long shifts, and we have heard a steady stream
of stories about medical errors resulting in potential and
real patient harm, car accidents and deteriorating physical
and mental health.
One doctor related a story where, after a 30-hour
shift, they put the wrong patient's details on a form for a
blood transfusion. "In my state of fatigue [I] wrote down
her neighbour's details," she explains. Serious consequences for the
patient were narrowly avoided.
Another submission from a doctor working in a ward
for newborn babies reads: "One of the sick [newborns] …
had fallen from the incubator because I had forgotten to
close it. I was so tired I did not even notice that the incubator
was left open."
"A 30-hour continuous shift limit defies what is humanly possible"When people outside the hermetic medical fraternity
learn that someone had been working without rest for 24,
30 or even 36 hours, they are shocked. They are horrified
to discover that this affront to common sense is standard
throughout South Africa.
The aftermath of my classmate's tragic death has seen
a revival in public interest in doctors' working hours, and
has again illustrated the reticence of the department of
health and, in particular, the Health Professions Council
of South Africa (HPCSA) to review an ingrained practice
that is clearly harmful to both patients and practitioners.
Numerous recent articles have emphasised that the
current HPCSA internship guideline of a 30-hour continuous
shift limit defies what is humanly possible.
Safe Working Hours submitted documentation to the
HPCSA internship committee in April, urging for the
continuous shift limit to be reduced — initially to 24
hours and then, with further review, to be in line with
best evidence. A petition started by the campaign, calling
on Minister of Health Dr Aaron Motsoaledi to review
continuous shift limits, has now gathered more than
5 600 signatures, and will soon be handed to the minister.
The HPCSA has been mute in the past weeks and this is
worrying, given that their internship guidelines continue
to allow the shifts in question to be enforced by health
departments and hospital management throughout the
Writing in the Cape Times, Dr Beth Engelbrecht, head
of the Western Cape department of health, was quick to
point out that institutions "ensure that interns do not
work hours over and above the stipulated time frame",
before reproducing the HPCSA 30-hour guideline in
She took the additional disingenuous step of writing
that interns are, "by and large, responsible for their own
roster allocation". This seems to imply that interns have
been forcing each other to work the hours in question,
but the truth is interns are expected to work "calls" in a
rigid fashion and simply decide among themselves who
will be taking which days.
Read more: Rural hospitals struggle to stay afloat due to staffing crisis.
Shorter shifts can reduce medical errorsHiding behind archaic and dangerous working hour
regulations is typical of clinical management throughout
the country. It is up to them to take steps to make working
hours at their institutions safe for both patients and
doctors, and to work towards innovative solutions in lieu
of more responsible regulations.
Myopic suggestions such as "post-call" napping facilities
(where doctors can sleep before attempting the trek
home), obliging interns to live on hospital premises, and
shuttle services miss the point — a shift that so impairs
doctors' driving abilities also destroys their ability to care
Innovative ways to implement shorter shifts with stringent
handover guidelines can reduce medical errors and
improve safety. Further options include a pre-call rest
period and protected sleeping time during longer shifts.
The problem is not unique to South Africa and several
countries have successfully dismantled the culture of
long continuous shifts.
The department of health has responded to the emerging outcry by declaring a drive to train more doctors. This welcome announcement, however,
does not engage with the issue at hand.
More doctors don't
necessarily translate into abolition of similar continuous shifts until regulators
require this: in the United States, which has nearly 10 times the amount of
doctors per population as South Africa, doctors work similar long continuous shifts. Their response also implicitly attempts to shut down the conversation
with a vague assurance to revisit it only once such plans have come to fruition
ten to twenty years in the future.
Additional regulations must be created that apply not
only to interns, but also to all doctors. Further delay continues
to place the safety of staff and patients at risk.
Koot Kotze is a medical doctor working as an intern.
He is a founding member of Safe Working Hours. Visit
www.facebook.com/safeworkinghours and view the
petition at http://tinyurl.com/SafeWorkingHoursSA
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