Medical interns are leading the battle to reduce the dangerously overlong working hours that compromise the safety of patients.
All around South Africa, patients in public hospitals are being treated by young doctors so fatigued that some can’t even manage to stay awake at the wheels of their cars on their way home.
It is common practice for doctors, particularly medical interns (newly graduated doctors who have to do two years of mentored service at public hospitals) and community service doctors (those who have completed their internships have to do another public service year before they’re allowed to register as doctors), to work shifts of more than 24 hours, and often up to 36 hours or more.
An intern may start at 7am on a Wednesday, work through the day and night and then complete another day’s work and finish at 5pm on Thursday.
The practice is as entrenched in the profession as white coats and stethoscopes. Being on call or having to “spoed” (“speed”) is regarded by many as a rite of passage to becoming a fully fledged doctor. But being “on call” is mostly a euphemism; many work continuously, rarely having the opportunity to escape to bed, from which they can be called.
These hours are regarded as being part of the job and are rationalised in many ways. For example, internship years are seen as a teaching opportunity and longer hours are thought to translate into more learning. But there is no evidence to support this and at least one systematic review has shown that excessively long hours are detrimental to education.
South Africa suffers from a shortage of doctors and in many public institutions everyone has to chip in to lighten the load. But this has extremely dangerous consequences.
A 2006 review of the evidence, When Policy Meets Physiology, by Lockley and others for the Harvard Work Hours Health and Safety Group, concluded that medical staff who work for more than 24 hours a shift are 36% more likely to make serious medical errors and six times more likely to make serious diagnostic errors than staff whose shifts are limited to 16 hours. In addition, those working longer than 24 hours are also 2.3 times more likely to be involved in vehicle accidents immediately after their shifts.
Besides the substantial evidence highlighting the dangers posed by tired doctors, the international science journal Nature has reported that, “after 24 hours of sustained wakefulness”, cognitive psychomotor performance decreased to a level “equivalent to the performance deficit observed at a blood alcohol concentration of roughly 0.10 [g per 100ml]”.
The legal driving limit for alcohol in South Africa is 0.05g/100ml.
According to Harvard sleep researcher Christopher Landrigan, fatigue is not something you can become conditioned to.
Reacting to the situation in South Africa, medical students, interns and community service doctors launched the Safe Working Hours Campaign last month. It was started by Stellenbosch University’s medical students and calls on Health Minister Aaron Motsoaledi to review working hours and to limit continuous shifts to 24 hours. He has agreed to talks with the organisers but no date has been set for the meeting.
A petition, which is part of the campaign, has garnered the signatures of more than 1?700 doctors, interns, medical students and members of the public.
A Cape Town doctor who signed it said: “Doctors and patients deserve better. I have made mistakes out of sheer exhaustion, working 30-hour shifts with no sleep, and have seen others do the same.”
Motsoaledi said in a reference to the campaign during an interview on CapeTalk last week: “Throughout the world, we are missing four million healthcare workers.”
To address this, he said, South African medical schools are expanding their intakes, more medical schools are due to open and 2?700 South Africans are training as doctors in Cuba.
Safe Working Hours accepts that there is a critical staff shortage and acknowledges the lengths to which the health department is going to address it in the long term, but it contends that, in the interim, shorter, regular shifts (coupled with improved handover procedures) can reduce the risk to both patients and healthcare practitioners and improve the quality of healthcare.
Many public institutions have managed to limit shifts to 24 hours or less, or with frequent rotation have introduced 12-hour shifts.
But interns working at some hospitals experience vastly different shift systems between departments, which begs the question: Are shift structures the result of patient load and staff numbers, or because of shift co-ordinators’ and administrators’ unwillingness to deviate from tradition, even at the risk of adversely affecting patient safety?
Safe Working Hours advocates that every institution should seriously consider implementing improved, bare-minimum standards by taking all the evidence into account. It believes the 24-hour limits advocated by the department of health and the Health Professions Council of South Africa (HPCSA) could be a valuable move in the right direction.
According to the South African Patients’ Rights Charter, patients are entitled to a safe environment.
The Safe Working Hours Campaign aims to challenge and stimulate debate about the issue and to involve as many stakeholders as possible. The campaign wants to effect a lasting change to the way doctors and healthcare administrators approach fatigue, risk and safety.
But it is unlikely that the issue will progress without public awareness and participation.
The HPCSA took steps in 2007 to limit interns’ shifts to 30 hours but there are many reports of this being violated.
The council did not respond to requests from Safe Working Hours and journalists to comment on the petition or on the conditions that have led up to it.
Koot Kotze is a fifth-year medical student at Stellenbosch University and is involved with the Safe Working Hours Campaign
“Doctors and patients deserve better. I have made mistakes out of sheer exhaustion, working 30-hour shifts with no sleep, and have seen others do the same.”
Koot Kotze is a medical doctor and researcher from South Africa, currently based at the Department of Primary Care Health Sciences at the University of Oxford.