Sunday, 15 August 2010

Working Time Directive

There has been a great deal recently in the media about the effect of the working time directive on the training and quality of hospital doctors. If the articles here and here, and others are to be believed we are training a generation of doctors who will be totally inferior in every way to their illustrious, dedicated and eminent predecessors. In case you had not noticed I am being sarcastic.

I remember full well my own years in training. Working at times over a hundred hours a week, with occasions of continuous duty of 96 hours. We were released unsupervised onto our patients far earlier than would today be considered acceptable and expected for the most part to learn from our experience. In other words we learned from our mistakes, plenty of them. We gained so much experience that eventually we could do the job in our sleep, which is just as well because sometimes we did.

There is no doubt in my mind that as the working time directive has been gradually introduced there has also been a huge improvement in the quality of training. The trainees may get less hours at work, but the hours they do get are better filled. The trainees themselves are just as dedicated, intelligent and enthusiastic as they ever were. So what is my perception of the end result?

In my own speciality, when I look at the trainees coming to the end of their training, and newly appointed consultants, I stand in awe of their knowledge and abilities. What they know, and what they can do leaves me with an uneasy feeling of inferiority. There is always going to be a spectrum but my view, with over 30 years of observation, is that the standard is getting higher. In those specialities other than my own I am also of the view that, without themselves realising it, my younger colleagues are at least as good as, and probably better than their predecessors.

In the Telegraph article Dr Tony Strong rants about his opposition to the WTD, but gives no evidence to support his views. He proudly boasts that he works 80 hours a week thus affirming that the surgical dinosaur is not yet extinct.

He states “If I had to give one piece of advice to any patient worried about going under the knife in a UK hospital, I'd advise them to check when their surgeon started their specialist training”
Well I think this arrogant cretin is wrong. There is plenty of evidence that working long hours without adequate rest detracts from cognitive and physical performance. Mr Strong of course is  a surgical superman and is not affected by the laws of physiology like us lesser mortals.

The WTD is not just for the benefit of the doctor but is also in the interests of the patient. If I was about to go “under the knife” the first question I am going to ask my surgeon is how many hours he expects to work that week. If he is stupid enough to admit that he (unlawfully) works 80 hours a week, then he’s not coming anywhere near me with anything sharp in his hand.


  1. The 48 hours that trainees get may be better-filled these days, but there is still a long way to go.

    Take outpatients. Practice varies from hospital to hospital (and consultant to consultant), but outpatient clinics are overbooked / underbooked / booked by clinic not by doctor / booked without holding any slots back for urgent referrals / not cancelled when annual leave has been granted / etc / etc.

    This chaos has many consequences for both doctors and patients, of course. On the EWTD it means that trainees are sometimes left twiddling their thumbs mid-clinic, or regular clinic over-runs mean that something else cannot be squeezed into the 48 hours, or both.

    If the 48 hours are so precious, how come this hasn't been sorted out long ago? (Perhaps it has, where you work...?)

  2. These problems are nothing new and long predate the WTD. Why is it any more acceptable to waste trainees time or saddle them with over-runs if their working hours are longer. Bearing in mind how little time off they had in the past I would say that is worse.
    Also these problems are not insurmountable or even difficult to solve. All that is required is the will.

  3. Agreed. But what I don't understand is why the will is apparently lacking.

    After all, chaos in clinic is also harmful to the patients who are disrupted and delayed as a result, with implications for clinical outcomes. The RCSEng lists "audits about the process of care" as core information for revalidation, so the topic is given prominence within the profession. Moreover, as you indicate, the problems could be solved unilaterally by each consultant, without needing permission or money from managers or anyone else.

    Are consultants simply fed up with being badgered by managers over the years about outpatient management, and therefore passively resist the whole subject? Is it because rigorous science, which doctors are accustomed to in medicine, has previously been lacking in this area? Or is it something deeper?