I have been trying to work it out – just HOW unsafe is a doctor after being continuously awake for many hours without uninterrupted break?
I’ve just worked the weekend on call for emergency in our small rural hospital. We work a 1:6 (one 24 hr period ‘on call’ for hospital emergencies shared between the six doctors, hence 1:6) but by mutual agreement divvy up the weekends similarly, so that we can all enjoy mostly uninterrupted weekends, with every sixth being on call. The weekend shift starts 8am Friday through to 8am Monday – 72 hours. We then usually continue our ‘day job’ of routine consulting in primary care in our private practice for the Monday.
Generally on calls are relatively quiet – the local residents are understanding of the demands of being on call and try to limit their presentations to mornings and afternoons…meanwhile the frontline emergency nurses do a good job of triage, sorting out minor problems that don’t need the ministrations (or fees!) of a doctor. Of course there is the tacit understanding that the doctor can & should be called for any serious emergency, whatever the hour.
On Kangaroo Island, our on calls tend to be quiet in winter and busier in summer as the tourist visitors increase – along with the inevitable embedded fish-hooks, marine stings, lacerations, heart attacks, broken bones and road trauma.
The weekend just gone has been a hard one for me. I won’t discuss clinical cases in public, but suffice it to say that genuine emergencies kept me busy, including an uninterrupted stretch of 40 hours with no sleep. This is (thankfully) rare. However even downtime (no clinical contact) was interrupted by phone calls for advice and the usual poor sleep that being on call engenders (like many doctors, I tend to ‘worry’ – either about cases I have admitted…or about what ‘might’ happen). Which makes me wonder – what is the deal for safe hours for rural doctors?
As an intern in London, we worked ridiculous hours. This was seen as a ‘good thing’ in that we were exposed to a variety of conditions and had to make decisions even when battling sleep. I am not so sure that it was good for the public, but I am pretty sure that it was a good thing for the NHS which had it’s pound of flesh off me before I fled for the more civilised (and sane) working conditions in Australia. Now I look back with rose-tinted spectacles and have been known to bemoan the ‘easy life’ that today’s interns have of it.
“Aye, you current interns are soft I tell thee. Sleep? We didn’t know what sleep was when I were a lad. Why w’d get up half an hour before we went to bed, lick th’ patients clean before the consultant ward round each morning at 5am and PAY the NHS for the privilege of working. Sleep were for wimps? I had to share a sharps bin with six other interns to sleep in…and THAT were luxury – my registrar had to sleep in the pan room sluice and be hosed down with liquid shite every few hours. You young ‘uns don;t know how good you’ve got it…”
Sharing the on call weekend with my colleagues might sound an easy solution – but given there are three rosters (one for emergency, one for obstetrics and one for anaesthetics), it means that three of the six doctors are on call in any one period. Splitting the weekend will lead to more roster shortfalls and make it impossible to ever have a whole weekend off – something that we treasure, particularly on an Island where a trip to mainland capital city is best left for a ‘free weekend’. Add to this the increasing demand – locations like Kangaroo Island see tourism peaks and troughs…so there is marked variation in demand depending on the population (Easter and Christmas are usually insufferably busy). There is also increasing demand through Government initiatives such as the HealthDirect phone line and the Medicare Locals After Hours initiative. Both seem to place more and more burden on already busy rural doctors.
HealthDirect & GP After Hours – increasing demand, not solving the problem
HealthDirect was touted as a solution to inappropriate Emergency Department attendances – for things that ‘a GP could manage’. Somehow health planners (and hence politicians) have equated triage 4/5 presentations as ‘GP-type patients’. Experienced clinicians know this is tosh – the triage score is an indicator of urgency to treatment, not complexity – indeed the majority of triage 4/5 patients have conditions that DO need a well lit, well staffed & well-equipped ED to sort out rather than a GP surgery (think X-ray, wound repair, immediate blood tests). Moreover many of these patients require admission to hospital – the little old lady with profound hyponatraemia causing confusion and falls, the patient with a Colles fracture needing reduction under GA, the mental health patient with profound depression and actively suicidal. These aren’t usually fixed in GP clinics in a 15 minute consult. Politicians LOVE HealthDirect as it is seen as a sop to the masses who cannot access a doctor and to relieve pressure on EDs – there is now good evidence to suggest that
- patients who self-present to an ED generally need to be in an ED (ie : they attend appropriately)
- triage 4/5 patients often require admission and are not ‘GP patients’
- Patients who do use ED for primary care needs (eg: a simple UTI) are not vast consumers of time or resources – indeed the lowly intern or resident can fix these in a few minutes…it’s the complicated polytrauma or sepsis that chews up senior time and resources. Prof Nagree’s research in WA demonstrates that telephone triage is NOT the answer to ED overcrowding
- Phone triage such as the UK’s NHSDirect and Australia’s HealthDirect are both dangerous (noone can diagnose over the phone) and due to protocol-based approaches erring (one hopes) on the side of caution, can actually INCREASE attendances at EDs
Medicare Locals are charged with running the GP After Hours service. Ostensibly this is for ‘after hours emergencies’. Now I am pretty sure that I know what an emergency is – it is a condition that cannot wait until next day and needs to be seen. But I am not sure what an after hours GP emergency is – to my mind, primary care is well-served to deal with chronic conditions and relatively straightforward illness. But any problem that needs the ministrations of a doctor at 3am sounds like it would be best off being dealt with in an Emergency Department – you know, those well-lit, well-staffed and appropriately equipped places designed to deal with emergencies. Better that than a knackered GP trying to fix you at home in dark light with rudimentary equipment…it was all well and good for GPs in the 1950s, but we should expect better than that nowadays.
I have asked Medicare Locals for a definition of a GP After Hours emergency – but they were similarly unable to define this for me. Bit odd considering they hold the pursestrings for these multimillion dollar initiatives. Nevertheless, they consider it a ‘good thing’ and to be encouraged – regardless of the fact that dragging a doctor out at 3am is hardly a good use of resources when that doctor needs to front up the next day and see one patient every 15 minutes all day in his or her clinic.
Demands need real solutions
And so back to the conundrum of working hours. Rural doctors, by necessity, work in their clinic in the day and work on call after hours via the hospital, seeing emergencies. We are a de facto after hours emergency service – but we do not expect this service to be abused with ‘wants’ not ‘needs’.
‘Wants’ might include seeing a doctor for a script for usual blood pressure medication at 8pm in the evening after finishing work – ‘needs’ might include being seen for a suspected kidney stone or a lethargic child with a rash. I have no problems with genuine ‘needs’ but struggle with unrealistic demand for ‘wants’, fostered by Medicare Locals as an arm of politicians wishing for a sop to the public to win them more votes.
Seeing ‘your doctor’ at anytime of day or night for non-urgent problems is not sustainable. Supporting rural doctors and managing demand would seem preferable.
But how good is that support? Again, I can only speak for my location. A recurring theme is the tension between demands of a busy private practice and being on call for the State-funded public hospital. With only six doctors on Kangaroo Island, the need to maintain three rosters (Emergency, Obstetrics, Anaesthetics) and the variation in demand, having locum relief is invaluable. I am tempted to wonder – just whose responsibility is it to staff the roster? The local doctors? Or the State government
If 1 or 2 doctors retire, resign or withdraw (eg: though ill health), there is an expectation from Country Health SA that the remaining doctors will ‘pick up the slack’. They do not see responsibility for the roster as their responsibility, as providing locum doctors comes at a cost roughly 10x that of using the existing rural doctor workforce.
Clearly less doctors working longer hours more frequently is not tenable, unless one sacrifices both one’s own health and the viability of one’s private practice (being on call for the hospital impacts significantly on the ability to see routine GP clinic patients, causing a vicious cycle). This in turn feeds into recruitment difficulties and the potential collapse of services.
It is getting harder as doctors get older (I turned 46 last month). I can’t see myself working at this intensity beyond 50 years of age.
Tricky.
These are tricky issues, indeed.
Here’s a hypothetical model that hasn’t really been thought through at all: suppose the government paid you a salary, plus an appropriate on-call allowance and recall structure (with you sacrificing your Medicare billings) and in return, you committed to work a roster that encompassed your day-to-day primary care role, ED coverage, anaesthetics, etc… Would that work?
I suppose that takes away some of the autonomy and I have no idea what it means for an individual doctor financially, but I wonder if the relationship is changed from government-contractor to an employer-employee one if some of these issues are resolved.
The reason I ponder this is that the conditions surrounding your work are then necessarily regulated by industrial relations structures, and the responsibility to ensure a roster is covered lies clearly with the employer.
Just a thought, anyway 🙂
Andrew this employer-employee arrangement is very common in QLD with Queensland Health SMO/rural generalist positions. It’s essentially an hourly rate for your services, with conditions described by an overarching award. The problem however is still the same; not enough doctors for the hours/patients. Until this mismatch is properly addressed we will continue to burn through our rural doctor who are just not prepared to carry the system along like this. There seems to be a great reluctance to recognize the importance of things like improved morale, better work life balance, time for education, sensible work hours in keeping rural doctors happier and therefore in their jobs for longer. I would have though the extra outlay ( for more staff) is more than compensated for in the long run by a more stable workforce, much better patient care and less money spent on recruiting new cannon fodder and stop gap locums.
Tricky indeed!
And those of us who are closer to 30 than 50 looking at our future working lives are far less likely to chose the flogging work roster that our senior colleagues have endured. Gen Y loves a good work-life balance but this also creates a vicous cycle as people are turned off from working in the places that are most in need.