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Shorter hours, fewer nights: Life as a British resident

Elisabeth Paice, FRCP, describes efforts to improve training in the U.K.

From the October ACP Hospitalist, copyright © 2007 by the American College of Physicians

By Stacey Butterfield

Sidebar: Hospital at Night

To U.S. physicians, limiting resident work hours to 48 per week seems unimaginable. But to Elisabeth Paice, FRCP, dean of postgraduate medical education for the city of London, it's all part of effective medical training.

As the director in charge of training for over 8,500 doctors and dentists, Dr. Paice tries to ensure that British medical residents provide high-quality care, receive effective training and have time for a life. She sees these goals as related rather than mutually exclusive.

"We need humane training to develop humane doctors," Dr. Paice recently told an appreciative audience at the national meeting of the Committee of Interns and Residents in Philadelphia.

Efforts to improve residency in the U.K. have included work-hour limits, changes to hospital scheduling and assessment of the relationships between residents and other hospital staff, Dr. Paice said.

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Shorter hours for residents

British residency officials administered several surveys recently to uncover the most pressing issues troubling their trainees. When first-year doctors were asked about their top stressors, the most popular answers were all work-hour related: sleep deprivation, overwork and too little personal time. Residents complained that work hours were costing them relationships with spouses, children and friends.

"Reading that sort of thing has made me very sad," said Dr. Paice.

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Elisabeth Paice, FRCP.
Photo courtesy of the Committee of Interns and Residents.

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To alleviate those problems, the U.K., along with the rest of the European Union, has gone much further than the U.S. in limiting resident work hours. Currently, British trainees are permitted to work no more than 56 hours in a week and 12 hours in a shift. In 2009, the weekly limit will go down to 48 hours.

Dramatically shortening trainee hours does have an impact on the operation of the hospital, however, noted Dr. Paice. "The trouble with trying to do something about hours is you have to do something about shift work," she said.

Since research has also shown that night shift workers, both medical and other, make more mistakes, learn less and are involved in more accidents than their daytime counterparts, British officials decided to tackle both problems at once.

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Longer hours for the hospital

The "Hospital at Night" project (see sidebar) originally began as a pilot, and was successful enough that it is now being implemented in hospitals throughout England. Under the program, hospitals minimize night work by extending "daytime" hours into the evening.

"A lot of what was happening at night was work that should have happened before night, or could have waited until after 7 a.m. or could have been done by someone who is not a doctor." —Elisabeth Paice, FRCP

"If you're going to knock off work at 5 p.m. in general, then you're going a very, very, very long time without normal services. Whereas if you extend the hospital's normal working day to 18 hours, then it's easier to shut down at night," explained Dr. Paice.

With the new system, specialists make rounds as late as 9 p.m. and labs stay open into the evening. The project also requires the support of primary care providers, so that hospitals are not solely responsible for primary care after 5 p.m.

"A lot of what was happening at night was work that should have happened before night, or could have waited until after 7 a.m. or could have been done by someone who is not a doctor," Dr. Paice said.

The urgent work that must be done during the night is also handled differently. At the Hospital at Night facilities, a multidisciplinary team rounds on patients so that physicians as well as ancillary staff know from the start where the sickest cases are. There is also a shift coordinator, usually a nurse practitioner, who screens pages and decides which require a response and where a physician is needed.

"People who have implemented this say, 'I've never before felt so in control,'" said Dr. Paice. "It reduces the number of doctors working at night, and early outcomes have shown it is safer."

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No more bullies

Feeling in control is an issue for residents during the day as well as the night, Dr. Paice noted. In the surveys of new docs, about 18% of English trainees reported that they had been bullied on the job.

Inappropriate bullying behaviors included belittling, undermining, sarcasm and teaching by humiliation. The trainees were bullied by attendings, nurses, even other residents. "It really worries me because you have someone who could be a superb doctor having their career undermined by someone else," said Dr. Paice.

Residents in surgery, ob/gyn and the emergency department were most likely to report bullying. The survey also found that there were consequences of the bullying, other than the negative impact on residents' self-esteem.

"Bullying is a patient safety issue. Bullying is not a poor doctor, poor trainee issue," Dr. Paice said. In hospitals with high rates of bullying, residents were more likely to make errors and less likely to report them, the surveys found.

The solution to the problem has turned out to be fairly simple, she reported. After receiving the results of the annual survey of resident experiences, officials send letters to the chief executives of the hospitals with the worst bullying rates. "For two years running, we've seen the worst hospital in the survey switch over to being the best hospital in the survey," said Dr. Paice.

Hospital CEOs always want the names of the bullies on their staff, but since the responses are kept confidential, the most effective anti-bullying tactics have turned out to be consciousness-raising meetings and discussions of the issue, Dr. Paice said. "It's not about naming, shaming, blaming. It's about changing the culture."

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Hospital at Night

• Normal working day is extended to 18 hours
• Specialists make rounds at 9 p.m.
• Labs stay open in the evenings
• Multidisciplinary teams make rounds
• Nurse practitioners screen pages
• Primary care providers pitch in

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Photo by Comstock Complete.

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