Working-hours of physicians in hospitals

From WorkingTimeSociety

Contents 1 Overview over reasons brought up 1.1 Explanation I: Change of work 1.2 Explanation II: Hospitals run by religious orders 1.3 Explanation III: Content and Structure of work 1.3.1 General Practitioners and Specialists 1.3.2 Processess in Hospitals 1.4 Explanation IV: Job market 1.5 Explanation V: Income 1.6 Explanation VI: bottlenecks in resources and qualifications 1.7 Explanation VII: being trained to work long hours 1.8 Explanation VIII: individual responsibility for patients 2 Historical facets 2.1 Austria 1880 2.2 US 1890 2.3 US 1960's 2.4 19th century 3 Geographical distribution 4 Other material 4.1 Links: 4.2 Papers 5 Info on this page

Overview over reasons brought up

So far the following possible reasons were brought up (in the order they were brought up).

Explanation I: Change of work

Physicians were only "on call" and usually got enough sleep each night. But the number of patients per doctor has increased, as has the number of health problems that are "treatable", so the workload per doctor has increased enormously! (email Folkard)

Explanation II: Hospitals run by religious orders

It could be that there is a relationship between the long working-hours of physicians and the fact that most hospitals were run by religious orders in the first place. A connection to prayer times could be possible. (email Kundi)

Explanation III: Content and Structure of work

General Practitioners and Specialists

First of all, in the past doctors travelled around the countryside, and rendered their services wherever they were needed. This meant long working hours and lots of travelling.

In most western countries the profession of a doctor is divided in different specialisms, simply, the General Practitioner (GP) and the doctor Specialist, such as a Gynaecologist. Medical care must be provided round the clock. At first a patient can call upon a GP, but if special care is needed it is necessary to call a specialist. And this is why they work long hours. Only a part of giving medical care can be planned between 8.00 and 17.00 hours. The other part takes place during the other hours.(Korver)

Processess in Hospitals

TASKS

A reason is the way care (the process) is structured. Take for instance a hospital: Patients in a hospital are woken up between 6.30 and 7.00. They are washed and fed, receive their medication. After that patients are prepared for visits by their doctors. After the visits doctors have their work in the policlinic and they might work in the operating room. At the end of the day doctors discuss the condition of their patients in presence of their colleagues (and pupils) and nurses who work in different shifts. Another task is handing over patients to colleagues, completion of patient files and delay in office work. All this is one of the causes of these long working hours.(email Korver)

TRAINING

A second reason is that doctors are expected to have their share in training new doctors. As a consequence of how patient care is organised this is normally done in the hospital during the evenings.(email Korver)

SPECIALISATION, SIZE OF HOSPITAL

Third: Doctors are responsible for 24 hours service. If a doctor works in a small hospital, this is harder than working in a large hospital for the simple reason that more specialists are available to do the job.(email Korver)

Explanation IV: Job market

The inflow of new doctors is regulated by the availability of training facilities and regulation by the doctors themselves. This way doctors determine the numbers of competitors.

Explanation V: Income

• The doctors got paid by the individual patients for their services, so the number of services determined their income.
• Today another factor is the way the government regulates the finance of new doctors. With fixed budgets there is choice between an extra doctor and a higher income.

Explanation VI: bottlenecks in resources and qualifications

The capacity of the operating room. There still is a shortage of qualified staff of operating rooms, so the schedules are tight and small delays cause bigger delays and longer hours.

Explanation VII: being trained to work long hours

For student doctors the situation is even harder. In the past, working long hours meant that young doctors were able to prove their skills and responsibility.

Explanation VIII: individual responsibility for patients

Responsibility:

As physicians are responsible for 'their' patients (with as little of handing over as possible)

Different ways to go about things:

Physcians are aware of making mistakes, different ways to go about things - and do not want others to interfere, or be in trouble because others may critize the approach a physician took

Historical facets

It is clear that these long working hours are 'usual' for many years

Austria 1880

In december 1880, a student of Christian Albert Theodor Billroth and co-founder of modern surgery, Johann von Mikulicz-Radecki (1850-1905) , got married. According to the austrian tradition at that time, a married assistent wasn't allowed to have a permanent position with a university hospital because he was supposed to be "married" with the hospital itself, to be able to work there and serve the hospital at any time required.

From the ministry, Billroth obtained for Mikulicz a prolongation of the latters position as an assistent for one year which amazed everybody because the ministry hadn't made such an exception for a quarter of a century. The ministerial permission (Dispens) said: "Assistent professor Mikulicz is allowed to get married and live outside of the hospital area, the assistent position will be prolonged for one year until 1. october 1881." (email from Skopec)

US 1890

William Halsted, M.D., who was Surgeon-in-Chief at the Johns Hopkins Hospital in the 1890s who founded the surgical training program there, and proposed that the residents live on the hospital and not marry, made residents work very long hours and live on continuous call. He did this himself and worked very long hours. One factor in his setting such an example, however, may have been addicition to cocaine....( see attached review) (email Lockely)

US 1960's

In the early 60's interns and residents worked a day on and a day off but were not allow to be off until all their responsibilities were completed for the patients they admitted. So, they might work 36 or even 48 hours on patients admitted on monday's 24 hours. By then Tuesday (their off day) had passed and Wednesday their next day on was again upon them. This cycle continued through the week days. When they were on for the weekend, they started Friday night and worked through until Monday AM, 7 weekends in 8. They would sleep (really nap) in rooms set aside for them. They were responsible to answer any questions any time about the patients they admitted. I do remember that there might be some sharing of patient responsibilites between interns, but this was frowned upon. The interns admitted a patient, the residents were responsible for overseeing the interns work. This is as I remember between 1962-1964 at Columbia Presbyterian Medical Center in New York City, the teaching hospital for Columbia Univeristy (email Glazner)

Even until 1950s and 1960s, getting married was prohibited in some US resident programs ...that's why the term 'resident' is used for physicians.(email Lockley)

19th century

As a (disturbing) side-note: The physicians working those very long hours did not have very good lightning. Without electricity and corresponding bulbs it must have been a nightmare to do surgery. Still it seems they worked long hours.

Geographical distribution

• Scandinavian countries tend to be more restrictive concerning maximal working hours of personnel working in hospitals.
• The European working time directive is now meant to apply to doctors, and they are meant to work only 56 hours per week now, and down to 48 hours per week in 2009. Certainly the UK is now regulated by this.
• Austria is well in the 55h - 60+Hours per week
• In Germany there are hospitals that work towards reduction of working hours to mid 50's
• In Portugal physicians in hospitals work about 57 hours in a "normal" week (f.ex. 24hrs., 7 hrs., 7hrs., 12hrs., 7hrs., and 2 days off).

Other material

Links:

• Document on the integration of parttime work of medical specialists (in Dutch)
• Medical magazine with surveys on working time of physicians (in German)
• The Royal College of Physicians issued various guidance papers on this topic
• Media:2006_Czeisler.pdf

Papers

• Effects of work hour reduction on residents' lives: a systematic review - Fletcher KE, Underwood W, Davis SQ, Mangrulkar RS, McMahon LF, Saint S JAMA 294(9) 1088-100 (2005)
• Editorial BMJ 2005;330:1404 (18 June), doi:10.1136/bmj.330.7505.1404
• Junior doctors' shifts and sleep deprivation: New on-call rotas do not work - Short Article BMJ 331(7515) 514 (2005)
• Junior doctors' shifts and sleep deprivation: "Weeks of nights" give the illusion of working fewer hours - Varughese GI BMJ 331(7515) 515 (2005)

Info on this page

The informations are from an email discussion on the mailing list of the working time society. If you want to add information:

• members of the society can edit the web-page directly (passwords provided by gaertner@ximes.com)
• or send an email

Please do not alter citations.