Abstract
The European Working Time Directive (2003) has had a significant impact in reducing the total number of hours worked per week, as well as shift-lengths. There is, however, no agreement on optimal shift-lengths and day/night work balance in different medical specialities. Given the time it takes for clinical events to unfold, particularly in relation to labour, there may be advantages in retaining the 24 hours on-call shift for obstetricians––in the interests of patient care and training. Increasingly seen as a relic of the past, this shift-length merits further research, which should include the impact on clinician well-being.
Keywords: sleep, stress, on-call
In January 2019, for the first time in 35 years, my name did not appear on a hospital's 24 h on-call roster. At 61 years of age, my clinical commitments would now be confined to daylight hours. Although I had been looking forward to this age-related dispensation for quite some time, my emotions were surprisingly mixed. Expectations of rejuvenation were reality-checked by intimations of my own mortality. Lines from Yeats sprang to mind––and were subverted for the occasion: ‘The hospital at night is no country for old doctors’. Like the Yeats of ‘Among School Children’ and ‘Sailing to Byzantium’, I now had ‘sixty or more winters’ on my head. In what felt like the blink of an eye, I now found myself close to the end of the organizational age conveyor-belt.
Unlike Yeats, in his sixties, I felt I still had a lot to offer. In my book, I was neither a ‘tattered (white) coat upon a stick’ nor ‘a comfortable kind of old scarecrow’. Recalling obstetrician–paediatrician–poet William Carlos Williams's description of leaving the comfort of his bed to attend a patient: ‘They call and I go/It is a frozen road/past midnight’, I felt more than a tinge of nostalgia for the sense of duty and camaraderie that comes with toiling in the clinical trenches into the wee small hours of the morning.
Despite being reasonably fit, in the run up to coming off the 24 h on-call roster, I had recognized that being up at night and, in particular, working the next day was beginning to take its toll on me. It was taking me increasingly longer to recover. Being twice as old as some of my non-consultant medical colleagues and almost three times older than many of the midwifery and medical students just served to illustrate the point in large bold font.
The transition, however, took longer than expected––six months, in fact. I found it strange to re-adjust to going to bed without the near certainty of being woken up––to answer the phone, to make decisions in the dark, to get dressed, to drive into the hospital, to deal with an emergency, to deliver a baby, to talk to relatives, to supervise the registrar doing a Caesarean section, to drive home, to catch a few hours shut-eye before the next call or the 7.30 morning meeting––whichever came first.
For over a third of a century, I had gone to sleep on-call like one of Chaucer's ‘smale fowles’ in the General Prologue ‘That slepen al the nyght with open ye’. When it came to waking up, I had developed the same well-honed, trigger-hair reflexes. From now on, my professional energies would be focused on the diurnal.
With more time on my hands, it was an opportune time to reflect on working on-call at night as a doctor over an extended period. Although I am not a sleep scientist, I have had plenty of practical experience in the complex relationships that exist between day, night, sleep and work.
I recently read Adam Kay's frighteningly honest and irreverently entertaining fly-on-the-wall diary of an NHS junior doctor This is Going to Hurt. It brought back memories of feudal serfdom: 85–90 h shifts, three-and-a-half-day weekends that started on a Friday morning and ended on a Monday evening and of going on ‘night-patrol’ in a US hospital, that had a strong military ethos and where sleeplessness was considered a badge of machismo honour––like a battle wound. Hearing the late Euan McColl singing on YouTube about the hardships endured by herring fishermen in the first half of the last century: ‘And I used to sleep, standing on me feet’––evoked the same memories of sleep-deprived, ultra-marathon shifts.
Thankfully, in more recent times, the negative impacts of excessive hours worked, long shifts, sleep deprivation and disrupted circadian rhythms have been well-documented in relation to cognitive function, clinical decision-making, technical dexterity, communication skills, patient safety, physician well-being and job satisfaction. The introduction of the European Working Time Directive (EWTD) in 2003 (2003/88/EC) was a big step forward in addressing many of these issues, followed by the development of new training/work-related and occupational health guidelines by professional training bodies and health service authorities. Although the speed varied at which EWTD compliance was achieved in different European jurisdictions, the net effect, over the period of time since its introduction, has been a reduction in the total number of hours worked per week (to a maximum of 48 h), the maximum length of shifts (to a maximum of 24 h) as well as the entitlement to rest-breaks. The rate limiting factors in achieving full compliance have mainly related to manpower issues and money. In the Republic of Ireland, which for a long time has had one of the lowest ratios of obstetricians in the OECD, the need to comply with the EWTD led to the expansion of the specialist training scheme and increased consultant appointments––as well as an increase in the number of non-training non-consultant posts to fill the gaps. The threat of statutory financial penalties for non-compliance was an important accelerant of change at the level of health service bureaucracy.
What is clear, however, in my experience, is that (a) those running our health services need to continue to invest in training more doctors, if doctors are to work fewer hours; attractive enticements to train and work abroad are beginning to exert a significant strain on staffing levels; (b) doctors may have less experience when they complete their training if they work shorter shifts; (c) shorter shifts may delay decision-making (until the next shift); (d) fewer significant clinical events unfold and are completed during shorter shifts––with implications for continuity of care, clinical understanding and learning; (d) there will always be a need for doctors to attend emergencies in the middle of the night whether she/he is on-call or off-call; (e) one's ability to perform complex clinical tasks in the middle of the night with little sleep is dependent on one's training to do so (going through medical school in the late 1970s and early 1980s, I had the experience of month-long day and night residencies as part of both core curricular and elective clinical attachments); and (f) no-one yet knows what constitutes optimal shift-lengths and day/night work balance in different specialities––in relation to patient care, training and maintenance of expertise.
Over the course of 35 years, I have not had any problems in working a 24 h shift that allowed me to sleep at night (either in the hospital, or at home––a 10 min drive away) when activity levels subsided. In the context of the physiology of labour and managing a labour ward, there is a lot to be said in favour of a 24 h shift for obstetricians.
Like most of my contemporaries, I learned, early in my apprenticeship, how to go to sleep/wake up/get up/go back to sleep again. I have had little or no difficulty going to sleep in the knowledge that I would be called soon. A comfortable bed, a well ventilated/heated room, dim corridor lights and the absence of noise are all key components in getting off to sleep quickly. Sadly, not every hospital on-call room lives up to these standards––although most do now. Over the years, I also learned that reading non-medical material, preferably a poem or a page or two of a novel, invariably helped me switch-off and fall asleep––and I have recommended this ritual to others.
Although my sleep on-call was light and interrupted, it was, nonetheless, refreshing––a kind of restorative mini-sleep that Shakespeare would have recognized as a knitter of ‘the ravell'd sleave of care’. Unlike Hamlet, however, I have no recollection of perchance dreaming while sleeping on-call.
In my opinion, a 24 h shift for obstetricians with the facility to sleep on-call when it is quiet––and with the day off afterwards––has significant advantages in terms of patient care and medical training. Increasingly seen as a relic of the past, this length of shift merits further research, which should also include the impact on clinician well-being.
It has been my experience that less sleep is more likely to be problematic in the context of shifts that extend beyond 24 h––and increasing age. My limited exposure to ‘the week of nights’ roster reinforced a more general view that this kind of roster results in disconnected clinical thinking by doctors and is, as such, a wholly unsuitable medical model of care. For doctors in private practice, providing a personalized service based on 24/7 availability may also significantly interfere with sleep––both in quantitative and qualitative terms––irrespective of clinical workload or calls at night. The development of group practices with pragmatic cross-cover arrangements should be welcomed by both doctors and their private patients alike in terms of patient safety and clinician well-being.
Importantly and on a personal note––disruptive sleep patterns, whether on-call or off-call, were always more likely to be caused by, rather than to be the cause of, work-related stress. In the highly litigious context of medical practice in the Republic of Ireland, obstetricians often feel they are just one step away from the High Court and two steps away from an adverse newspaper headline. I expect that this is a common experience among other clinicians too. Clearly, more research is needed to explore the relationship between work, day, night, sleep, well-being and burn-out.