The working hours of junior doctors here have been in the spotlight lately.

A study published in the Singapore Medical Journal this year, which surveyed close to 500 medical residents across 34 specialities in three public hospitals, showed 8 in 10 responders felt burned out.

This point was brought home more vividly through the account of a medical houseman, who wrote a newspaper forum letter about having have to work for 12 to 17 hours daily on weekdays, and up to 10 hours on weekends.

When on night duties, he has to work 30 to 36 hours continuously, in addition to the regular long working hours.

Why are young doctors working so hard? Can anything be done and what is the cost of the remedy?

A LOOK AT THE HOURS

All medical school graduates here have to work first as a house officer for a year, then as a medical officer or a medical resident for three to four years to accumulate enough clinical experience before they can be a general practitioner or proceed to further their training as a specialist.

So what is the work routine of a medical officer or resident in a public healthcare setting?

First, they have to care for both inpatients who are hospitalised and outpatients who visit specialist outpatient clinics.

In public hospitals, as most outpatient specialised clinics open at 9am, doctors must start their inpatient rounds by 7.30 am or 8 am so as to finish seeing the hospitalised patients before going over to outpatient specialist clinics on time.

Most surgeons start their operations by 8am so they often make their inpatient ward rounds even earlier.

As part of their training, junior doctors are expected to have done the ward rounds before the senior staff comes, so junior doctors start work even earlier.

Most specialised outpatient clinics and surgeries finish by 5 pm, when senior doctors would review their inpatients and postoperative patients.

Junior doctors are expected to follow the evening rounds, which can last 30 to 60 minutes. And they often then have to stay back to complete whatever tasks the senior doctors assign during the evening rounds. This explains why junior doctors often finish work late.

In addition to routine workload, all doctors - junior and senior - still have to attend group meetings for departmental operations, teaching and research.

As it is difficult to get all doctors to come together during office hours, such meetings are often scheduled either before or after office hours.

Junior doctors are rostered to do several night calls a month to take care of emergency situations in hospitalised patients.

Night calls typically start by 8am in the morning and finish by 1pm the following day, though the junior doctors do get an hour or two of sleep in the night if there are no emergencies.

This is the 30-36 hour shift that the medical houseman was lamenting about in his letter.

If there is sufficient manpower, those who stay overnight for night duty could be discharged from duties by lunch time, so they can have the afternoon to rest before resuming a normal shift the next morning. But if manpower is tight, they may have to work till 5pm the following day after completing their night duties.

This kind of working hours have been in place for decades. Every senior doctor would have gone through the same kind of tough hours when they were junior.

This explains the relative lack of empathy among senior doctors for the plight of junior doctors. If the senior doctors could do it 20 years ago, why can’t the young ones do it now?

But that is not to say that just because a practice has worked for years, it should not be changed.

There is no denying that medical education is best done through apprenticeship.

Yet long working hours, especially the 30-plus-hour night duties, are actually bad for both patients and doctors.

Tired or sleep deprived people are more likely to make mistakes and errors, as they take longer time to respond to stimuli, and have difficulties in focusing on tasks.

Multiple studies have showed that sleep deprived doctors make more mistakes and errors.

So, what can we do about it?

For one, learn from the aviation industry. Pilots also work long hours and are expected to quickly respond to sudden changes without errors. The Federal Aviation Administration of the United States limits flight time of pilots to maximum of nine hours, and mandates rest time of minimum 10 hours before the next flight.

Currently, the Singapore Medical Council (SMC) stipulates that junior doctors’ work should not exceed 80 hours per week, including night calls.

And they cannot be scheduled for more than 24 hours of continuous active duty. Perhaps more has to be done to enforce such rules.

Besides, should doctors run their meetings and teaching rounds out of office hours? Or should senior doctors allocate one afternoon per week to have all meetings and training sessions?

Meeting and educational rounds should be counted as “work” and not be held outside office hours.

Also, on one or two days a week, hospital clinics and operating theatres (OT) can close earlier than 5pm.

Urgent cases could still be directed to the Emergency Department, where medical care is provided round the clock.

We can also separate inpatient and outpatient workload.

So instead of one team of doctors seeing both in- and out-patients, we should have separate teams. This helps ensure most doctors could finish by 5 pm.

We could instead rearrange the working hours of junior doctors assigned night duty.

Instead of starting in the morning and working till the next afternoon, they can start at 5 pm and finish by 8am the following day, ie, running over a 15-hour period.

Junior doctors should not be expected to work full time after the night call, but be sent back home for rest and recharge.

These changes will of course require more manpower.

But with the three medical schools here churning out close to 400 new doctors every year, there should be a sufficient supply of junior doctors for some of these changes to be implemented.

The quality of the training however cannot be compromised and a junior doctor must still equip himself with basic skills of clinical practice during his apprenticeship.

With shorter working hours per week, a junior doctor may have to spend a longer apprenticeship before he can be a consultant.

All stakeholders, including the Ministry of Health, SMC, doctors, patients, should start asking if the current system is optimal.

And before we implement any change to the current system, let us ask ourselves if the cost is worth the benefits.

ABOUT THE AUTHOR:

Dr Desmond Wai is a gastroenterologist and hepatologist in private practice.