The European Working Time Directive, the surgeon and training

Abstract

Th e European Working Time Directive (EWTD) has limited average working hours for junior doctors to 48 per week from July 2008. Th is raises concerns about its eff ect on patient care, as well as its implications for the cost of health services. In addition, both the Royal College of Surgeons in Ireland and the Royal College of Surgeons of Edinburgh have raised concerns about its eff ect on the training of future surgeons. Th is is a concern which has echoed throughout Th e Surgeon for the last three volumes, and which is referred to in two papers in the present issue. Jameson et al. report that the eLogbook project, which was started as a collaborative venture between the British Orthopaedic Association Education Committee and the Royal College of Surgeons of Edinburgh, can provide in-depth analysis of surgical training.1 Th ey recommend that thresholds should be set for operative training. Extension of this system to all specialties would allow monitoring of any decrease in operative experience which might occur as a result of the EWTD. Haji et al. describe a system whereby patients can be selected for elective laparoscopic cholecystectomy by surgical trainees, based on predictive factors.2 Th ey found that gallbladder wall thickness can be used as an independent predictor for shorter operating time, and by implication for junior surgical training lists. A great deal more thought will have to be put into the selection of patients for training and the development of specialist lists for that purpose with the decrease in time available. Th e negative eff ect of shortened hours on training has been previously highlighted in other papers in Th e Surgeon. Th e eff ect of limited average working hours for junior doctors to 58 hours per week in 2004 was examined in cardiothoracic surgery by West et al.3 One hundred per cent of the respondents felt that the EWTD had had a negative impact on training, and only 30% of trainees were satisfi ed with their training to date. Trainees’ concerns that they can be trained satisfactorily in a 48 hour working week were raised in a pilot project by Garvin et al.4 Th ey reported that all SHOs reported a deterioration in the quantity or quality of training. Interestingly, 81% of SHOs in that paper also felt that patient care suff ered. Th is was also confi rmed in a paper by Ledwidge et al.5 Th ey noted that surgical trainees performed fewer operations with the limitation in working hours. Th ey also noted in their paper that the introduction of shift patterns had reduced continuity of patient care. Th ey felt that this not only had a negative eff ect on patient care, but also on surgical training. Much of surgical training takes place in the context of emergency care, and this has also been highlighted as an area which is likely to be strained by the shorter working week. Wong wrote about trauma education of junior hospital doctors at a major Australian trauma service.6 He noted that the resident medical offi cers, including basic surgical trainees, had minimal exposure to major trauma, restricted access to trauma education and limited self-perceived confi dence. It was a concern that this would be further compromised by shortening the working week. Court-Brown et al. noted that the numbers of emergencies and unplanned admissions to Scottish hospitals are much greater than appreciated by many surgeons, managers and politicians.7 Th ey were concerned that recent changes in the working hours proved detrimental to the provision of good care for emergency patients. Th is could potentially limit even further the access of doctors in training to this important area. Th e Surgeon has also been concerned with strategies which might be developed to cope with the shorter working week, and to continue to produce excellent surgical trainees. Th e move away from the traditional apprenticeship model of training may in part be compensated for by virtual reality simulation. Th is was addressed by Tsang et al. who reviewed the evidence that this form of training in endovascular surgery was valid.8 Th ey concluded Surgeon, 1 August 2009, pp. 196-97 editorial