On June 3 a recently graduated doctor and classmate of mine died in a motor vehicle accident. The night before, she had worked for more than 24 hours at Paarl Hospital in the Western Cape, where she was doing her internship. She was, like many interns around South Africa, “post-call”.
She is not the first of my classmates to be involved in a serious car accident while “post-call” in the six months since we started working.
Every time one of these fatigued doctors go home, the odds are stacked against them arriving home safely. Every time, they have been caring for patients until moments before they departed.
Safe Working Hours and the Junior Doctors Association of South Africa (Judasa) have been collecting information from doctors about their experiences during and after long shifts, and we have heard a steady stream of stories about medical errors resulting in potential and real patient harm, car accidents and deteriorating physical and mental health.
One doctor related a story where, after a 30-hour shift, they put the wrong patient’s details on a form for a blood transfusion. “In my state of fatigue [I] wrote down her neighbour’s details,” she explains. Serious consequences for the patient were narrowly avoided.
Another submission from a doctor working in a ward for newborn babies reads: “One of the sick [newborns] … had fallen from the incubator because I had forgotten to close it. I was so tired I did not even notice that the incubator was left open.”
“A 30-hour continuous shift limit defies what is humanly possible”
When people outside the hermetic medical fraternity learn that someone had been working without rest for 24, 30 or even 36 hours, they are shocked. They are horrified to discover that this affront to common sense is standard throughout South Africa.
The aftermath of my classmate’s tragic death has seen a revival in public interest in doctors’ working hours, and has again illustrated the reticence of the department of health and, in particular, the Health Professions Council of South Africa (HPCSA) to review an ingrained practice that is clearly harmful to both patients and practitioners. Numerous recent articles have emphasised that the current HPCSA internship guideline of a 30-hour continuous shift limit defies what is humanly possible.
Safe Working Hours submitted documentation to the HPCSA internship committee in April, urging for the continuous shift limit to be reduced — initially to 24 hours and then, with further review, to be in line with best evidence. A petition started by the campaign, calling on Minister of Health Dr Aaron Motsoaledi to review continuous shift limits, has now gathered more than 5 600 signatures, and will soon be handed to the minister.
The HPCSA has been mute in the past weeks and this is worrying, given that their internship guidelines continue to allow the shifts in question to be enforced by health departments and hospital management throughout the country.
Writing in the Cape Times, Dr Beth Engelbrecht, head of the Western Cape department of health, was quick to point out that institutions “ensure that interns do not work hours over and above the stipulated time frame”, before reproducing the HPCSA 30-hour guideline in question.
She took the additional disingenuous step of writing that interns are, “by and large, responsible for their own roster allocation”. This seems to imply that interns have been forcing each other to work the hours in question, but the truth is interns are expected to work “calls” in a rigid fashion and simply decide among themselves who will be taking which days.
Shorter shifts can reduce medical errors
Hiding behind archaic and dangerous working hour regulations is typical of clinical management throughout the country. It is up to them to take steps to make working hours at their institutions safe for both patients and doctors, and to work towards innovative solutions in lieu of more responsible regulations.
Myopic suggestions such as “post-call” napping facilities (where doctors can sleep before attempting the trek home), obliging interns to live on hospital premises, and shuttle services miss the point — a shift that so impairs doctors’ driving abilities also destroys their ability to care for patients.
Innovative ways to implement shorter shifts with stringent handover guidelines can reduce medical errors and improve safety. Further options include a pre-call rest period and protected sleeping time during longer shifts. The problem is not unique to South Africa and several countries have successfully dismantled the culture of long continuous shifts.
The department of health has responded to the emerging outcry by declaring a drive to train more doctors. This welcome announcement, however, does not engage with the issue at hand.
More doctors don’t necessarily translate into abolition of similar continuous shifts until regulators require this: in the United States, which has nearly 10 times the amount of doctors per population as South Africa, doctors work similar long continuous shifts. Their response also implicitly attempts to shut down the conversation with a vague assurance to revisit it only once such plans have come to fruition ten to twenty years in the future.
Additional regulations must be created that apply not only to interns, but also to all doctors. Further delay continues to place the safety of staff and patients at risk.
Koot Kotze is a medical doctor working as an intern. He is a founding member of Safe Working Hours. Visit www.facebook.com/safeworkinghours and view the petition at http://tinyurl.com/SafeWorkingHoursSA