A tragedy waiting to happen

Overworked doctors pen their accounts of tragedies waiting to happen on the Facebook wall of the group named Safe Working Hours.

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Johannesburg - One by one they pen their accounts, which read like multiple tragedies waiting to happen.

“At 34 weeks pregnant and doing a 24-hour shift, I drew blood on one of the last patients I was seeing.

“Exhausted, I sustained a needle-stick injury of a high-risk HIV patient.

“The stress, the ARVs and everything that went with it could have easily been avoided if I was not already seeing double after working such long hours.”

Signed, anonymous.

The next reads: “I was involved in a motor vehicle accident (the only accident I have ever had) when I was post call in my community service year.

 

“I was on my way to a clinic after about a 26-hour shift without a break. Still had to work about another five hours.

“It was not a high-speed accident, and I am still unsure who made the mistake, as the insurance companies resolved the matter.

“Luckily nobody was hurt, but my car had R40 000 damage and I can recall that I was completely surprised when the car hit me. I was unaware of the car, which was speeding through a traffic light.

“I think I would have been more aware if I was not so tired.”

Signed, Dr Dalene von Delft.

And so the accounts go on, shared on a Facebook wall of the group named Safe Working Hours, which is advocating for safer working hours for South African doctors.

The aim of the shared stories is to highlight the seriousness of the long-held problem in the medical sector, namely the long working hours doctors continuously have to work under, often to the detriment of their and the patients’ health.

In 2014, the campaign was launched with the aim to review working-hour guidelines for doctors in South Africa.According to the Health Professions Council of South Africa (HPCSA) 2013 Handbook on Internship Training, medical interns should work a maximum of 40 hours a week with 20 hours commuted overtime, resulting in 60 hours a week or 240 hours a month.

The guidelines also state that continuous service should not exceed 30 hours, and for the campaign - uniting medical students, junior doctors, activist organisations, unions and concerned members of the public - working that long on a continuous shift is simply unacceptable.

Over recent weeks, fierce debates have arisen in the media and social platforms on whether doctors should be working long hours - and what the effects are.

The issue was given prominence following the death of 25-year-old Paarl Hospital intern Ilne Markwat, who was driving towards Cape Town on the N1 near Klapmuts around 10am one day last month when she fell asleep behind the wheel and collided with a bakkie.

She, like many of her colleagues, was exhausted after knocking off from a 24-hour shift.

A woman who was in the bakkie Markwat crashed into later died in hospital.

Safe Working Hours submitted documentation to the HPCSA internship committee in April arguing for the continuous-shift limit to be reduced, which, according to campaign representative Helene-Mari van der Westhuizen, the council still hasn't responded to.

A petition was also started by the campaign, calling on Minister of Health Dr Aaron Motsoaledi to review the continuous-shift limits. It has close to 6 000 signatures and will soon be handed to the minister.

“We hope the current HPCSA regulation stating that the maximum duration of a continuous shift is 30 hours be reduced to 24 hours as an immediate interim arrangement, with further reduction to 16 hours to be in line with the current evidence,” Van der Westhuizen told The Star.

She said Safe Working Hours and the Junior Doctors Association of South Africa had been involved in talks with the Western Cape Department of Health, which had indicated its support for a reduction in the continuous shift.

When The Star approached the minister’s spokesman, Joe Maila, to comment on the issue and what steps the department was taking, he said: “We know that our doctors are working hard, and the Department of Health and the HPCSA are looking into the matter.”

Speaking on radio recently, Gauteng Health MEC Qedani Mahlangu acknowledged that the issue was of concern to the department, but added they had found that some senior doctors shirked their responsibilities of supervising intern doctors to moonlight in their private practices, yet earned a salary from the department to be at public hospitals, leaving junior doctors with heavier case-loads.

The campaign has compiled published research on sleep and working hours in relation to medical error.

While it may have been conducted outside the South African context, the campaign believes the data has “direct and immediately important” implications for doctors in South Africa.

The abstract to Lockley et al’s 2006 review “When Policy Meets Physiology” pre-emptively addresses concerns with efforts to reduce continuous-shift lengths, stating: “While numerous opinions have been published opposing reductions in extended work hours due to concerns regarding continuity of patient care, reduced educational opportunities and traditionally defined professionalism, there are remarkably few objective data in support of continuing to schedule medical trainees to work shifts greater than 24 hours.

“An evidence-based approach is needed to minimise the well-documented risk that current work-hour practices confer on resident health and patient safety while optimising education and continuity of care.”

In the US, the maximum duration of shift lengths for interns is 16 hours, and for more senior doctors in training it is 28 hours, following an Accreditation Council for Graduate Medical Education ruling in 2011.

This was in turn influenced by a 2008 report by the Institute of Medicine which found that this (and other aspects of residents’ working hours) was excessive and potentially harmful to patients and staff, noting that “there is enough evidence from studies of residents and additional scientific literature on human performance and the need for sleep to recommend changes to resident training and duty hours aimed at promoting safer working conditions for residents and patients by reducing resident fatigue”.

Van der Westhuizen also tackled how the pervasive notion that “every doctor went through it” was wrongly adding to perceptions that doctors could work continuous shifts with no consequences to themselves or the patients.

“Some see this medical internship as initiation’ into the profession, and that interns should grin and bear it’.

“We strongly contest this, as your ability to care for patients is impaired, and it leads to an increase in medical errors.

“We have focused our campaign on doctors currently doing their internship because their training conditions are regulated by the HPCSA. However, we support safe working hours for all doctors,” she pointed out.

Van der Westhuizen said that at many South African public hospitals there were already examples of best practice - using a combination of innovative shift systems, protected sleeping time on call or “post call” cover to limit the duration of a continuous shift.

The Star asked the HPCSA what had informed the current regulations and whether having heard the campaign’s call, there were any plans afoot to change them.

“The HPCSA internship subcommittee is aware of the matter and this will be tabled at the Medical and Dental Board meeting on July 26. Further information will be provided post the meeting,” said HPCSA spokeswoman Priscilla Sekhonyana.

In the meantime, junior doctors and the public wait for changes to be implemented and hope that more tragedies don’t happen.

vuyo.mkize@inl.co.za

The Star