Should Shift work for House Officers be abolished?

One may question this after an enlightening letter by a House officer, Dr. Timothy Cheng, who wrote :
Revamp current shift system

The main issue that gave birth to this shift system was the concern for the well-being of the house officers.
With the current shift system, continuity of care of patients is disappearing as house officers are not able to care for one patient longer than 12 hours at a stretch.
Most doctors that have gone through the on-call system realise the stress and the workload it brings but are also thankful for the training and skills that it equips them with.
As a house officer, I wish we had shifts that are at least 24 hours long, enabling us to follow patients’ progress closely.
We have also forgotten that medical officers work with the on-call system. How are we supposed to function as medical officers in the future after two years of working with the shift system?
It will only lead to a whole new breed of medical officers who cannot function after 12 hours of work, again to the detriment of patients under them.
And the main drawback of the shift system is that it has given birth to a new breed of doctors that work with the “shift” in mind, putting their working hours before patient care and well-being.
The shift system has reduced us to be pampered, mechanical robots that work just to complete a shift rather than to save lives.
I hsve had (and still have) colleagues that disappear right on the dot after their shift ends, leaving work to the house officer of the next shift, with the reason being that they are “off duty”.
Patient management that is planned for the next shift is done haphazardly as there is no accountability once a house officer gets off work.

The topic of House officer training is a subject of a long discussion thread in Dobbs, the Malaysian Doctors forum, and with the permission of the original poster, I am reproducing some of the issues he encounters as a supervisor of House officers:

As a current trainer of HOs, the consensus in the hospitals is now less about shift work but more of HO performance. I too went through the crazy days of EOD calls with no post-call off. Though educational & spirit-building, I do not wish for those days to continue as they put both HOs and patients at risk. A form of shifts is good but patient welfare and safety must not suffer. Unfortunately, it is suffering despite the larger numbers of HOs nowadays.
Why is this so? From my observations, there are a few problems which appear consistently. A non-exhaustive list:
1) Poor knowledge. A problem of the less established med schools. I have met HOs who do not know the normal range of blood sugar, who can’t name me the 4 valves in the heart, who can’t tell me what antibiotics to give for pneumonia, who don’t know aspirin is the 1st line therapy for ACS.
Though bad, lack of knowledge can be overcome, and has, by the willingness to learn. Met a few who really tried and succeeded to be competent safe doctors.
There are a few who truly lack the IQ to be doctors, but for those I blame the medical schools for taking them in and passing them.
2) Lack of common sense. This one is difficult. How do you teach common sense?? A patient with BP 70/40 was not informed to the MO (despite the MO asking ‘any unstable patients?’) because the patient ‘looked’ well. Hepatitis status to be traced before dialysis:- not notified to superiors that the results were not available because the order was to ‘trace’, not to ‘inform’. 3 jobs to do: get USG appt, send FBC, set iv line for inotropes – left the ward to do the 1st one. DM patient with hypoglycemia – gave dextrose drip, as well as insulin, at the same time.

3) Lack of insight. Despite being informed (orally and in writing) of their substandard performance, many HOs refuse to acknowledge their weaknesses. They live in their own rosy world with no connection to reality. Any criticism is greeted with disbelief, blaming the trainers for being too demanding, not understanding etc. They do not seem to realise their actions impact directly on patient welfare. This trait is associated with the ability to function in only 1 gear. Doesn’t matter if there are 2 or 8 patients to care for or 1 – 6 patients to clerk, they work at the same speed. Who is to be blamed when they can’t finish their jobs at the end of the shift?
4) Attitude. This is the hardest to tackle. I have one chap who took EL whenever he felt like it, MIA from the ward, turned up late, didn’t review his patients etc. Almost all the sins of HOship. When he was extended, he made a complaint to MoH of being bullied. There is one who told the MOs he had 3 degrees, and therefore didn’t need to heed their orders. A HO under extension still gives verbal orders without reviewing the patient when nurses notify him of problems. And these are the ones who kick up a fuss when they are asked to work 66 hours a week, who demand 2 days off a week but refuse to put in a 12 hour shift. Can someone tell me how to put in a 60 hour week with 2 days off when you REFUSE to work for 12 hours a day?

Some trainers have given up and let the HOs do whatever they want, because threats of MoH complaints, lawyer letters etc. Forget about extensions, assessments, quality etc, easier to just get them out of the dept.
Thankfully my colleagues are as stubborn as me. We try to maintain some sort of standards before allowing them to leave the dept.

So should the Shift system for House officers in Malaysia be abolished? What do you think? Just take the Yes or No poll below:

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Malaysian physician, haematologist, blogger, web and tech enthusiast

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2 comments on “Should Shift work for House Officers be abolished?
  1. YM Ng says:

    I’m a HO in the UK and the shift system here is well established following the implementation of the European Working Time Directive. The system does have its own problems but tired doctors make mistakes!

    I do not think the shift system should be abolished. Rather, it should be reviewed and improved further. Other than the valid points written above, I think the most important thing to emphasise in the shift system is GOOD HANDOVER. A system should be in place to ensure handover is done appropriately e.g. handover meetings, handover sheets, job lists, prioritisation with seniors etc etc.

    Having the shift system does not mean we leave at the end of the shift tepat tepat. I often stay very late to tie up my workload anyway.

    To emphasise again,
    1. Tired doctors are bad doctors – they make lots of mistakes
    2. GOOD HANDOVER IS KEY in the shift system.

    We have a good quantity of doctors in malaysia – if it is planned properly, the shift system should work.

  2. andre das says:

    just a few comments and to correct misunderstandings:
    1.There has been no conclusive evidence about what defines the limit of working hours that results in tired doctors.Many doctors on whatever system do not sleep during their so called rest period (i leave it to your imagination what they do) hence it is too simplistic to conclude that a shift system ensures adequate rest.
    2.Shift system has been shown to be unsuitable for certain disciplines eg Surgical based ones as far as quality of training is concerned.
    3.Shift system was enforced in Europe because of labour law requirements not because the old system was bad
    4.We need a critical mass ( may be much more than old system) to facilitate the shift system
    5.Malaysian shift system was set up with no clear objectives. Many believe that it was to provide Ho with adequate rest and if this is the objective then I am against it as per the 1st point above and I feel the most important objective should be proper and adequate training!

    My personal opinion is that systems cannot be generalised and has to be tailored to suit the local situation as well as the dept concerned and need clear set objectives as a guide.