Hours,volume, and type of work of preregistration house officers.

OBJECTIVE--To determine the hours, volume, and type of work undertaken by preregistration house officers. DESIGN--Continuous observation of 472 hours of work performed by 12 preregistration house officers based in medical wards, using standard procedures for studying work patterns. SETTING--A teaching hospital with 340 beds assigned to general medicine and coronary care. SUBJECTS--12 Of the 16 preregistration house officers in medicine at the hospital. MAIN OUTCOME MEASURES--The hours, volume, and type of work undertaken by preregistration house officers in February 1989, as recorded by trained observers on a one to one basis. RESULTS--The hours of duty ranged from 83 to 101 hours each week, the longest period of continuous duty being 58 hours. Each shift, house officers spent up to 25 minutes travelling between wards and an average of 85 minutes treating patients in wards that were cross covered. Between 50% and 71% of house officers'' time was spent on patient oriented duties during the day; this fell to between 21% and 53% at night. Each doctor spent an average of 40 minutes filing when off duty after 6 pm. CONCLUSIONS--Established procedures for studying workload were effective in monitoring doctors'' hours, providing accurate information on the volume and type of work, which is essential to resolve the problems of medical staffing. The study showed that more house officers were needed and that the cross cover system should be stopped. As a result three extra preregistration house officers were appointed.     

Introduction of a partial shift system for house officers in a teaching hospital.

OBJECTIVES--(1) To introduce a partial shift system to reduce the hours of work of preregistration house surgeons to an average of 64 a week to comply with the New Deal for junior doctors; (2) to test linking the partial shift concept to an existing structure of "on call" firms. DESIGN--Formal assessment after three months of a pilot partial shift system for eight house surgeons on three firms instituted on 1 November 1991, followed by questionnaire and interview evaluation at three and six months of a revised system implemented on 1 February 1992. SETTING--Department of general surgery at St Bartholomew''s Hospital, London. SUBJECTS--24 house surgeons attached to three surgical firms. RESULTS--In eight weeks each house surgeon worked one week (five shifts) of night duty, one week of "cover" (afternoon and evening) duty, and six weeks of normal daytime hours. Each weekday a house surgeon from the firm on call worked an extended daytime on call shift until 10 pm. Weekend duties were split between two house surgeons from the firm on call. A computer generated graphical display of the rota was used to facilitate leave planning. Average working hours were reduced to below 64 per week, including prospective cover, without detriment to patient care and educational standards. Within the shift system individual house surgeons could be on call with their own firm by day and at weekends. Opinions were equally divided among junior staff as to their preference for either on call or partial shift systems. CONCLUSIONS--The principles of this partial shift system are generally applicable and the model can readily be adopted by district general hospitals.     

Preregistration house officers in general practice.

OBJECTIVES--To obtain from house officers who had rotated through general practice in their pre-registration year their views about their experience; and, separately, to compare the overall hours and type of work performed by hospital based and general practice based house officers. DESIGN--Postal questionnaire; and self recording of working hours and duties during four consecutive weeks. SETTING--Inner London teaching hospital and nearby general practice. PARTICIPANTS--28 preregistration house officers in general practice, 1981-91; and 12 preregistration house officers, four each in medicine, surgery, and general practice. RESULTS--26 out of 28 questionnaires were returned (response rate 93%). Twelve respondents were following or thinking of following a career in general practice. Twenty five respondents were satisfied with the clinical and educational aspects of the general practice rotation and would recommend the rotation, and 25 thought four months was about the right length of time in general practice. With regard to hours and type of work performed, hospital based house officers worked on average 55.5 hours a week (excluding on call), with an average of 12.5 hours (22.5%) spent in clinical activities; general practice based house officers worked about 41 hours a week, of which 24 hours (58%) were in clinical activities. House officers in hospital received less than one hour''s specific teaching a week; those in general practice received nearly three hours'' a week. CONCLUSIONS--A preregistration rotation in general practice is a popular alternative to the hospital based rotation. Although this is a limited study, other medical schools should consider introducing general practice options for preregistration house officers.     

How easy is it to contact the duty medical doctor responsible for acute admissions?

OBJECTIVE--To ascertain ease or difficulty of contacting duty junior doctors responsible for acute medical admissions by telephone. DESIGN--Telephone survey of hospitals in six health regions in England and Wales. SETTING--70 Randomly selected hospitals, 15 of which were excluded because of non-acceptance of acute medical admissions. PARTICIPANTS--71 Duty doctors (duty house physicians, senior house officers, or registrars responsible for acute medical admissions) in 48 hospitals; seven duty doctors in seven hospitals were excluded (four declined to participate and three required a written explanation of the survey). 67 Doctors gave full information to all questions. MAIN OUTCOME MEASURES--Time taken for hospital switchboards and duty doctors to reply to telephone call, diagnoses of patients recently admitted, and on call rotas and hours of sleep of duty doctors. RESULTS--Hospital switchboards responded within 30 seconds in 87 (74%) calls, and in 76 calls (64%) the duty doctor requested was contacted within a further two minutes. Chest pain, possibly due to myocardial infarction, was the most common reason for acute medical admissions. Nearly half (48%) of the duty doctors in larger hospitals reported having 4-5 hours sleep or less on their nights on call. Most (30) were on a one in three rota; two were on a one in two rota. CONCLUSIONS--Despite impressions to the contrary contacting the duty medical team by telephone seemed fairly easy. Although most junior doctors were on a rota of one in three or better, insufficient recognition may be given to their deprivation of sleep during nights on duty.     

Shift system for senior house officer on call duties on a neonatal intensive care unit

To reduce the number of hours that senior house officers in the neonatal department at Southmead Hospital, Bristol, have to work continuously a new on call rota was devised. The rota changed the traditional one in three system of 24 and 32 hour periods on call to one with two shifts each day, and it spread the workload more evenly among the personnel. The continuity of care of the patients was improved, no extra staff were recruited, and the new system was favoured by senior and junior medical and nursing staff.     

Senior house officers: the lost tribes.

There are more senior house officers than doctors in any other training grade in Britain but nobody knows what they do in hospitals or has a clear idea what skills they should be learning. Nobody is responsible for them and they suffer from having a poor career structure and inadequate training. Now that there are government initiatives to reduce the hours that junior doctors work and to limit the time it takes to train to become a specialist, the problems that senior house officers face can no longer be ignored. A conference for senior house officers held last week talked about the problems that they face and tried to find some solutions.     

Effects of sleep disruption on cognitive performance and mood in medical house officers.

Twelve medical house officers were tested on a battery of memory, concentration, and work related tasks after three conditions: a night spent off duty; a night spent on call; and a night spent admitting emergency cases. Short term recall, but not digit span, concentration, or work related abilities, was impaired after a night of emergency admissions. A night spent on call had no effect on cognitive performance. Self reported mood scores showed that house officers were more deactivated (indicating a lack of vigour and drive) after nights of emergency admissions but not after nights on call. Significant between subject differences were found for five of the eight cognitive tests. Though loss of sleep and long hours of work have an effect on memory and mood, the individual differences among doctors are the main source of the variance in performance of tasks.     

Preregistration house officers in the four Thames regions: I. Survey of education and workload.

OBJECTIVE--To assess the education and workload of preregistration house officers in the four Thames regions. DESIGN--Postal questionnaire. SETTING--Teaching and non-teaching hospitals in the four Thames regions. PARTICIPANTS--1064 Preregistration house officers. RESULTS--Response rate was 70% (740 replies). Nine per cent of house officers (66/729) worked a rota of one in two. The average house officer had 20.4 inpatients under his or her care and admitted 23.2 patients per week. Sixty two per cent of house officers (459/740) felt that they spent an excessive amount of time on non-medical tasks of no educational merit; 75% (546/725) had never received adequate guidance on breaking bad news and 64% (467/729) had never received adequate guidance on pain control; 34% (249/731) did not feel confident that they could perform cardiopulmonary resuscitation unsupervised. House officers would tend to recommend their post to a friend. CONCLUSIONS--There are deficiencies in preregistration training in the four Thames regions. The General Medical Council''s requirements are not being heeded.     

Preregistration house officers in the four Thames regions: II. Comparison of education and workload in teaching and non-teaching hospitals.

OBJECTIVE--To detect differences in the education and workload of preregistration house officers working in teaching and non-teaching hospitals. DESIGN--A postal questionnaire. SETTING--Teaching and non-teaching hospitals in the four Thames regions. PARTICIPANTS--1064 Preregistration house officers. RESULTS--Response rate was 61% for teaching hospitals and 73% for non-teaching hospitals. House officers in teaching hospitals had significantly fewer inpatients under their care (house physicians 16.9 v 22.9, house surgeons 17.9 v 20.3) and admitted fewer emergency patients per week (house physicians 7.7 v 12.7, house surgeons 6.5 v 9.8). More house officers in teaching hospitals reported that they had too few patients to provide adequate clinical experience. More of their time was consumed by administrative activities devoid of educational value. CONCLUSION--Preregistration house officer posts at teaching hospitals provide less clinical activity and are perceived as less educationally satisfactory by their holders than those elsewhere.     

Adverse changes in mood and cognitive performance of house officers after night duty.

The effects of long hours of work by junior doctors are the subject of growing concern. Experimental investigations of the effects of night duty on young doctors are few and have given inconclusive results. To measure the effects of long hours of work and reduced sleep on cognitive performance and mood 20 house officers (14 men and six women; mean age 25, range 24-35) were examined for 35 minutes in one session towards the end of a normal working day and in a second session at the same time after working for up to 31 continuous hours with reduced sleep. The order of the sessions was counterbalanced across the subjects. Each session comprised a series of cognitive tests: choice reaction time, vigilance reaction time, and haptic sorting tests and completion of a profile of mood states and a general questionnaire. After night duty there was a significant slowing in cognitive processing together with a decline in reaction times in the vigilance test. Loss of sleep contributed only to increased variability in the choice reaction time. Significant deleterious changes in mood after night duty occurred in all the mood scales after night duty. Continuous working may adversely affect the cognitive function and mood to the detriment of the welfare of doctors and their patients.     

Counselling needs and experience of junior hospital doctors.

A sample of 106 senior house officers who had graduated from Nottingham University in 1987 was surveyed about their experience of and need for careers guidance, performance appraisal, and stress counselling. Of the 80 who replied, a quarter had received no careers guidance and a quarter no feedback about their work performance. Many reported having had difficulties in their post, but few had received help from senior staff or their consultant. The perceived needs for counselling were considerable. Careers counselling was thought to be essential in the preregistration year by all of the doctors and in senior house officer posts by three quarters. Nearly all would have chosen regular appraisal and nearly half wanted counselling for particular difficulties. Doctors in the training grades clearly believed that they needed counselling, but in most cases they did not receive it.     

Preregistration house officers in the Thames regions: changes in quality of training after four years.

OBJECTIVE--To measure changes in the training and workload of preregistration house officers over four years. DESIGN--Postal questionnaire. SETTING--The Thames health regions. PARTICIPANTS--1049 preregistration house officers. RESULTS--Response rate was 69% (725 replies). The proportion of house officers officially on duty > 83 hours a week fell from at least 42% to 21%, and the proportion officially on duty < or = 72 hours rose from no more than 9% to 40%. Adequate guidance in breaking bad news increased from 25% to 46% (p < 0.0001; 95% confidence interval for difference, 16.2% to 25.8%) and guidance in pain control increased from 36% to 46% (p < 0.01; 5.0% to 15.0%). The number of house officers attending an induction course increased from 61% to 94% (p < 0.001; 28.9% to 37.1%). There was no change in the proportion unable to attend formal educational sessions because of clinical commitments or in levels of satisfaction with consultants'' educational supervision. The median number of inpatients under house officers'' care fell from 20 to 17, but the numbers of patients clerked in an average week showed little change. House officers were less satisfied with the clinical experience their post provided (proportion dissatisfied rose from 30% to 39%; p < 0.01; 4.2% to 13.8%) and less enthusiastic about recommending their post to a friend (proportion neutral or not recommending rose from 30% to 42%, p < 0.0001; 7.9% to 16.9%). CONCLUSION--Despite progress in reducing hours of duty and providing induction courses, the training that hospitals and consultants provide for house officers is still unsatisfactory and inconsistent with the General Medical Council''s recommendations.     

Senior house officers and their training. I. Personal characteristics and professional circumstances.

To assess the experience and perceptions of training of senior house officers in medicine a population survey of senior house officer training was conducted on senior house officers, registrars, senior registrars, and consultants in six medical specialties in South East Thames region by interview and postal questionnaire. The overall response rate was 72%, varying from 62% to 83% according to status and from 61% to 80% according to specialty. Although most of the 226 senior house officer respondents were aged 28 or under (168/225), had been qualified for four years or less (168/225) and were British (176/223), a quarter were older and had been qualified for five years or more; in all, 17 other nationalities were represented. Twenty two were aged over 33, and 17 had been qualified for more than 10 years. Thirty five senior house officers worked more than the mode of the distribution of duty rotas (one in three). Among postgraduate qualifications achieved or pursued, those related to general practice were highly represented (164 examinations); 111 senior house officers intended becoming general practitioners, 63 non-teaching hospital consultants, and 34 university or NHS teaching staff. Analysis of career progression showed that an appreciable number (31/221) had had more than three senior house officer posts. The findings indicate that the main implications for training and education are time for study, careers advice, and revision of educational programmes.     

Preregistration house officers in eight English regions: survey of quality of training.

OBJECTIVE--To assess the quality of preregistration house officer training in eight English regions. DESIGN--Postal questionnaire. SETTING--Thames, East Anglian, Mersey, Northern, and Wessex regions. PARTICIPANTS--1670 preregistration house officers. MAIN OUTCOME MEASURES--Education, hours of work, workload, conditions of work, and attitudes to job and medicine as a career. RESULTS--Response rate was 69% (1146 replies). Most house officers had attended induction courses (1036/1129 (92%)); 74% (757/1024) found them satisfactory. The proportions who had never received adequate guidance on how to break bad news and how to control pain were 59% (670/1135) and 56% (634/1136) respectively. There was much variation between regions. Overall, 65% (736/1138) reported confidence in performing cardiopulmonary resuscitation. Most respondents (95% (1089/1142)) worked an on call rota, 3% (36) a partial shift, and 0.6% (seven) a full shift; 19% (202) were on duty for average weekly hours that exceeded the targets for 1 April 1993. House officers had a median of 20 patients under their care and clerked a median of 10 emergency cases, six routine cases, and two day cases a week. Over half (690/1128 (61%)) could not obtain hot food after 8 pm, 20% (223/1095) did not always have clean sheets available in their on call room, and 45% (462/1036) did not consider the protection of staff against violence to be adequate at their hospital. The most important problems with the preregistration year were inappropriate or non-medical tasks (ranked first by 360 respondents), hours of work (359), and pay for out of hours work (167). Overall 57% (646/1125) would encourage a friend to apply for their post, but only 24% (266/1112) would encourage a friend to take up medicine and 44% (494/1112) would discourage the idea. CONCLUSIONS--House officers'' training is deficient in important respects, with inappropriate tasks and heavy clinical workloads impeding the provision of proper education.     

Senior house officers in medicine: postal survey of training and work experience.

OBJECTIVES: To describe working conditions for senior house officers in medicine in Scotland and to relate these to the quality of clinical training they receive. DESIGN: Postal questionnaire survey. SUBJECTS: All senior house officers in medicine and related specialties in post in Scotland in October 1995 (n = 437); 252 (58%) respondents. MAIN OUTCOME MEASURES: Questionnaires covered hours, working patterns, measures of workload, an attitudes to work scale, and experience of education and training. RESULTS: In the week before the questionnaire, doctors on rotas had worked a mean of 7.4 (95% confidence interval 5.8 to 9.0) hours in excess of their contracts, compared with 3.7 (2.0 to 5.5) hours for those on partial shifts. The most common reason for this was "the needs of the patients or the service." Those on partial shifts reported significantly less continuity of care with patients than those on rotas (Mann-Whitney U test, z = -4.2, P < 0.0001) or full shifts (z = -2.08, P = 0.03). Doctors in general medicine reported significantly higher measures of workload (number of acute admissions, number of times called out, and fewest hours'' uninterrupted sleep) than those in subspecialties. Consultants'' clinical teaching and style of conducting a ward round were significantly related to factors extracted from the attitudes to work scale. CONCLUSIONS: The quality of senior house officers'' training is detrimentally affected by a variety of conditions, especially the need for closer support and supervision, the need for greater feedback, and the lack of time that consultants have to dedicate to clinical training. Efforts should be made to improve these conditions and to reinforce a close working relationship between trainee and supervising consultant.     

Senior house officers and their training. II. Perceptions of service and training.

Aspects of teaching and learning at senior house officer level in South East Thames region were investigated by analysis of the responses of consultants, senior registrars, registrars, and senior house officers to a postal questionnaire. Responses to sections about who teaches senior house officers, how senior house officers learn, and the relation between the service and training elements of these posts varied significantly, according to the status of the respondents; certain grades commonly overestimated their own contribution when compared with the estimates of the other grades. Although the replies of senior house officers showed that they were taught by various grades, 47% of this group did not regard the consultant as their main teacher. Senior registrars and registrars rather than consultants were regarded by senior house officers as best at teaching (63% v 48% respectively). Consultants and registrars were considered to require more commitment to training, personal educational training, and to be more approachable. Inquiry about teaching methods used most by senior house officers showed absence of a systematic approach to training. Only about half of senior house officers cited ward rounds with consultants. Views on the relation between training and service were significantly different among grades, but there was general dissatisfaction. Overall, the findings disclosed the ineffectiveness of senior house officer training posts. This arises from lack of a clear distinction between training and service elements, of educational training for teachers, of a clear contractual obligation to teach im the consultant grade, and of allotted time for training and study for the teachers and senior house officers respectively. Reversal of these current trends is needed for senior house officer posts to fulfil their main training function.     

Application of airline pilots' hours to junior doctors.

OBJECTIVE--To determine the staff required if the rules for airline pilots'' hours of work are applied to junior doctors. DESIGN--Junior anaesthetists recorded their workload from 1 March 1988 to May 31 1988. SETTING--District general hospital. SUBJECTS--Two groups of three junior anaesthetists sharing a one in three rota to provide continuous emergency cover. INTERVENTIONS--By using the guidelines published by the Civil Aviation Authority in The Avoidance of Excessive Fatigue in Aircrews schedules were drawn up to cover the hours that junior doctors had been on duty. RESULTS--Each anaesthetist provided emergency and routine cover for 48-112 (mean 75) hours each week. To cover the work of six junior anaesthetists on an annual basis would require 26 doctors if they were working within the Civil Aviation Authority''s guidelines. CONCLUSIONS--Junior anaesthetists'' hours are much longer than those of airline pilots. Both professions entail considerable periods of monitoring interspersed with episodes of high demands on physical and cognitive skills. Errors induced by fatigue made by anaesthetists and pilots could result in death. The medical profession should define rules similar to those of the aviation authority to prevent junior doctors having to work unsafe numbers of hours.     

Preregistration rotation including general practice at St Mary's Hospital Medical School.

A rotation for the preregistration year which included medicine, surgery, and general practice started at St Mary''s Hospital Medical School in August 1981. Initially approved by London University for an experimental period of three years, in 1984 it became an established rotation subject to normal review. Special arrangements were made for clinical work, supervision, prescribing, teaching, and other aspects of the general practice component. Data relating to the general practice consultations of the nine participating house officers show that they obtained wide experience, and their comments on the post itself were generally favourable. The four months spent in general practice were needed to allow time for the house officers to adapt to the new setting but did not seem to have an important effect on their experience in medicine and surgery.     

"Short report" staffing in practice: five years' experience of a consultant based service in obstetrics and neonatal paediatrics.

Recent government plans include the concept of a core of doctors of intermediate grade providing 24 hour emergency cover in hospital departments. Hinchingbrooke Hospital has, since its opening in 1983, been run on a two tier basis, with consultants and a part time senior registrar supported only by senior house officers in their first post, usually on general practice vocational training schemes. With a planned rate of around 2000 deliveries per year all high risk obstetric and neonatal paediatric procedures, including ventilation of very small babies, have been carried out within the hospital. A study of the first five complete years of operation of the obstetric and paediatric departments showed that the perinatal mortality rate was low (hospital rate 4.7/1000 in 9149 deliveries during 1984-8 v district rate 5.1/1000 during 1986-8), and patient satisfaction seemed to be high. In a separate prospective study of out of hours work performed by consultants in paediatrics (four weeks) and obstetrics (20 days) three consultants in paediatrics spent 71 hours working out of hours; for the obstetricians, of the 56 request for advice and 38 interventions, only five and six respectively occurred between midnight and 9 am. Although successful at this hospital, the two tier system would be expensive under the Royal College of Obstetricians'' guidelines of one consultant to a maximum of 500 deliveries. An equal mixture of two tier and three tier systems might be the best solution for patient care and training of junior doctors.     

Source of stress in women junior house officers.

OBJECTIVE--To determine the causes of stress in women doctors and relate these to levels of depression. DESIGN--Questionnaire study. SUBJECTS--Of 92 women doctors who had graduated from the universities of Leeds, Manchester, and Sheffield in 1986 and had been working as junior house officers for eight months 70 (76%) returned completed questionnaires. MAIN RESULTS--Mean score on the general health questionnaire was 13.79 (SD 5.20) and on the symptom checklist for depression was 1.43 (0.83). The scores of 32 subjects (46%) were above the criterion for clinical depression. Overwork was perceived as creating the most strain, followed by effects on personal life, serious failures of treatment, and talking to distressed relatives. Both stress and depression were related to effects on personal life, overwork, relations with consultants, and making decisions. Sex related sources of stress were conflicts between career and personal life, sexual harassment at work, a lack of female role models, and prejudice from patients. In addition to these, discrimination by senior doctors was related to depression. CONCLUSION--Changes are needed in the career paths of women doctors, and could be implemented.