Medical practice: Take a break

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Medical practice: Take a break
Medical practice: Take a break

Take a break

Anyone who has had to stay awake for 24 hours at a time performs just as poorly on behavioral tests as a person with one per thousand alcohol in their blood. Physicians, who are regularly forced to work shifts with such a lack of sleep, should nevertheless always make the right decisions, because they are vital. That can't work. Weeks of doctors' strikes determined the news in the summer. As with any collective bargaining dispute, it was about the salary – but also about reasonable working hours. Wages can now be discussed in detail, and unpaid overtime is more the rule than the exception for most workers these days. In this case, however, the industrial dispute affected us all: Because doctors who are on duty 24 hours or more make more mistakes - this has now been proven by a number of studies. And shift work of this length is not uncommon, with weekly working hours of eighty hours and more.

It took a strangely long time before fatigue and overwork and the associated consequences became a topic of discussion in medical circles and the public. And the number of studies on this is still comparatively small. How different is the situation in the areas of transport and industry, where a connection between working conditions - and thus also excessive working hours - and their harmful effects is made and also recognized much more frequently.

The foundation stone was laid in a publication from 1971 in which researchers found that interns made almost twice as many errors when evaluating ECGs after a 24-hour shift as their colleagues who had had a good night's sleep [1]. However, the topic only found its way into the media with the report of the Institute of Medicine of the US National Academies of Sciences, according to which incorrect medical decisions are said to be responsible for 44,000 to 98,000 deaths in US clinics every year [2]. However, the authors were largely silent on the influence of fatigue on the performance of medical staff.

In the following years, the number of studies and publications on patient safety increased significantly [3]. And the focus changed: While previously the main focus was on medical malpractice, the articles now focused much more on the areas of organizational culture – as well as staffing and working hours.

Building on their previous studies, which had found a lower error rate for reduced on-call times - under 16 hours instead of over 24 hours - Harvard University's Charles Czeisler and his team now examined how the incidence of long on-call times changed the performance of residents [4]. More than 2,700 young doctors filled out detailed monthly online questionnaires about working hours and sleep phases and also had to state how many – according to their own estimation – they had made due to fatigue and other mistakes and how often they nodded off or even fell asleep during their work or in seminars.

The statistics finally provided clear figures: if the residents had to put up with up to four long on-call shifts a month, the risk of a treatment or diagnosis error due to fatigue was 3.5 times higher than in a month without long shifts. If the young doctors approached at least five times, this percentage even rose to more than seven times. And dozing off at inopportune moments - during rounds or even during operations - was much more common. Correspondingly, he alth impairments associated with this increased among the patients.

One thing to keep in mind with these numbers is that there is more to it than just the error itself - after all, it also has psychological consequences for the medical professional who feels guilty. But that triggers a real vicious circle: The resulting insecurity leads to further mistakes, the constant pressure - even self-inflicted - can ultimately lead to burn-out symptoms, as other studies have shown.

A reduction in working hours would therefore be necessary, the data seem to show. In fact, however, some corresponding attempts showed another effect, which in turn can increase the error rate again: lack of communication. Because the shortening also means that a doctor can now look after a specific patient less intensively. However, the necessary changes between colleagues only go smoothly if all the necessary information flows during the handover - and this is where there are obviously problems in some cases. This interrupted doctor-patient contact is therefore often used by doctors themselves as an argument against reducing working hours.

More than 24 hour shift work should become the exception to the norm, at least in Germany, according to the new tariff conditions. Weekly working hours of 42 hours at university clinics and 40 hours at community hospitals were agreed. A doctor can now add up to 16 hours of on-call duty to a normal working day of eight hours, with this being paid differently depending on the workload. The maximum working time per week is 58 hours - but can be increased even further with the doctor's personal consent.

From the point of view of the Marburg Federation, the introduction of flexible working time models and electronic time recording would be particularly important in order to make the numerous, previously unpaid overtime hours of doctors visible and thus affordable. Because here some doctors express another point of criticism: With the restriction of the previously usual working hours, the salary also falls. For example, some clinics are reporting that their doctors do not want their overtime to be compensated in terms of free time, but financially.

Together with agreements on further training measures, freedom for research and teaching, which previously often had to run on the side, and the prospect of better organized work processes, the new contracts could perhaps pave the way to a better working world for doctors - if they weren't there again the well-known problem that for all these beautiful sounding things also sounding coins are needed, which are missing everywhere. In addition to more efficient doctors, they also enabled greater safety for patients - and that is really in all of our interests.

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