Cape Town - Young, inexperienced, exhausted. And your life is in their hands. Junior doctors across South Africa are asleep on their feet as they are forced to work shifts lasting up to 36 hours, placing themselves and their patients in serious danger.
These doctors at the bottom of the medical pecking order are sick of treating patients while so tired they might as well be drunk, and are petitioning Health Minister Aaron Motsoaledi to review their working hours.
“Your competence decreases because of exhaustion. You end up blaming yourself when people die. You feel like you’re abused, and lose your passion for medicine.”
Dr Courage Khoza is the president of the Junior Doctors Association of South Africa (Judasa). He is doing his community service year at Bernice Samuel Hospital in Mpumalanga.
“You still have to drive home after not having slept for 30 hours or more,” Khoza said. “You are a danger to yourself and to others on the road. A doctor who has not slept for that long is just as dangerous as drunken driver.”
A 1997 study showed that after being awake for 24 hours, cognitive psychomotor performance drops to the same level observed in people with a blood alcohol level double the legal limit for driving. And doctors drunk on fatigue are much more likely to injure themselves and others.
“In the long term, if you make mistakes you can have needlestick injuries and get infected with HIV. It poses a huge risk,” Khoza said. “You are also a danger to people that you treat.”
In South Africa, doctors spend six years studying for their degree. After they graduate and can officially be called “doctor”, they must complete two years of internship and one year of community service as employees of the national HealthDepartment.
Only once their superiors have signed off these three “junior doctor” years can they legally practise medicine in South Africa wherever they choose. Interns sign up to work a maximum of 80 hours paid overtime a month in their contracts with the government. However, many hospitals ignore this regulation, and interns have no choice but to work far longer – unpaid.
Khoza said the problem was nationwide, as junior doctors were placed by the Health Department in hospitals anywhere in the country. A few complain to Judasa about their working hours, but most keep quiet and endure it because it’s only three years.
“They’re also afraid they won’t get signed off and won’t be able to become practitioners,” Khoza said.
There is legislation in place to protect junior doctors against unsafe hours – but many hospital departments are so understaffed that they end up abusing interns.
Dr Zameer Brey, provincial head of the SA Medical Association (Sama), said this battle had already been fought and won seven years ago when he was part of Judasa.
“I have personal experience having worked intensely for 20 hours, then making potentially life threatening mistakes just due to fatigue,” he said. “Realising how much of a risk I was to patients, I went through a labour relations process and challenged the system.”
The Health Professions Council (HPCSA) capped intern hours at 60 a week, 30 in one continuous shift, and 80 hours overtime a month. But the gains of Brey’s battle are being forgotten as hospitals try to fill their service gaps with junior doctors.
“Unfortunately our experience in the Western Cape is that a number of hospitals seem to be taking advantage again,” he said. “There needs to be some intervention. Interns are there primarily for training, not to fill gaps in the call roster.”
An article published in the South African Medical Journal in 2012 described interns as “slaves of the state”, enduring “forced labour and sleep deprivation amounting to and cruel and degrading treatment”.
The article said junior doctors were working up to 200 hours overtime a month, “rendered involuntarily under threat of not qualifying to practise medicine in South Africa”.
The Western Cape Health Department investigated the claims.
“We confirm that we are aware of the issue of the working hours of junior doctors and can confirm that the department strives to strictly adhere to the Guidelines for Internship Training as published by the HPCSA,” said Western Cape Health Minister Theuns Botha.
He summed up the situation: the Western Cape has 2 613 doctors in the public health service, of whom 321 are interns and 174 are community service doctors. Each hospital with interns has representative structures which are supposed to offer safe platforms for interns to raise their concerns. Hospital heads are tasked with ensuring that overtime hour logbooks are completed correctly.
“Interns are by and large responsible for their own roster allocation,” Botha said. “Each hospital in the province monitors the working hours and conditions of interns as per the policy parameters.”
But Brey says some hospitals don’t play by the rules, compromising patient quality of care “in a very direct manner that affects morbidity and mortality”. The ordeal is often the result of poor management.
“Too often I’ve heard managers saying we can’t afford to get a locum to cover the call shift; let’s get an intern,” Brey said. “It’s an unreasonable expectation on junior doctors, and it’s pushing them out of the profession.”
For Dr Jennifer Crombie, community service at the new Khayelitsha District Hospital was enough to put her off working in state hospitals for the rest of her career.
“I couldn’t handle any more government work. Part of it is the hours, partly the patient burden, partly the working environment.”
She and her husband Kenneth did their community service in Pietermaritzburg.
“Interns are very junior doctors,” Kenneth said. “We weren’t very prepared. We often felt out of our depth. The stress burdens you.”
Kenneth started taking antidepressants within the first few months of the internship. Before their shifts were synchronised, he would go a week without seeing his wife – even though they lived together.
“Often we were working up to 100 hours overtime,” he said. “A lot of doctors turned to medication just to sleep, then lots of coffee and Red Bull to stay awake. Some people didn’t cope.”
When the Crombies moved to Cape Town in 2012 to do community service in Khayelitsha, they thought it would be easier. But the new hospital had teething problems of its own, and the trauma ward was too chaotic for Jennifer to bear.
“You’re stitching up drunken men while they laugh about their injuries,” she said.
“I put a chest drain in for a 12-year-old girl after she and her friend decided to stab each other in the back. There is no regard for life.”
Jennifer had a nervous breakdown.
“I felt like I was putting my life on the line for the job.”
She and Kenneth both suffered needlestick injuries and he had to take a course of antiretrovirals. The lack of sleep, bad nutrition and little exercise made them sitting ducks for infection. Both are now on treatment for tuberculosis.
“You can never prove where it came from, but it’s most likely from working for the government for three years,” Jennifer said. “Why should you be punished with intense hours and traumatic circumstances for wanting to help people?”
While she now practises as a GP in private practice, Kenneth is working at Groote Schuur. He said that surviving as a junior doctor might be tough, but it produced excellent doctors.
“South African doctors are trained well, and it’s probably because we’re thrown in the deep end from a young age.”
And even while they’re battling, they are offering top-notch medical care. “We are providing a great service to a great number of patients,” Kenneth said. “We just need more doctors.”
For the four Stellenbosch medical students who started the petition calling for safe working hours for junior doctors, even a 24-hour work limit would be a victory.
The students’ campaign began with an ethics assignment and a shocking revelation.
Fifth-years Elsie-Marie van Straten, Koot Kotze, Victoria van der Schyff and Helene-Mari van der Westhuizen were investigating the causes of medical errors in South African hospitals.
“We were shocked to find that most errors were systemic,” said Van der Westhuizen. And the studies clearly showed that more errors occured when doctors were exhausted.
Hosted online by change.org, the petition says: “You would not trust an exhausted pilot to fly your plane, so why should you trust an exhausted doctor with your life?
“If doctors work more than 16 hours continuously, they become a danger to themselves and their patients.”
The four Stellenbosch students are not yet interns, but they saw the effect of fatigue on their older friends – and resolved to change the system before they themselves were too overworked and exhausted to campaign about it.
“When we qualify in 18 months, we want to give our patients the best,” Van der Westhuizen said.
Kotze, who comes from a family of doctors, said hospitals exploited interns because it made financial sense.
“An intern has the lowest wage. On paper it’s cheaper to overwork interns.”
There is even an incentive to work them beyond the allowed 80 hours overtime. “Interns are compelled to work these hours to be signed off,” said Van der Westhuizen.
She said interns didn’t speak up because they’re too tired.
Van der Westhuizen said the on-call system had been devised in a bygone era when hospitals dealt with far fewer patients.
The HPCSA and the national Health Department did not respond to requests for comment.