John Roos
I wish to express grave concern for the safety and well-being of our junior doctors and their patients. Junior doctors in the State sector regularly work in excess of 30 hours per shift, sometimes without a break.
On the morning of Friday, June 3 – it seems to have escaped everyone’s attention – a young doctor named Ilne Markwat appears to have fallen asleep behind the wheel of her car on the N1 freeway, on her way home after a long night shift at Paarl Provincial Hospital. Her car crossed the freeway into oncoming traffic and crashed head-on into two other cars. Private and Provincial Emergency Medical Services were dispatched to the scene shortly after 10am, including the SA Red Cross Air Mercy Service helicopter.
She was pronounced dead on arrival at Milnerton Medi-Clinic. I do not know how many other injuries or fatalities there may have been.
We know from Dawson and Reid’s landmark article, published in the journal Nature in 1997 (this is old news), that 28 hours of fatigue from sleep deprivation is equivalent to the psychomotor function of a blood alcohol concentration of 0.1g/100ml. This has been independently corroborated by other re-searchers (I am happy to provide references on request).
The legal driving limit in South Africa is 0.05g/100ml. Not only should it be “criminal” to allow doctors to treat patients when their psychomotor impairment is DOUBLE that of someone deemed too drunk to drive on our roads, but it should also be criminal to allow these doctors to drive home. They are quite clearly a potentially lethal danger to themselves, their patients and members of the public.
The Health Professions Council of SA and the government’s various Departments of Health KNOW THIS, but choose to do nothing about it.
We have the Basic Conditions of Employment Act, Act 75 of 1997, and the Department of Labour’s Code of Good Practice on Working Time, that limits the maximum number of hours any worker may work, including maximum numbers of hours worked per week, shift duration, etc.
Doctors, however, are CONTRACTED to work a MINIMUM number of hours per week that exceeds the MAXIMUM number of hours that a factory worker, artisan or other worker is permitted to work, even if doing so voluntarily.
This state of affairs exists because the Department of Health has been exempted from the Department of Labour’s regulations.
How is it that there can be different rules governing safe and humane working conditions – for the butcher, baker and candlestick maker – when we all share the same physiology and psychology?
State doctors are contracted to a minimum of 56 hours per week – a seven-day working week in anybody else’s language – every week. State doctors regularly work shifts in excess of 24 hours, approaching 30 hours and sometimes beyond.
If this accident had happened to a truck driver, a mine worker, a factory worker or similar, there would be criminal prosecution of the employer – but, at the Department of Health, nobody even seems to have noticed this death; there is no sense of culpability or any kind of liability, and certainly there will be no prosecution.
The inconvenient and un- welcome truth is that, two Fridays ago, the medical profession has unwittingly snuffed out one of its rising stars, through its complicit silence and unwillingness to speak up in the protection of its fledgling fellows. Like the Steve Biko saga, this too is one of our moments of crying shame. We, as an allegedly caring profession, have not covered ourselves in glory. Our indifference silently screams itself to the world.
More frightening is that these “zombie doctors” are driving home “post-call” every single day of the year, and it is simply a matter of time before another one becomes a sleeping rogue missile on our roads.
Never mind what these ex-hausted, incapacitated individuals are doing to patients as they near the end of the inhumane shifts they are forced to work…
I can relate many anecdotal stories of colleagues who have crashed their cars on their way home from a long, arduous night shift. Doctors crashing their cars is common. But crashing cars and killing people dramatically and spectacularly is uncommon, and hence nobody notices. It would be insightful to review the insurance records of young doctors. How is it that both the Health Professions Council and the Department of Health get away with labour practices and conditions of employment that would see almost every other employer in the country behind bars?
Airline pilots are not allowed to work more than eight hours on short-haul (local) flights, and a maximum of 12 hours on long-haul (international) flights. If they breach these limits, they have to report these breaches to the Civil Aviation Authority – by law!! How come the same rules and regulations don’t apply to doctors?
The UK implemented the European Work Time Directive a number of years ago, which limits the maximum working hours of junior doctors to 48 hours per week – and for good reason! Our authorities are VERY aware of the reasons for instituting these regulations, yet choose to ignore them. How can this be possible, never mind acceptable in the 21st Century?
We know that fatigue in health care kills. I can provide you with statistics and references of material related to doctor fatigue and breaches of patient safety, published in the most prestigious international and scientific medical journals. Extremely alarming is a recently published article in the British Medical Journal which asserts that, of all-cause mortality in the US, death from preventable medical error is the third overall leading cause of death!!! What are exhausted doctors doing to their patients? We have NO IDEA how many patients doctors are harming and killing in this country because there is NO research on the subject. We know that the figures from the US, Australia, UK and Canada are truly staggering. Again, I can provide statistics and references on request.
When are we going to start treating doctors’ working hours and working conditions in a manner similar to commercial airline pilots?
How many patients are we going to allow burnt-out doctors to kill, and how many doctors are we going to allow the government to passively kill through 18th Century working conditions?
We know that resistance to fatigue and exhaustion are not trainable. This has been well-researched. There is no way to counter circadian dips (troughs in physiological function that occur in the wee small hours). This inescapable biological phenomenon has been scientifically demonstrated over and over again.
We know that fatigue and sleep deprivation affect our perception, attention, vigilance, memory, mood-state and reasoning. Cognitive performance and clinical reasoning are particularly severely affected by fatigue and sleep deprivation. This is well-researched and well published in the Industrial Psychology, Ergonomics, Medical and other scientific literature. It is no secret, and it is not news. No health care manager can honestly claim they do not know about it. But the authorities choose to stick their heads in the sand and ignore it.
To argue that “That is the way it has always been” is not a valid argument. In that case we would still own slaves, women would not have the vote and apartheid would be alive and well.
Neither is it valid to argue that it is acceptable because it is legal. Legality is determined by those in power, not by society’s custodians of morality, righteousness and fairness. Naziism was legal.
Some will say that the system cannot “afford” for doctors to work fewer hours. How come the system can afford for pilots to work humane and safe hours? How come the system allows factory workers, miners, artisans and bus drivers to work fair and reasonable hours? How can we afford for doctors not to work safe and humane hours?
How can an exhausted, incapacitated doctor manage patients with complex, demanding diseases if they do not possess the alertness and psychomotor ability to even drive a motor car? How long are we going to allow the institutionalised, systematic exploitation and abuse of young medical professionals in this way, and when will the profession and society take a stand against it???
The above is my personal opinion and does not reflect the opinion of my employer or any organisation or institution with which I am affiliated or associated in any way.
l Roos is a concerned citizen and member of the medical profession