Press releases Monday 2 November to Friday 6 November 2009

Please remember to credit the BMJas source when publicising an article and to tell your readers that they can read its full text on the journal's website (http://www.bmj.com).

(1) Restricted working hours may compromise surgical education and patient care
(2) Renewed warning over use of home fetal heart monitors

(1) Restricted working hours may compromise surgical education and patient care
(Analysis: How long does it take to train a surgeon?)
http://www.bmj.com/cgi/doi/10.1136/bmj.b4260
(Editorial: Working time regulations for trainee doctors)
http://www.bmj.com/cgi/doi/10.1136/bmj.b4488

Restrictions on the working hours of doctors may be compromising surgical education and patient care, warn two senior US surgeons in an article published on bmj.com today.

Gretchen Purcell Jackson and John Tarpley argue that greater flexibility is needed in applying these regulations.

Not all countries regulate working hours, but in those that do, the maximum hours per week for a doctor in training can range from as little as 37 hours in Denmark to 80 hours in the United States. The European Working Time Directive (EWTD) decreased the weekly hours for all trainee doctors in Europe to 48 from August 2009.

But do these restrictions provide enough time to train a competent surgeon, ask the authors?

Since working hours were limited, some research has shown worrisome changes in the nature of surgical experiences. For example, one study found a 40% reduction in technically advanced procedures with a compensatory 44% increase in basic procedures done by fourth and fifth year residents.

Studies on the effects of restricting hours on patient safety also show alarming negative trends. At one US trauma centre, complication rates significantly increased and missed injuries doubled after adoption of the 80 hour working week, while research from Germany showed increases in length of stay, complication rates, re-interventions, and readmissions after legislation reduced daily shifts from 12 to 8 hours in 1996.

Strict legislation also poses challenges for staffing and creates ethical dilemmas for trainees, say the authors. One survey showed that a majority of residents from medical, surgical, and paediatric specialties exceeded their working hours, usually because of concerns about patient care, and nearly half admitted to lying about their hours.

The authors estimate that about 15,000 to 20,000 hours are required to master both the cognitive and manual skills of surgery. As such, they recommend flexibility, discretion, and common sense for regulations of shift lengths and periods of rest to allow enough time for residents to be exposed to an adequate breadth of cases throughout their training.

"If enough hands-on patient care as well as operative experience cannot be achieved during a restricted working week, surgical training should be extended," they suggest.

"Patient care and physician integrity are the founding principles of surgical training; regulations on duty hours must not be constructed in a way that compromises them," they conclude.

In an accompanying editorial, Professor Roy Pounder from the University of London argues that solutions are possible within the current system. He rejects the argument that 80 hours a week is insufficient for surgical trainees to gain the necessary experience, and points to evidence showing that patients do not want a familiar but exhausted person operating on them.

The old ways of training, time serving apprenticeships, and inflexible (essentially continuous) work are over. Instead, rotas must take account of part-time working, individual decisions about opting out of the working hours regulations, and the day to day measurement of hours of work when non-resident on call.

The Department of Health must move from their single minded implementation of the 48 hour week, to the flexibility that can now be provided by sophisticated rostering, thereby helping to improve patient safety, service delivery, and medical training, he concludes.

Contact:

Analysis: Gretchen Purcell Jackson, Assistant Professor of Surgery and Biomedical Informatics, Vanderbilt Children's Hospital, Nashville, TN, USA Tel: +1 615 936 1050
Email: gretchen.jackson@vanderbilt.edu

Analysis: Editorial: Roy Pounder, Emeritus Professor of Medicine, University of London and Chairman, RotaGeek Ltd, London, UK Tel: +44 (0)7977 038 199 Email: roypounder@gmail.com

(2) Renewed warning over use of home fetal heart monitors
(Feature: Dangers of listening to the fetal heart at home)
http://www.bmj.com/cgi/doi/10.1136/bmj.b4308
(Commentary: Don't try this at home?)
http://www.bmj.com/cgi/doi/10.1136/bmj.b4421

Doctors are again warning expectant parents not to use over the counter fetal heart monitors (Doppler devices) at home because they can lead to false reassurance and delays in seeking medical help.

This is the second case published by the BMJ this year and highlights the tragic consequences these devices can have in untrained hands.

Abhijoy Chakladar and Hazel Adams from the Princess Royal Hospital in Haywards Heath, part of Brighton and Sussex University Hospitals NHS Trust, describe the case of a 34 year old woman who presented to their labour ward unable to detect her baby's heartbeat with her fetal heart monitor. She was 38 weeks pregnant with her first baby and was fit and well, with no medical history.

The previous Friday she had noticed a reduction in her baby's movements but had reassured herself by listening to the "fetal" heartbeat over the weekend. However, an urgent ultrasound scan showed no fetal heart activity and intrauterine death was diagnosed.

Analysis of the fetal heart rate is commonly used during pregnancy and labour to monitor the health of the fetus, explain the authors. But in untrained hands it is more likely that blood flow through the placenta or the mother's own pulse will be heard.

After this experience, they searched the internet and were surprised by the number of fetal heart monitors available. Although some retailers state that the device should not replace medical supervision, they also make claims such as "easy and safe to use to hear your unborn baby's heart beat."

This death may have been unavoidable, but the use of a fetal heart monitor certainly delayed presentation to hospital, say the authors.

They warn that monitors are for entertainment purposes only and can be dangerous if used otherwise, and they call on manufacturers and retailers to make the limitations of these devices absolutely clear.

They also suggest that obstetric services need to educate expectant mothers about the limitations and the potentially fatal consequences of untrained use of fetal heart monitors and to present clear guidance about when to seek medical review.

An accompanying commentary outlines the concerns of several organisations about the growing availability of these products in recent years.

Contact:

Abhijoy Chakladar, Research Fellow, Department of Anaesthesia, Princess Royal Hospital, Brighton and Sussex University Hospitals NHS Trust, UK
Email: abhijoy.chakladar@gmail.com

FOR ACCREDITED JOURNALISTS

For more information please contact:

Emma Dickinson
Tel: +44 (0)20 7383 6529
Email: edickinson@bma.org.uk

Press Office telephone : 020 7383 6254 (Weekdays : 0900hrs - 1800hrs)
British Medical Association
BMA House, Tavistock Square, London WC1H 9JP

and from:

the EurekAlert website, run by the American Association for the Advancement of Science (http://www.eurekalert.org)
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