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September 9, 2018

Medicine Balls, Private Eye Issue 1476, 10 August 2018
Filed under: Private Eye — Dr. Phil @ 9:58 am

Tiredness and Overwork can be Lethal

MD’s first ever Eye Column (Eye 785 17/1/92) featuredjunior doctor Chris Johnstone ‘who won the right to sue Bloomsbury health authority for subjecting him to a particularly onerous obstetrics job.  Johnstone had taken his decision after falling asleep at the wheel: he used a portable EEG to measure his cerebral activity during a 48 hour shift and found that he was registering sleep waves while sewing women up after labour. Despite his high court victory, the job remained the same and the doctor who followed him spent time in intensive care after a paracetamol overdose.’

Like many junior doctors at the time, MD made catastrophic errors while overworked and sleep deprived, and drove his car off the road after an 81 hour shift. Several colleagues committed suicide during or after such long shifts, and it became clear that poor judgement, exhaustion and mood disturbance caused by sleep deprivation and work related stress was contributing to the deaths of doctors and their patients. 30 years ago, junior doctors were paid just a third of the standard rate for overtime, so it was much cheaper to make one work 120 hours a week than to hire three to work 40.

But the problem wasn’t just political resistance to funding and staffing the NHS safely. Many senior doctors embraced the macho culture of workaholism, and often the alcoholism and drug addiction that went with trying to keep your eyes open for 81 hours. Some would boast of being on call 24 hours a day, 7 days a week when they were juniors, in a secretive culture where cock-ups were buried. In the 1992 election, MD stood against Health Secretary William Waldegrave with the strapline ‘If junior doctors were prisoners of war, then under the Geneva Convention the sleep deprivation they suffer would be considered torture’.

There is now clear evidence for the danger of sleep deprivation for everyone. The less you sleep, the quicker you die from any combination of depression, anxiety, dementia, stroke, heart disease, obesity, cancer, diabetes, suicide and accidents, especially falling asleep at the wheel. Doctor specific research found that they are far more prone to diagnostic, treatment and surgical errors when they are sleep deprived and fatigued, particularly when having to make complex decisions under pressure. They are also more prone to needlestick and scalpel injuries, and crashing on the drive home. This helped convince the government to legally cap the hours doctors can work. They are not supposed to do more than a maximum 72 hours in any 7 days, with a maximum shift of 13 hours with rest breaks every 4 hours. They can still be on call for 24 hours, or 48 at weekends if it is somehow deemed to be ‘safe.’

The problem is that doctor numbers have not increased to compensate for the reduced hours and increased demand of very sick patients with multiple illnesses and the myriad high tech treatments that could help or harm them. And there are no legally mandated safe staffing levels to protect junior doctors (and nurses) from abuse. So they work very intensively and often longer than they are supposed to because their rotas are often not fully staffed and they are covering several jobs. The fatigue from this level of overwork is likely to be very dangerous, particularly when combined with alternating shift patterns that disrupt regular sleep routines and diminish recovery. Even worse, they are hung out to dry if they make an honest and inevitable error in such dangerous circumstances.

When Dr Hadiza Bawa-Garba returned to Leicester Royal Infirmary in 2011 from 13 months maternity leave she may already have been sleep deprived. She certainly needed induction training. Yet she was put straight on call for paediatric emergencies with no induction and an absent consultant and registrar. She had to cover 6 hospital wards across 4 floors, responsible for dozens of critically ill children during a 13 hour shift with no time for breaks. The IT system crashed.  An emergency prevented her from attending the vital morning handover. Amid largely great care she made serious errors in one case (Eye ). The Crown Court deemed this to be gross negligence manslaughter. The GMC then compounded this injustice by striking her off. Over £300,000 was donated to her appeal to overturn the GMC decision. The Appeal Court  verdict is awaited from the lord chief justice, Ian Burnett; master of the rolls, Terence Etherton; and the lady justice of appeal Anne Rafferty. Doctors are stuck between a rock and a hard place, legally and professionally obliged to admit errors but punished by the court and GMC if they do. And neither take into account the proven dangers of overwork, lack of rest and sleep deprivation. To destroy the career of a brilliant paediatrician with a previously unblemished career for honest mistakes in such an unsafe setting is simply unforgivable.