Illegal working hours of junior doctors throughout the country

TO,

THE NATIONAL HUMAN RIGHT COMMISION
NEW DELHI


Sub: Illegal working hours of junior doctors throughout the country
And routine (!)Death of patients due to this forced negligence.

Sir,


This is to bring in to your notice the illegal and unhealthy working hours of junior doctors in the Government hospitals and teaching institutes throughout the country and the adverse effect it has on the safety of poor patients. Today in all other sector where continuous round the clock duty are required i.e. Telecommunication, Railways, Airlines, Travel, Forces etc., the norms of 48 hours/week or less and shifts and night duty norms are followed (compensatory off are given, if stretched any time beyond recommended limit). It is unfortunate, as well as inconsistent with their own principles, that the organizations most vitally concerned with the health of the community should in many cases show such DISREGARD for the health of their own employees. The issue of long working hours in medical and health services is particularly important, not only because the staff/doctor has not only to provide care, mostly on a round the clock basis, but also because THEIR WORK INVOLVES A HIGH LEVEL OF RESPONSIBILITY FOR THE HEALTH AND WELL-BEING, AND SOMETIMES THE SURVIVAL OF PATIENTS.

As per the directives of the Honourable Supreme Court in its judgment dated,25.9.87, in writ petition No. 348-352 of 1985, all the State Governments, Medical Institutions and Universities are required to amend their rules and regulations to introduce a uniform residency scheme by 1993.

THE HONOURABLE SUPREME COURT IN ITS ORDER STATED

“A uniform practice has to be evolved so that the discipline would be introduced. We
accordingly allow the present arrangement to continue for a period of five years
I.e. upto 1992 inclusive. For admission beginning from 1993 there would be only one
pattern. All Universities and institutions shall take timely steps to bring about
such amendments as may be necessary to bring statutes, regulations, and rules
obtaining in their respective institutions in accord with this direction before the end of
1991 so that there may be no scope for raising of any dispute in regard to the matter.
The uniform pattern has to be implemented for 1993. It is proper that one uniform system is brought into vogue throughout the country.”

In this connection Ministry of Health & Family Welfare, Govt. of India has sent directive to all states & U.T. administrations vide letter No. S-11014/3/91/ME (P) dated 05 June, 1992. Unfortunately many States in India refused to obey that orders till date.

Ministry of health and family welfare, Government of India sent consolidated instructions to all states and UT administration vide letter number S-11014/3/91 ME(P) regarding implementation of Uniform Central Residency Scheme after the directives of the Supreme Court in its judgment dt. 25.9.87 in writ petition No. 348-352 of 1985,
The instruction No.13 of this letter ‘Hours of Work', it is mentioned that
"Continuous active duty for resident doctors will not normally exceed 12 hours per day. Subject to exigencies of work the resident doctors will be allowed one weekly holiday by rotation. The resident doctors will also require to be on call duty not exceeding 12 hours at a time. The junior Residents should ordinarily work for 48 hours per week and not more than 12 hours at a stretch subject to the condition that the working hours will be flexible as may be decided by the Medical Superintendents concerned keeping in view the workload and availability of doctors for clinical work."
As we see, here total weekly hours of work (48 hrs/week) as well as the maximum hours in single stretch (12 hours) are clearly defined. Of course the authorities may remind us the flexibility given in above instruction. However we would like to state the following.
a) Any flexibility given by law or constitution should only be used as a special measure and must not be used as ROUTINE. Today Medical colleges in India are forcing Junior doctors to work continuous 24 Hrs (!) and this is being practised routinely for last many years.
b) That flexibility is given for 'Working hours' & not for hours of work that is, while authorities are free to post any doctor in day or night or in holidays, they must stick to the norms of "hours of work" that is Maximum 48 hours in a week and 12 hours Finally even if the total no. of doctors posted (when all posts are filled) are not able to cope with work load under normal working-hours-limit then the no. of post must be increased. In no case junior doctors to be forced to work more than what is permitted by law and various recommendations. in a single stretch.

The International Labour Organization, Geneva (India being the member of the same) as early as in 1962 in its recommendation No.116 concerning Reduction of hours of work in its General principle No. 4 states as
PRINCIPLE 4: Normal hours of works should be progressively reduced, when appropriate with a view to attaining the social standard indicated in the Preamble of this recommendation without reduction in the wages of the workers as at the time hours of work are reduced.
PRINCIPLE 6 states as - Where normal weekly hours of work are EITHER FORTY EIGHT OR LESS, MEASURES FOR THE PROGRESSIVE REDUCTION OF HOURS OF WORK in accordance with paragraph-4 should be worked out and implemented in a manner suited to the particular national circumstances and the conditions in EACH sector of economic activity.
Further in Determination of Hours of works 12(1) it states: The calculation of normal hours of work as on average over a period longer than one week should be permitted when special conditions in certain branches of activity or technical needs justify it.
Recently ILO in its Night Work Recommendation 1990 (No. 178) states that "the normal hours of work of night workers should generally be less on average than those of workers performing the same work to the same requirements by day."
Considering that today in India in 5 days week most of the office workers perform a 42-43 hours/week and the maximum limit is set as 48 hours/week for all including the health sector, the total hours of work of doctor (especially Junior doctors , interns) per week must be less than this (i.e. 48 hours/week) as they perform most (all) of the night duties.
Further in this recommendation it is clearly stated that IN NO CASE should two consecutive full time shifts be performed, except in cases of FORCE MAJEURE (The allowed hours of shift in a single stretch is MAXIMUM 12 hours) & In No case further extension of this limit (12 hours) should be done. Presently, we Junior doctors are forced to work continuous 24 Hours (!) in a single stretch. In many departments weekly hours (Normal average) are 65-80 hrs/week & it crosses even 100(!)Hrs/week.
Further it states that at least 11 hours of rest period should be granted between two shifts (One must remember, shift are of Maximum 12 hours) as far as possible.

Presently Resident doctors (Post graduate students in Medical colleges) in India are forced to work 85-105 hrs/week in most of the clinical departments without the protection of any service rules because they are students. This is done under the instruction of the Head of the Departments concerned. Junior doctors pursuing their post graduation course, whose final assessment are in hands of these authorities, i.e. HODs. There fore no one normally risks their career. This way exploitation of this floating population of junior doctors goes on and on the other hand patients suffer routinely and many times even die due to this forced negligence. While stretching duty hours our learned authorities simply forget the PROVEN FACT that errors and accidents increases sharply (An exponential graph) in mental and physical work, when duty hours are stretched beyond 10-12 hours continuous duty.

As the graph of errors and accidents increases steeply this 100% increase (24 hrs continuous duty in place of 12 hours maximum limit) in duty hours is sufficiently enough to do BLUNDERS AND ENDANGER human life.

"A doctor at his 20th-24th hour of continuous duty in Emergency ward, if not able to provide proper care to the patient for whom even a single minute can prove life saving or Fatal. This way if patients suffer than who will be HELD RESPONSIBLE, the Doctor on duty or the HOD or DME or the Govt.?”
Because doctor is performing unofficial extended hours, and he/she has the reason to state that doctor was not in his/her proper mental and physical condition due to chronic sleep deprivation and exhaustion. In fact this extended hour coincides with the mid night and early morning time, when all those patients who come to casualty irrespective of there diagnosis, feel that if they will delay till morning it may be harmful/fatal to them and most of the times indeed these emergencies are life threatening. With great hope in mid night when they visit hospital for proper care, they find a drowsy, tired, exhausted doctor, who is not even able to examine properly. The general impression becomes that doctor has neglected him, where as patient hardly knows doctor’s real condition. After all patients do deserve the proper and efficient care, especially when there is no scarcity of doctors and this duty regime is artificially motivated. The finding of Justice Ranganath Mishra, former National Human Rights Commission, about delay and negligence in treatment of accident victims, are actually related with this illegal duty hour practice. Under growing public demands for health quality services the question which involves life of human beings, cannot be left unanswered.

After approximately eighteen hours of work Doctors have got the equivalent psychomotor dysfunction as having a blood alcohol level of .05. So not only at .05 you're not allowed to drive but at the equivalent level of psychomotor dysfunction you're allowed to look after patients. And by the time you've worked for twenty-four hours you've got the equivalent of having a blood-alcohol level of .1 and that's just ridiculous.

In most of the countries there is a limitation on extra hours, the average over month or quarterly it must be with in norms, which varies 40 to 48 hours per week in different countries. In most of the states in India no duty hour’s norm exists. Most hospital authorities do not even bother how many hours a junior doctor has worked, and so it increases up to inhumane levels as high as 103 hours in a week.

One should also note that a number of countries have enacted duty hours regulations for doctors. In Denmark, Norway and Sweden, residents work only 37-45 hours per week. In Netherlands, residents’ duty hours are limited to 48 hrs per week. France has a 35 hour per week limit.

The unexpected death of Libby Zion, 18 yr old daughter of an attorney and writer for the New York Times, at New York hospital in 1984, led to series of investigation that resulted in profound changes in residency duty hours in USA.

In similar situation in London in December 1990 a junior doctor obtained a preliminary judgement from the court of Appeal on a claim for damages against Bloomsbury Health Authority. The court said that health authorities could not lawfully require junior doctors to work for so many hours that there was a foreseeable risk of injury to their health. The Vice-Chancellor, Sir Nicolas Browne-Wilkinson, said: “In any sphere of employment other than that of junior doctors, an obligation to work up to 88 hours in any one week would be rightly regarded as oppressive and intolerable." The doctor had served a writ on the health authority in March 1989 after working a 112-hour week which included a 49-hour shift over a weekend. He felt that his health had suffered so much that he resigned from his job at University College Hospital, London, and gave up medicine for a time.

Great public and media attention was drawn in September 1990 when two doctors in the neonatal pediatrics unit of the Southern General Hospital, Glasgow, were threatened with dismissal for refusing to carry on working 115 hours a week. After two sessions working the 115-hour week, the doctors said that chronic sleep deprivation was severely impairing their medical judgment and putting the lives of new-born babies at risk. In the same month a hospital patient in Middles borough died after a tired doctor gave her the wrong injection. The doctor had been on duty for 30 hours with just three hours interrupted sleep when she gave the fatal injection.

The comments of the acting coroner in the inquest into the death of a New Zealand woman, the innocent party in a car crash, reinforce the importance of addressing the issue of fatigue. The patient survived the accident, but died following a mishap while in hospital. A significant issue for the coroner was the extent to which the fatigue of one of her doctors may have played a part in her demise. The coroner remarked that there was a growing level of concern, both nationally and internationally, over the hours of work of doctors in hospitals, and suggested that the medical professional bodies address the issue of extended periods of work.

Hope in India, justice will not get delayed until some VIP will die. Negligence and irritative behaviour (due to chronic sleep deprivation) of doctors in government hospitals are known to every one and the death due to such forced negligence are nothing but routine (!) death of hospitals.

With great hope, that commission will look in to the matter and take necessary steps to end this violation of human rights of both patients and junior doctors.



March 5th 2006


Ref.
1. Honorable Supreme Court in its judgment dated, 25.9.87, in writ petition No. 348-352 of 1985
2. Letter No. S-11014/3/91/ME (P) dated 05 June, 1992.
3. Letter No. S-11014/25/89- ME(P).
4. Letter No. S-11014/39/80-ME(P)
5. Conclusion from general report (Latest), Standing technical committee for Health & Medical Services, ILO, Geneva.
6. ILO`s recommendation No. 178, 116.
7. Swan, N. Juniors' Hours: International Overview. BMJ 1990; 301: 830-832.
8. Olson LG, Ambrogetti A. Working harder -- working dangerously. Fatigue and performance in hospitals. Med J Aust 1998; 168: 614-616.
9. Williamson A. The effects of workload and long hours of work on medical officers. Sydney: National Institute of Occupational Health and Safety (WorkSafe Australia ), 1995.
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11. Fein EB. Flouting law, hospitals overwork novice doctors. New York Times, 14 December 1997; 1.
12. Holmes G. Hospital medical officers: hours of work and workloads, A strategic approach to occupational health and safety. Canberra: Australian Medical Association, 1995.
13. Department of Transport. Investigation into the Kings Cross Underground Fire. London: HMSO, 1998.
14. Coroner's Court. In the matter of the death of Patricia Margaret Ross. Rotorua, New Zealand : 15-17 October 1997; 18-20.
15. Permanent Working Group of European Junior Hospital Doctors. Working conditions for doctors in training. Conference Proceedings, Executive Summary. Brussels: European Union Publications Office, December 1995.
16. European Union. Directive on Working Time, 93/104. Brussels: European Union Publications Office, 1993.
17. NHS Management Executive. Hours of work of doctors in training: guidance on regional task forces.London: Department of Health; 1991.
18. Neurosurgery 54:925-933,2004 Resident duty hours in American Neurosurgery.