When I see paediatric patients, I often introduce myself as the “sleepy doctor”. I explain that I’m going to “make you sleepy, not me”. It’s an awful joke and I’m fairly sure in no way builds rapport but I find it mildly amusing so I’ve stuck with it.
On my Facebook profile, I recently created a completely non-scientific poll to determine what rest facilities on-call doctors have. The guesses ranged from:
- On-call room with bed
- Camp bed in an office
- Jacuzzi, free bar*, money counting room, fairground…
- Variations on “lots of opioids”
- One of the many spare NHS beds
The truth is “many and none of the above”.
I’ve worked in about 10 different hospitals and rest facilities vary. Often anaesthetics has different facilities to the rest of the hospital because of restrictions on where we should be at any given time.
The hospital I’m currently at is unique – both on-call anaesthetists have a room with a bed in it. This is very much the exception rather than the rule. The only reason it happens is because, bizarrely, consultants regularly work night shifts at the level of their junior colleagues at the trust. As such, the managers would have to claw the rooms back from the cold, dead hands/absent posts as the consultants got a job elsewhere.
Normally, medics and surgeons have to make do with the doctors’ mess. This is usually a glorified living room with sofas plus blankets and pillows with which one makes do. Often, there isn’t enough space for everybody to sleep lying down.
When I was still doing internal medicine as a junior grade, I rarely had time to get any sleep anyway. Although the work isn’t as intense as my current job as an anaesthetic/critical care registrar, there’s more routine work. Putting in cannulas, taking blood, rewriting drug charts, clerking patients. As out-of-hours anaesthetist, you’re usually either doing nothing, or you’re doing something pretty full-on.
A&E almost invariably doesn’t have rest facilities and they would be perfunctory anyway. They will have a kitchen with seats in it. If you’re lucky, they seats will be comfortable ones which you can sleep on. Given you’ll probably have somebody beating you with a stick to meet the 4 hour target, it’s kind of irrelevant.
As for me, in the last 4 years as an anaesthetist and intensivist, I’ve been provided with, in order of comfort:
- A dedicated room with a bed in it
- An office with a mattress + linen in it
- An office with a two sofas long enough for you to lie flat for two doctors to sleep in
- An office with a reclining chair that doesn’t go completely flat
- An office with a two sofas neither long enough for you to lie flat for two doctors to sleep in
- An office with two reclining chairs for two doctors
- An office with a broken airbed (brought in by a doctor) that was (unsuccessfully) supported by pillows
- A bunch of chairs in a handover room that were really not very comfortable
I’ve been to one trust, as a locum during the day, where the regular juniors said the trust actually provided beds to all on-call doctors. Again, this is very, very much the exception.
Why doctors don’t deserve rest facilities
The term “on-call” historically referred to a doctor who was at home and only got called in for the most dire emergency. Simply, there was just less stuff a doctor could do – calling them in the middle of the night was pointless. Doctors being on-call for 24 hours didn’t actually involve being in the hospital.
In the second-half of the 20th century, that changed and by the 1990s, doctors were still working 24 hour shifts but were often awake for the majority of those shifts. (And were often paid half-time for working out-of-hours). Doctors basically working harder than they did during the day, were paid less for the privilege and weren’t really “on-call” – they were dealing with the sickest patients in the early hours of the morning.
Nonetheless, doctors normally lived on-site and so could pop back to their accommodation for shut-eye when they got the chance. As such, the hospital didn’t have to provide beds specifically for doctors on-call. (Note: the accommodation was of the standard of old-school University halls of residence – one of the consultants joked you had to be careful when you got out of bed in case you stepped on a rat.)
Various reforms came into place not least the European Working Time Directive 2003 which limited working to fewer than 48 hours a week. As such, hospitals introduced shift systems similar to those used by nurses. EWTD mandated rest periods of 11 hours between the 13 hour night shifts.
Once this was done, hospitals argued that they were not obliged to provide somewhere for doctors to sleep. After all, they were on shift just like nurses, healthcare assistants, midwives, porters etc – why did doctors need sleep more than everybody else?
It’s not an argument without merit. Indeed nurses are instructed not to sleep on their night shifts.
Why doctors deserve a warm bed at night
Firstly, the notion that nurses and other staff shouldn’t be allowed to sleep on their breaks at night is garbage. The Association of Anaesthetists of Great Britain and Ireland (AAGBI) recently produced resources for hospitals on protecting from fatigue. They have specific advice on what to do at night within which they state that a “15-20 minute nap can significantly improves alertness” echoed by 2006 Royal College of Physicians publication stating similar. This fits with our understanding of sleep physiology.
Doctors are basically drunk when they drive home:
and so unsurprisingly have accidents:
and some die because of exhaustion:
- Exhausted doctor killed driving home from night shift when he ‘fell asleep at the wheel’
- Grieving father: junior doctor hours require urgent review
So why is it different for doctors?
Arguably it’s not. But doctors-in-training (so-called junior doctors) are often obligated to live long commutes away from their hospitals. The rotational nature of the training programmes means that I live in Sheffield but have to work in Barnsley (35 min away at rush hour), Rotherham (25 min) and Doncaster (50-60 min). Sheffield is the smallest anaesthetic deanery in the country; the deanery is now changing to cover Yorkshire and the Humber.
A colleague who recently got on to the specialty training programme for anaesthetics was told her first post was over 1 hour away from both her home and any base hospital in the nearest city (where they calculate travel times from) outside of rush hour. This suggests a commuting time of closer to 70-80 minutes. She was told there was no accommodation available. Following a 13-hour night shift, she would be expected to drive 70-80 minutes, 4 times in her week of nights.
Another colleague’s husband was a paediatric surgical trainee. He was told with two weeks notice that he would be moving to a hospital 2-2½ hours away. They had a toddler at the time. Clearly, this is not commutable but the short notice and variation in distance to travel makes organising your life very difficult.
At about 1pm today, I attempted to open a beside cabinet. I couldn’t find the handle as I thought it was at the top left of the door and it wasn’t there, albeit with only the bedside lamp on. I assumed the handle had fallen off. I pried it open then discovered that the handle was actually halfway down rather than at the top. I felt like a prize idiot.
At 5am the day before, with 13 hours less sleep, I was operating an ultrasound machine and trying to site two lines into somebody’s internal jugular vein (translation: big vein in neck, near the carotid artery, involves big needle). Here’s a video if you’re wondering what it entails:
As mentioned above, the AAGBI has now produced standards of what they think hospitals should offer their anaesthetists overnight. There is no reason this shouldn’t be applicable across all specialties. I also don’t think the standards are unreasonable for people who are commuting long distances regardless of whether they’re doctors, nurses, porters or clerical staff.
A mattress in a room normally used as an office seems to me a reasonable demand. A bed or mattress in a currently unused room also seems reasonable. Indeed, a ward not currently used and switched to a series of rooms for doctors to sleep in would make the most sense, particularly for sleeping after night shifts before driving home.
I think it’s the responsibility of an organisation which mandates its staff switch regularly between day and night shifts to provide adequate rest facilities. You shouldn’t be having an accident on the way home because of tiredness. And you certainly shouldn’t be dying.
*hospitals did used to have bars. Now, it’s a “bring your own” affair.**
**we don’t really bring our own alcohol.