JISCMail - ACAD-AE-MED Archives

This isn't intended to be an answer but it's just some things to think about (fairly random musings I'm afraid):

When consultants resident on call have been used in the past it has tended to be resident but sleeping. In Emergency Medicine that was the way it was done in Stoke and for a brief period in Dudley Road Hospital in Birmingham. Other specialties have done the same thing (Paediatrics and Anaesthetics have done it in smaller hospitals and Orthopaedic Surgery has done it in Oxford). That is probably sustainable long term and a 3 hour PA seems reasonable. The issue is that as has happened with juniors there tends to be a bit of creep from resident but asleep to resident but up and working if there are any patients waiting to on the floor all night providing supersision with no on call room to first on. As you cut the amout of time you spend in bed it becomes less sustainable with lower numbers and the lower rate of pay seems less reasonable. I guess you want to think from the start whether you want to try for resident at a relatively low rate of pay with the risk of mission creep or just accept that it's going to drift towards first on so agree to that from the start and accept a lower rate.

Nobody who has done it has posted yet. Wrexham is currently doing it. They seem to have a nice bunch there and are happy to talk about it when I've met them. As I understand it they do Monday through to Thursday night on the same rota as the Specialty Doctors but they only do it 3 times a year (which works out slightly fewer nights a year than your 1:24 but not desperately). They seem to find it sustainable. It may be worth contacting them. http://emj.bmj.com/content/early/2011/04/13/emj.2010.107797.abstract is their article about it. I think Aruni Sen is the oldest consultant there although I won't speculate as to how old. He still seems to find it sustainable. However it is a relatively small unit and they are not doing weekend nights at present (although I think they have a lot of presence weekend days), so their nights may be quite low intensity.

Mark and I were registrars in North Staffs when the consultants were providing 24 hour cover. That was done with only 8 people on the rota with essentially nights being paid at standard rate. However it was 24 hours at a time (can't remember if they split weekends) and once they went to bed the consultant was called only about major trauma and cardiac arrests. Part of this was down to the fact that two of the eight were anaesthetists; part of it was down to the relatively high frequency of nights; part of it was down to the fact that it was less common for consultants to spend a lot of their time dealing with waiting times; part of it was down to long waits in minors being more acceptable. These days I think it might feel awkward for the consultant to go to bed while there was a significant wait. It may also be worth noting that while the reasons behind their leaving are debatable, none of the consultant Emergency Physicians involved in the experiment have stayed in Stoke.

I think the long term plan is important. However, age discrimination legislation being what it is I don't think you'd be able to set up a contract that definitely allowed you to come off the nights beyond a certain age. You'd have to rely on your colleagues being willing to take over from you. This could be tricky to work as a gentleman's agreement: it only takes one generation to have their doubts as to whether the next generation will let them pull off for the whole thing to collapse. It works in some specialties at the moment with pulling off nights in part because there are relatively few people at the age to stop the on call and in part because of an expansion meaning that you can sometimes let one person drop the on call whenever the number on the rota expands by one (so the on call remains the same for the rest). I think we have to look at how it will work when you're appointed to a consultant post in your early 30s and retire at 68. Possibly the best way would be to have a high enough rate of pay for nights that some people would prefer to do more nights combined with it being clear at job planning that an agreement to do unsocial hours shifts was for one year only and could be dropped without explanation after that year.

As to whether you can continue doing nights as you get older: it's possible. Nurses have always done it. Specialty doctors do it. Having said that, you don't find many Specialty Doctors over 50 doing night shifts. The other point that is unique about a consultant doing shifts is that there is a lot of complex decision making involved with no real back up. You might find that the way to do it would be to separate the complex and the simple stuff: either your consultant is resident but available only for the complex cases and gets to bed between them or they are up and working dealing mainly with the simple cases with a second consultant doing a more traditional consultant job available to come in from home and take over the complex cases.

Ray has mentioned the US. It's a bit different there. Most EM attendings work in community EDs with most of the work done by attendings supported by midlevels (nurse practitioner equivalents broadly)- only a minority of attendings work in departments with trainees. The community EDs are a lot smaller than any UK ED. (In Illinois for instance, the average size of population served by a Level 1 or 2 Trauma centre is smaller than that served by an average ED in England and the average Community Emergency Department sees under 25,000 patients a year). Set against that, it is usual for Emergency Physicians to cover sick patients elsewhere in the hospital. Also might be worth noting that last time I looked the average EM attending lasted under 10 years in the US. How you square that with what we should do in the UK I don't know.

Something else you may want to consider: is it worthwhile looking at how you can expand the amount of clinical work done during daylight hours? With 24 consultants and single night time coverage you've got a lot of daytime coverage. There's a limit to how much of this can be taken up by teaching and management duties. One way to deal with this is obviously to have more consultants on the floor at any one time . If you stream your minors separately there's something to be said for putting consultants supported by HCAs in there. In a smaller department, one consultant dedicated to minors during the day; in a larger maybe two. In both cases they can be separate from the consultant(s) in majors. (Birmingham General Hospital used to have one of the SHOs just in theatre doing the suturing and manipulations. That's maybe not a bad idea either). While it's unfashionable you might also want to consider whether it's worth having clinics and minor ops lists. There are reasons not to want to do this, but take over a couple of consultants' worth of minor ops work from your ortho and general consultants and you've got two more people on the rota (or two relatively straightforwards jobs for people to semi retire into. Surgeons and anaesthetists tend to move towards simpler work as they get older. There is usually no mechanism for this in EM). It sounds a bit backwards planning for the daytime work first, but I think it's an important thing to think of. If you've not got enough daytime clinical work for 24 consultants I could see a cash strapped hospital reckoning you can get 24/365 cover with 11 consultants and not putting any effort into recruiting more than that.

The other point that hasn't been addressed here is the evidence. It is kind of assumed that doing nights above a certain frequency or above a certain age isn't sustainable. That's not my reading of the evidence (my reading may be wrong). Shift work intolerance runs at around 25% of the population depending on how you define it. Its frequency rises with age (it is also more frequent in women and is associated with certain personality traits and rises with total number of night shifts worked- which is a confounding factor for the age effect). Some of the work done on age takes as its measure sleep length and quality, but does not adjust this for the age related decline in sleep duration and quality in those who do not work night shifts. I don't think the evidence (as it currently stands) points to a particular cut off any more than it suggests that only men should be doing night shifts. Given the importance of this issue at the moment, it is probably worth collating and sharing the evidence both on how to select doctors for night shifts and a quantification of the health hazards of night shifts. I suspect the evidence is limited and now may be the time for a Cochrane review with decisions being made on what studies should be funded to address remaining questions.

Matt Dunn