hospitals have made improvements with regards to doctors working long hours but junior doctors have an unrealistic view of medicine.
it is my opinion that long hours and hard work make you a better doctor, faster. if someone wants to work 44 hours/week and have 28 days/year leave, they should not be in medicine.
this was a very short paper published in 2005 about the past...
Sleep Deprivation in Junior Doctors (HOs) in Singapore
http://www.jniosh.go.jp/en/indu_hel/pdf/43-1-19.pdf„
HO survival guide made by a doctor (probably at least an AC now) in... 2003?
http://www.geraldtan.com/doctors/HO-Sur ... _ver31.doc
2011 letter to SMJ from doctors commenting about the "new" (and improved?) HO/MO on-call system (with background info on previous system):
http://apamedcentral.org/Synapse/Data/P ... -52-60.pdf
PDF wouldn't load, so here you go:
Singapore Med J 2011; 52(1) : 60
Letters to the Editor
IMPACT OF A NEWLY INTRODUCED MEDICAL OFFICER NIGHT-FLOAT ON-CALL SYSTEM IN
A MEDICAL DEPARTMENT IN SINGAPORE
Dear Sir,
Being a former colony of the United Kingdom (UK) prior to independence in 1965, Singapore’s medical system
was based largely on the British healthcare model. Over the past 40 years, medical care has progressed in tandem
with the rise in our nation’s economy and standard of living. Although our healthcare system has evolved, some
aspects of the system have changed little during this time. One of these is the junior doctors’ on-call system in
providing after-hours clinical services in major acute care hospitals. Medical officers (MOs) in Singapore are the
equivalent of residents in the United States (US) and senior house officers in the UK.
In all public acute care hospitals, on-call MOs in medical departments start their calls after a normal workday.
This continues overnight until the next working day where they will work till midday before going off-duty. By that
time, these MOs would have worked for a continuous stretch of 30 hours. MOs who are on-call during weekends
also work from morning till the next day. We wish to report the rationale and process of a recent transition from the
traditional MO on-call system to a night-float system in our hospital.
Our hospital is a 997-bed tertiary acute hospital and the Department of Medicine has an average of 240
inpatients under various medical subspecialties (excluding Cardiology and Haematology-Oncology). Under the
traditional on-call system, our MOs are on-call about six times a month. During these calls, the MOs attend to new
admissions as well as provide coverage to inpatients.
At the beginning of 2007, in response to the feedback from MOs regarding the increasingly heavy night-call
workload, a review of the night-call system was carried out. Issues reviewed included on-call duration, the number
of MOs on-call per night, distribution of wards between on-call MOs and proper handing over of patient care
between day- and night-call teams.
A brief informal survey of MOs who had completed rotations with the department in early 2007 suggested that
they were each clerking and reviewing a median of 20 (range 15–30) new admissions each weekday while on night-
call. 53% of those polled found the workload difficult to cope with about 30% of the time, while 64% thought that
our hospital had the busiest medical calls when compared with other major public hospitals.
In mid 2007, we decided to add another half-call MO to cover from 5:30 pm to 11:00 pm during weekdays as
this was deemed to be the busiest period of each call. Although the addition of a half-call MO helped partially in
spreading out the workload during the busy evening hours, this measure did not adequately address the unbalanced
workload distribution and the concerns of long working hours.
We subsequently considered a night-float system to address the above concerns. The hypothesis was that MOs
starting night-calls fresh can work more efficiently and safely in providing patient care. In considering the night-
float system, we were conscious of the ongoing discussions on the impact that long working hours may have on
patient safety and the potential loss of crucial clinical information during the transfer of care between the different
shifts of healthcare workers.(1,2) The concept of a night-float team is not new; many European countries and the US
have different variants of a night-float system to fulfil various manpower constraints.(3) The night-float system we
use, as far as we are aware of, is unique. Our proposed system is one that can be adapted to our local context and
practice.
The details of our night-float system are shown in Table I and are compared with the current system in Tables
II and III for weekdays and weekends, respectively. On weekdays, half-call MOs work from 5:30 pm to 10:30
pm and night float MOs from 8:30 pm to 8:00 am the following morning. On weekends, the half-call MOs work
from 11:30 am to 8:00 pm and the night-float MOs, from 6:00 pm to 8:00 am the following morning. There is a
two-hour overlap period between the half-call and night-float MOs. During this time, the half-call MOs finish their
outstanding tasks, review and pass over cases before going off-call. This workflow allows for the proper handover
of patients between the half-call and night-float MOs during the overlap period, and at the same time, provides more
manpower during the busy evening period
Table I. New night-float system.
Weekdays
Weekends
Time
Event
Personnel
Time
Event
Personnel
Involved
Involved
8:00 am – 5:30 pm
Normal weekday
Daytime MOs
8:00 am – 11:30 am
Weekend
Daytime
working hours
working hours
MOs
5:30 pm – 10:30 pm*
Half-call period
2 half-call MOs
11:30 am – 8:00 pm*
Half-call period
2 half-call
MOs
8:30 pm – 8:00 am
Night-float period 2 night-float MOs 6:00 pm – 8:00 am
Night-float period 2 night-float
the following morning
the following morning
MOs
Two-hour overlap period from 8:30 pm –10:30 pm during weekdays and 6:00 pm – 8:00 pm during weekends, where four MOs (two
half-call MOs and two night-float MOs) are present in the hospital.
MO: medical officer
Old night-call system
New night-float system
Time
Event
Time
Event
8:00 am – 5:30 pm
Normal weekday working hours
8:00 am – 5:30 pm
Normal weekday working hours
5:30 pm – 8:00 am
Night-call
5:30 pm – 10:30 pm
Half-call
8:30 pm – 8:00 am
Night-float
the following morning
Table II. Comparison of the old and proposed systems on weekdays.
Old night-call system
New night-float system
Time
Event
Time
Event
8:00 am – 11:30 am
Normal weekend working hours
8:00 am – 11:30 am
Normal weekend working hours
11:30 pm – 8:00 am
Night-call
11:30 am – 8:00 pm
Half-call
6:00 pm – 8:00 am
Night-float
the following morning
Table III. Comparison of the old and proposed systems on weekends.
The same two night-float MOs work five consecutive nights (Monday to Friday) while different MOs rotate to
cover as half-call MOs. The night-float MOs on Saturday and Sunday are different MOs. The cycle is repeated when
the workweek begins on Monday. After five days of night shift, the night-float MOs utilise the weekend to adapt
back to normal sleeping hours before starting work again on Monday. This strategy optimises our limited manpower
resource and minimises the disruption to inpatient care during working hours.
A four-week trial was carried out in July and August 2007 involving eight volunteer MOs and an informal evaluation
was conducted at the end. All eight MOs felt more alert during their night-float calls as compared to traditional calls.
They felt that this translated into better patient care. Being more energetic, the MOs reviewed patients more thoroughly
and were better able to apply problem-solving skills to arrive at more comprehensive differential diagnoses or problem
lists. This, in turn, resulted in better learning for the individuals. One of the advantages of being on-call five nights in a
row was that the MOs became more familiar with the patients under their care. This continuity of care also allowed the
MOs to follow up on the investigative and management plans that they had commenced the night before. In addition,
they reported having had more time to read up and review the literature to improve their knowledge and the management
of the medical conditions encountered.(4)
These unique learning opportunities were possible due to the MOs being on call on consecutive nights.
Moreover, they were supervised by the medical registrar on-call, thus ensuring that appropriate management plans
were promptly instituted. The number of patients seen per night per MO during the night-float week was a median of 15 (range 12–30) per weekday visit. Perhaps the most significant finding was that none of the MOs found the
workload difficult to cope with at any point during their calls. As quality of patient care can be compromised when
the workload exceeds manpower capacity, this was an important improvement. Feedback from senior clinicians
affirmed that the quality of documentation and clerking improved substantially during this trial period. This
suggested that our night-float call system is a workable solution in addressing the issue of excessive workload
during night calls.
The implication of the night-float system to manpower planning is that the night-float MOs are not involved in
daytime ward duties during the night-float week. At the same time, compared to the traditional call system where
post-call MOs go off-duty each weekday afternoon, there are now no MOs going off-duty on weekdays in the
new night-float system except on Monday afternoons, where the Sunday night-float MO goes off-duty, resulting
in less disruption to daytime patient care. With support from the hospital’s management board, our department
implemented this night-float system in May 2008.
Although the traditional night-call system in Singapore has been time-tested to be effective, we attempted to
investigate if there may be another system that can improve work efficiency and provide better patient care. There
are, at present, no objective measures, but we believe that the night-float system has had a positive impact on
patient care and MO training and welfare, and we are heartened by the positive responses during the trial. Impact
on workflow efficiency and ground processes is likely to be neutral or positive, and this can be addressed in future
surveys.
Yours sincerely,
[Signed, NUH Drs]
references & acknowledgements removed by me.
