Updated 12.20pm, adds MAM president's reaction

Doctors on duty for 32 hours at a stretch at Mater Dei Hospital are leading to overtiredness, errors and a loss of empathy to the detriment of patients, according to new research.

Overtired doctors have made mistakes that included drawing blood from the wrong patient and cutting corners by not ordering tests or updating patient records, the research by Alexander Clayman revealed.

One doctor even confessed to feeling relieved when a patient passed away.

All this was driven by doctors’ desperate need to sleep after they spent over 24 hours dealing with patients at Mater Dei Hospital.

In his MSc Public Health Thesis, titled "Sleepiness in post-duty house officers", Clayman found that doctors in many departments in Malta work 30-32 hours. A house officer is normally a doctor who has a junior post in a hospital and usually sleeps there.   

“This has been proven to have a negative impact on staff’s mental and physical health as patients experience poor empathy as well as accidental and non-accidental medical errors,” Clayman, a trainee psychiatrist, wrote.

As things stand, doctors working in most of Mater Dei’s departments work six out of seven days per week (Monday to Saturday), with an additional duty one to four times per week.

A duty provides medical services out of normal working hours and spans from one day to the next. So, for example, a doctor working from 7.30am to 2.30pm would work duty between 2.30pm tol 7.30am the following morning.

But their workday does not end there.

House officers in most specialties are expected to work post-duty on the day following the night duties, in this case from 7.30am to 2.30pm.

This means the same doctor would have clocked in at 7.30am and left at 2.30pm the following day. Scheduled breaks of six hours are granted to house officers in medicine and surgery, while unofficial breaks of varying lengths are possible for house officers in other specialities.

In his research, Clayman looked into the effects of post-duty sleepiness on house officers’ health and function.

He did this through a mix of quantitative and qualitative research: a cross-sectional analysis was conducted in two parts, measuring sleepiness before and after post-duties in a population of 139 house officers over the course of two-and-a-half weeks.

House officers working in the following departments were eligible to participate: medicine, surgery, obstetrics/gynaecology, orthopaedics and ENT.

House officers working in paediatrics, anaesthesia and accident and emergency were excluded as they do not work post-duty. Interviews were carried out with 10 of the doctors.

Results showed that house officers at Mater Dei were, on average, relatively alert pre-duty. On the other hand, the vast majority were, on average, excessively sleepy post-duty.

Doctors spoke about emotional exhaustion that manifested in the form of self-pity and lack of empathy.

"Often, post duty you’d be glad when a patient has passed away – just another name to cross off the list, one fewer venflon to insert, bloods to take, discharge letter to write."

One doctor said: “When you’re exhausted and on your 28th hour, you pity yourself a lot.

“When you’re pitying yourself it’s very difficult to empathise with others.”

Another said: “You start losing patience, your smile, gentleness… you become more irritable… no time to stay answering questions.”

In a shockingly candid comment one said: “Often, post duty you’d be glad when a patient has passed away – just another name to cross off the list, one fewer venflon to insert, bloods to take, discharge letter to write.

“Unless you knew the person it’s an all-round good thing for a house officer. And that’s a very unfortunate situation.

“I’ve spoken to other people who were not house officers, especially my partner. She thought it was a strange, evil, inhuman way of thinking about things but when you speak to other house officers they immediately understand.”

Self-doubt and errors

Results also showed that functional impairment was both involuntary – lapses in memory, genuine errors such as prescription error – and voluntary – deciding not to perform actions which they normally would have, conceivably due to deprivation of basic physiological needs, primarily acute partial sleep deprivation.

Post-duty, doctors described experiencing the need for sleep overtaking other motivators and becoming their dominant cognitive priority.

One doctor said: “Once I booked a whole set of bloods on a patient… and I took them from the wrong patient. On leaving the room, I asked her: ‘what’s your name?’… I discarded them… I told the patient I took them by mistake… she was nice and told me ‘ma jimpurtax ħi’ (it doesn’t matter, dear).”

"Sometimes, I want to sleep while I drive, especially when there’s traffic and it’s sunny. Obviously, the fact that I’d have slept three hours in 32 hours doesn’t really help."

Another doctor said: “You want to do everything faster. The main drive is: I want to go home… I’m much less receptive to people pointing out things.

“Sometimes, a relative will come up and say: ‘I don’t know if it’s important but he wasn’t using his right arm and you might just shrug it off and say: ‘don’t worry, he probably slept on it’. Really, you should be assessing the patient for a stroke… you don’t want to entertain the possibility that he might be having a stroke… because it means you’ll be going home later.”

As doctors reached exhaustion, some spoke about falling asleep at the wheel on the way home or eating junk food to keep going.

“Post duty, I’m more irritable, I’m more likely to be snappy so its best that, post duty, I just sleep… it’s best for everyone.

“Sometimes, I want to sleep while I drive, especially when there’s traffic and it’s sunny. Obviously, the fact that I’d have slept three hours in 32 hours doesn’t really help.”

Need for change

Clayman is aware that, so far, there has been no dramatic event that has highlighted the need to address this across the hospital. But he questioned the subtle undetected impacts.

“Are patients happy to be operated on by a surgeon who has potentially been there for 24 hours?

“Are they happy to go to a cardiology appointment to have someone who has not slept all night look at their ECG and decide if they need an operation,” Clayman questioned.

“Does Malta’s health system require a Chernobylesque event in order to trigger a policy review?

“The fact that there have been no well-known adverse incidents relating to post-duty doctors in Malta should not reassure anybody.”

This is why he does not want his thesis to gather dust.

Clayman has written to the Chief Medical Officer and the Clinical Director of Mater Dei Hospital about the matter.

No understaffing – ministry

A Health Ministry spokesperson said that doctors working in the public sector followed the European Working Time Directive.

When doctors opted to work additional hours at the hospital, they were requested to sign that it is their intention to opt out of the directive.

“Doctors are allowed to go home the day after they are on call (after being on call for 24 hours). Doctors who opt to have 32 hours on-call periods usually do so in the interest of their training, in the interest of continuity of patient care or for financial reasons.

“Therefore, it is a purely personal decision to work for additional periods of time and in no way related to understaffing,” the spokesperson said, adding that the sectoral agreement allows for shifts and “on call from home” for certain groups of doctors.

Doctors' association president reacts

Martin Balzan, president of the Medical Association of Malta, said that Malta – like many other countries – adopted a two-system approach when it came to doctors’ working hours.

In high-intensity areas - such as ITU, emergency and health centres - doctors worked shifts.

In other wards there was the duty system that sought to find a balance between patient safety and doctors getting their rest.

When doctors worked duty they were given adequate time to rest, he said.

This was generally possible since wards were quieter between 8pm and 8am. If they do not manage to rest, they have the legal right to go home after 24 hours and not work post-duty.

Balzan elaborated that house officers are on the front line and are the ones who worked the hardest. Things would improve as they progress in their career.

While, he said, there was room for improvement when it comes to the current system, this would only be possible if there were more doctors who could cover leave and sick leave.

Currently, he said, Malta had an adequate amount of doctors with about 120 graduating each year.