'My brain kind of stops functioning': Long working hours leave young doctors exhausted

After 20 hours at work, Kenneth starts losing his grip on reality.

It becomes harder for the young doctor to calculate medication doses and make decisions as his thoughts slow to a crawl.

"I find myself getting delirious," said the house officer, who was not using his real name. "And my mood is terrible - I may not be as patient as I was earlier in the day. I find that it is very easy to make mistakes."

Even so, his work is not yet done. There are still 10 hours to go.

Junior doctors have traditionally had to work overnight shifts, known as night calls, for the first few years of their careers.

But with the Covid-19 pandemic offering the opportunity for a reset in every industry, talk has resurfaced on whether it is time to rethink this arrangement in order to keep doctors sane and patients safe.

A national committee chaired by a "very senior doctor", according to Health Minister Ong Ye Kung, has been set up to look into the well-being of junior doctors in the public healthcare system. It will also look into factors associated with work-related stress, such as work hours, duration of night calls and work structure.

At present, the Singapore Medical Council's guidelines stipulate that junior doctors should not work more than 80 hours a week.

Included in this is the time spent on night calls - 24-hour shifts that effectively last 30 hours or more before duties are handed over the next day. Doctors should work approximately four to seven night calls a month.

But young doctors told The Straits Times that even when these guidelines are followed, the long hours - and especially the night calls - often leave them too exhausted to provide the best possible care.

All of these doctors were in the first year of their medical careers and declined to reveal their real names for fear of jeopardising their jobs.

A day in their lives

Night calls typically start at 6am - the same as a regular workday - and end around noon the next day. They take the rest of that day off, and are back to work at 6am on the third day.

While a junior doctor might be in charge of six to 10 patients during a normal shift, this can go up to three wards, or 100 patients, when on call.

They are therefore less familiar with most patients' medical histories, and have to quickly work out a solution when problems arise.

"When people have many overlapping medical conditions, the instinctive treatment may not be suitable for them," said Natalie, a house officer.

"But that's often what happens on call. You skim through the patient's history and try to fix the acute problem."

James, another doctor, said there is often no time to deliberate on a case, as his attention is urgently needed elsewhere. "One time, I was getting three calls to my phone at the same time. Nobody else could call me because the line was jammed."

The long, intensive work hours inevitably take their toll.

"My brain kind of stops functioning every once in awhile, like a car that has stalled," says Clarissa, describing the morning after being on call. "I have to 'shake it off' and reorientate myself as to what I am currently doing in order to keep going."

Says Kenneth: "There are many instances where I did (make mistakes). But luckily, the on-call pharmacists, nurses or senior doctors spotted them and prevented patient harm."

While these challenges are not new, the healthcare landscape has changed enough in the past few decades that junior doctors of today are operating in very different circumstances.

For one thing, patients and their family members have become more demanding, noted Dr Desmond Wai, a gastroenterologist in private practice who graduated from medical school in 1994.

Doctors also have to do more administrative work, which adds to their workload.

And Singapore's ageing population means that patients tend to be older, with multiple complex conditions that overlap, added Dr Tan Wu Meng, who chairs the Government Parliamentary Committee for Health.

But despite the decades of acknowledgment of its flaws, there has been little willingness to substantially change the call system, even if it leads to "near-misses" and exhausted junior doctors.

"One of the reasons that some senior doctors don't have much sympathy for these housemen is that they feel they have done it before and had it even worse," Dr Wai observed.

That aside, he believes it is an important learning ground for essential skills, where doctors come into contact with a wide range of illnesses.

"It's like casting a net into the sea to catch fish," he said. "For example, I saw only one appendix surgery as a houseman - and if you reduce their hours, the net becomes half the size."

It also helps doctors see how an illness evolves over time, added Dr Tan, who is also an oncologist at the National Cancer Centre Singapore and an MP for Jurong GRC.

Rethinking the issue

When Workers' Party MP Leon Perera brought up the issue of doctors' long working hours in Parliament last November, Mr Ong called the night call system a "traditional" and "longstanding practice" that all doctors have gone through.

It helps ensure seamless continuity of care for patients, and guidelines are in place to support doctors' well-being, he said, as he revealed the review committee's formation.

In response to queries from ST, the Health Ministry said the committee includes representatives from both senior and junior doctors, and added that more details would be shared in due course.

Singapore's three healthcare clusters - the National Healthcare Group (NHG), National University Health System (NUHS) and SingHealth - said there are measures to protect the well-being of junior doctors.

These include confidential counselling services, regular feedback and engagement sessions, and comfortable call rooms where they can nap.

They are also trying ways to change up work processes to alleviate the load on doctors.

For instance, SingHealth has staff from different departments cover for one another, allowing each department to have more resources during busy periods.

"A comprehensive review of the approaches to doing ward rounds is also under way," said Professor Terrance Chua, group chairman of SingHealth's medical board.

Dr Faith Chia, who is the designated institutional official for residency at NHG, added that duty hour requirements are closely monitored.

Many departments also allow junior doctors to take time off if they have been logging longer hours than usual, and have fixed hours for ward rounds so that they do not have to come in earlier than required, she added.

And since the Covid-19 pandemic began, workgroups have been set up to create activities that bolster staff well-being and provide psychological support for teams, a spokesman for NUHS said.

"For junior doctors, the heavy workload, long working hours, lack of sufficient rest, demands from patients and relatives, and fear of making mistakes are some of the pressures exacerbated by the Covid-19 pandemic," she said.

Dr Tan said data was needed in how lack of sleep and long hours affect doctors' performance in order to make improvements.

"For example, are near-misses more likely to happen towards the end of a shift? Does having a night shift system change the pattern of near-misses?" he said, noting that research into sleep deprivation and its effects on performance is commonly done in the aviation industry and the military.

Mr Perera also said Singapore should study the feasibility of doctors working 65- to 70-hour weeks and mandate rest periods as essential to both patient safety and doctors' health.

Studies have found that sleep deprivation and alcohol intoxication can have a similar impact on a person's functions, he added. "If we would not allow drinking on duty, sleep deprivation should be discouraged too."

The first-year doctors said night calls have taught them to better manage their time and prioritise their work, but do not provide the best environment for learning about medicine.

“I think you learn more when you are given the space to properly see a patient, without your phone ringing all the time,” James said. “I don’t think about the conditions to 100 per cent of my ability – it’s just something for me to clear so I can get on to the next thing.”