At the ESVS meeting, Christos Liapis (Greece), F. Benedetti-Valentini (Italy) and Klaus Balzer (Germany) chaired a UEMS-EBVS Symposium entitled Vascular Training and the Impact of the European Directive ’48-Hour Week’. This issue requires careful planning for effective implementation, under the directive that is soon to become law throughout Europe. Speakers presented the views from their country’s standpoint on the impact of the 48-hour working week directive on training and the provision of healthcare.
John Wolfe introduced the symposium by saying that one of the advantages of the introduction of the 48-hour working week directive would be the need for more doctors and more specialisation. He went on to present an example of how the system is being worked in Portsmouth, where the working day is from 8am to 5pm. The real impact of the directive, he said, will be the need for focused training and training for a specific specialty, which will require attendance at designated post-graduate meetings. This will also create a need for training on simulators and focused goals will need to be assessed annually.Denmark
Henrik Sillesen of Denmark then described how the European directive was “nothing new in his country, in fact shorter working hours has been a problem in Denmark for 20 years and they are now working towards a 37 hour week. He said that the impact wasn’t good but it did actually force the country “to try and build a more efficient system. In Denmark, despite the restrictions already in place, they have still been able to train good vascular surgeons. The Danish Medical Association pushed for a 48-hour week in 1981 and now a typical week is Monday to Friday 7.45 to 15.15 – a 33 and a half hour week. Sillesen did admit though that the specialist training in vascular surgery does not always comply with these hours, even so the result is a very long educational system that requires 15 months of internship, 12 months introduction to surgery, 12 months general surgery and then 36 months of vascular surgery after the common trunk training in order to be trained. One result of this extended training period was of that the mean age of 18 trainees was 42 by the time they became specialised vascular surgeons.
The weaknesses of the Danish system are that there are no exams, no quality control and no radiology or internal medicine training. Sillesen did say that since the year 2000, all specialist training has changed and that Denmark is moving to the Gentofte model, named after his University Hospital, of total care, which means there is more and better medical treatment and a greater focus on interventional procedures so that a trainee becomes a vascular specialist, performing vascular operations but also treating the underlying disease. Based on an internship of 18 months, 12 months introduction to surgery, and more specialist training of 48-72 months. Also included are nine months of research and some radiological, cardiological and internal medicine training. The aim is to reduce to reduce the training time to become a vascular surgeon – “there will be less general surgery and more internal medicine.Greece
Miltos Lazarides of Demokritos Univeristy, Greece, then provided the Greek perspective. Vascular surgery in Greece has been independent since 1989.
“The total duration of training is seven years, including three years in general surgery (common trunk), three years in vascular surgery and two semesters in cardiac and thoracic surgery.”
Lazarides pointed out that there had been an explosion of medical graduates recently, so they have to wait one year, then there are three years of continuous training in vascular surgery. “There are 14 vascular training units in Greece. Nine are located in Athens, three in Thessalonica, one in Crete Island and one in city of Alexandroupolis (our unit in Demokritos University Hospital), near the border with Turkey. At these centres there are 47 trainers (specialists) and 33 trainees (30 male, 3 female, mean age 34.5) to serve the country’s population of around 10 million.
All the trainees (N=53) in clinical units (not in labs) in Lazarides’hospital were surveyed by a closed questionnaire including five questions.
46 trainees answered the questionnaire (a response rate of 87%).
1) Which of the following represent a major problem during training?
a) Long time of waiting in lists to start/continue training – 27/46
b) Weak curriculum – 25/46
c) Exhaustion of the too many ‘on-calls’- 15/46
2) How many on-call rotas do you have per week?
3) When on duty out-of-hours, how long is your average continuous rest?
3.5 hours (range 0.0 to 6.0, SD=1.4)
4) Do you think that because of too many on-call duties out-of-hours you don’t have time to read/study at home?
5) Are you aware of a new European directive setting a weekly limit in hours worked by doctors in training?
Of the 53 trainees, 46 responded, of these 59% said that the weak curriculum was a major problem during their training, although 33% said that exhaustion, due to too many on-calls, was a major problem. 41% answered that they were doing more than three on-call rotas (24 hours) weekly and the estimated average working hours per week were 93.
This shows that Greece is some way off, at the present time, being ready to introduce this European legislation. Lazarides thinks that open vascular surgery is good in Greece, but that the other pillars of vascualr training, such as endovascular, critical care, vascular laboratory, basic science and CME are almost totally non-existent.
The causes of defective training put forward by Lazarides were:
- The department workload is largely provided by trainees in most vascular units. However there is an obvious conflict between service and training.
- Many trainees’hours are used by being on-call residents, also many duty hours are spent in administrative work or in wards and ICU, being poorly supervised. This is a weak form of training
He said that training requires dedicated time and effort, and cannot be expected to happen automatically. The avoidance of too many on-calls could save time for the trainees to be used in high value structured training. According to Lazarides, under certain prerequisites (e.g. more specialists, specific goals, simulators, OSATS, etc) the new directive could be helpful in vascular surgery training. However, problems in service will follow regarding the out-of-hours cover. This is a “hot”problem that hospital managers should solve, advised Lazarides.The Netherlands
Johan van Bockel from the Netherlands then gave his country’s view of the 48-hour working week. He highlighted the problem of manpower and that despite the need for an increase in the number of residents this increase will be minimal because of budgetary problems.
Currently, according to van Bockel, “The increase in the number of residents in surgery has been very limited and has been balanced against the expected number of surgeons retiring etc. This has been the policy of the Association of Surgeons of the Netherlands.
He then spoke about the problem of continuity of care. According to van Bockel, the directive and changes in training will result in less exposure to surgical procedures and relatively more on-call. His belief is that in order to meet the objectives less routine patient care needs to be handled by residents in training. In order for this to occur, “Others are being involved: residents not in training to become a surgeon (who are participating for one or two years in the work, and currently nurse practitioners and physician assistants are being trained).
“They need to be very targeted in what they receive in terms of training and they have to prioritise, being able to attend the operating room.”He called for “a broad scope of courses increasing the knowledge and skills (e.g. starting with courses like the basic skills course in the UK).
He said that in terms of operations per surgeon there should be a minimum of 600 after six years. Van Bockel and his colleagues collected some data, 234 questionnaires between 1990 and 2000, and this study showed that in 1990 there was about 1,200 operations per year of training and that in 1999 it was approximately the same number, so the operations per year of training have not decreased.
Main points arising from the symposium
- Difference in counties readiness for the working time directive.
- Though countries that are getting in line with the directive, they are looking to focus and specialise, and ensure that the routine is not what the trainees are concentrating on.