Despite a damaging report by the Geneva-based International Trade Union Confederation (ITUC) in 2014 that gave Malaysia a ranking of 5 “No guarantee of rights” (1 “irregular violation of rights” being the best; 5+ “No guarantee of rights due to breakdown of the rule of law” being the worst), working condition generally has improved. The Modified Flexi System for the housemanship training was introduced in 2013 to regulate working hours. However, this system does not include other health professionals such as the medical officers. There is a common perception that doctors do still work more than 36 hours continuously, with weekly working time of more than 60-80 hours.
In the European countries, a directive called The European Working Time Directive (EWTD) was introduced in 2003. The idea was essentially to limit average weekly working hours to less than 48 hours, including any overtime. Its main purpose was to lay down minimum safety standard for organising working time. Many studies have shown that long working hours and insufficient rest can have damaging effects. Long working hours also contribute to job burnout and poor work-home balance.
The EWTD establishes common minimum requirements which include:
- limits to working time (not more than 48 hours a week on average, including overtime);
- minimum daily and weekly rest breaks (at least 11 consecutive hours of daily rest and 35 hours of uninterrupted weekly rest);
- paid annual leave (at least 4 weeks per year);
- extra protection for night workers.
Adverse Health Outcome Associated with Long Work Hours
What is considered long working hours for doctors? The EWTD establishes the average weekly limit of 48 hours, with at least averaged 11 hours of rest daily. Recent study published in American Journal of Epidemiology examined more than 2000 workers, suggested that average 52 hours per week as best fit model for increased risk. Working 52 hours per week for 10 years were associated with increased cardiovascular and cancer incidence, compared to those who worked between 35-51 hours per week. Previous studies on the limit of working hours found that increased risk might occur from working more than 48 to 56 hours per week. Systematic review also showed consistent excess risk of coronary heart disease in employees working long hours.
There are increasing evidence showing positive associations between long working hours with poor health. Ettner SL et al reported in a cross-sectional study that workers who had higher levels of perceived constraints and neuroticism, worked nights or overtime, or reported serious ongoing stress at work reported more negative effects. The impact is not only physical, but also psychological. A survey using WHO Health and Professional at Work Questionnaire identified long working hours as one of the factors for high psychological distress.
For health personnel, in a survey of more than 1000 nurses, 4 out of 9 work-schedule characteristics were significantly related to musculoskeletal disorders. Those 4 characteristics were working full-time, working >8 hours/day, working 2-4 weekends/month and working other than day shift. A significantly greater proportion of healthcare workers who worked more than 2000 hours per year suffers work-related injury. Working at least 12 hours per day was associated with 37% increased hazard rate.
Many of us would be able to recall our colleagues who got involved in accident post night shift. Some may even have suffered such fate. A search in the internet would have revealed multiple news from all over the world regarding doctors involved in accident after night shift. In Malaysia itself, the cases of Dr Nurul Wahida Md Noor, Dr Afifah Mohd Ghazi and the latest Dr Nurul Huda Ahmad, were at least indirectly related to being post call. One may argues that those were all circumstantial evidence, but is that true?
Studies have demonstrated that long working hours was associated with deprived sleeping time. Acute sleep deprivation may result in significant changes in cognitive functioning, alteration of mental status resembling depression or anxiety and difficulty with short-term memory. Some other studies have found that sleep deprivation significantly affects physician performance, alertness and patient safety. There are wealth of evidence showing doctors with even partial sleep deprivation experienced severe sleepiness post-call.
In the study mentioned above as well, more than 10% of participants reported experiencing a car accident while driving home after on-call shift. This number is certainly an underestimation as survivorship bias dictates those who were involved in accidents may not survived to answer the questionnaire. In an old survey but very much relevant, nearly 50% of junior doctors reported to have fallen asleep at the wheel, especially post call. Another study showed nearly 10% of doctors were involved with crashes post night shift, with 60% were involved in near-crash. In a study published in the prestigious NEJM, working extended hours (>24 hours) increased the odd of having motor vehicle crashes by 2.3-fold, and 5.9-fold for near-miss incidents.
We do not want these deaths become part of the statistic – like Joseph Stalin would have said, “A single death is a tragedy, a million death is a statistic.” But what can we do? Call for actions was already being made before, but decisive actions are yet to be seen at the ground level. There was an unpublished survey in 2015 initiated by IMAM and PAPISMA regarding post call accidents involving health professionals. Subsequent meeting with DG of health was undertaken to discuss multiple strategies that can be taken to prevent this from happening.
There are many steps that can be taken, some are at individual level, while many can be done by the relevant authority.
- Limiting number of average working hours per week for health professionals
Housemen have what is called Flexi System, introduced by Ministry of Health in 2011 with the purpose of reducing working hours. In 2013, it was modified to accommodate housemen working time of 65-75 hours per week (Note that this is way exceeding the safety limit from previous studies). The system initially suffers many oppositions from healthcare professionals themselves. At this moment, there is no limitation to the working hours of other doctors in Malaysia.
- Better working condition for doctors
Studies have shown that work-related stress affect negatively on personal wellbeing. Better support for health professionals in terms of salary, resting hours, work-life balance, maternity & paternity leave and dedicated paid annual leave including doctors in training (Masters of Medicine). Currently, the fully-paid maternity leave is 2-months, with additional 1-month if required. Unfortunately for doctors who are continuing their study in Masters’ Programme, the 2-month compulsory maternity leave do not apply to them and many mothers only took a 2-week leave, fearing the need to extend the program.
- Protected sleeping time during on-call
Although many doctors would have practiced this method with their on-call colleagues to make sure they have some sleep during the night, this is not formalised. Studies have shown that breaking up the night shift with short sleep may improve alertness the next morning.
- Safety during the journey post-call
Understandably, accidents usually occur the day after the long night shift/on-call. Driving post-call can be dangerous as the mental alertness is reduced and we tend to sleep at the wheel as studies have shown. Some hospitals have taken active measure to provide transport or by covering taxi expenses to post-call doctors who need to go home. If this is not possible given the cost involved, these steps may be helpful for individual doctor involved:
- Know the limit. Although we tend to underestimate the effect of sleep deprivation on ourselves, knowing when it is safe to drive or whether someone should drive for us, is important. One may want to take a short 15-minute nap first, or drink some coffee before the journey.
- Time the journey. The National Highway Traffic Safety Administration (NHTSA) in the US reported that most accidents occur during rush hour, between 3pm to 6pm. The time between 2pm and 4pm was associated with more sleepiness as well, especially after heavy meal.
- Ensure safety. Wear seat belt and follow the speed limit. Speeding is a factor in 30% of all fatal crashes.
- Universal Insurance/Takaful cover for healthcare professional
In the unlikely event of accident, having universal insurance/takaful coverage for health professionals may help the spouse and children who were left behind. Cases of injury or death that happens during ambulance transfer should be covered as well.
- Opportunity for research
Although there are many researches done in this area internationally, there is a visible lack of data coming from the healthcare environment in Malaysia. We agree that copying other countries’ directive on working hours may not be appropriate, given the different circumstances under which we operate. However, without proper study being conducted, health policies will only become a top-down approach instead of evidence-based.
The noble profession of health professionals needs to be protected, not only from outward perceptions of patients but also the inward general well-being of the doctors, nurses and the healthcare assistants. Reports of untimely death, linking such events to being post-call need to be taken seriously if we want to move forward (or soar upward). This is an opportunity to review the health policy, especially in safety and better working conditions for all. Let it be more laughter.
“Mirth…. prorogues life, whets the wit, makes the body young, lively, and fit for any manner of employment.” Robert Burton, The Anatomy of Melancholy (1621)
 Ripp JA et al. Well-Being in Graduate Medical Education: A Call For Action. Acad Med (2017); May 2
 EWTD: http://ec.europa.eu/social/main.jsp?catId=706&langId=en&intPageId=205
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 Press Statement DG of Health 9 March 2016: Strengthening The Housemanship Training Programme. https://kpkesihatan.com/2016/03/09/press-statement-dg-of-health-9-march-2016-strengthening-the-housemanship-training-programme/
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 Ferner RE et al. Laughter and MIRTH (Methodical Investigations of Risibility, Therapeutic and Harmful): Narrative synthesis. BMJ 2013; 347:f7274.