Modifications to the current on-call system?
The passing of a paediatrician-to-be involved in a road traffic accident (motor-vehicle accident) recently is indeed a heart-breaking news to the whole medical fraternity. With the incident, a persistent recurring issue also resurfaced - work-related commuting accident ie road traffic accidents involving exhausted doctors after on-calls.
Currently, our medical on-call system can be categorised into active and passive calls, both on weekdays and weekends. A doctor being on active call works at least 15 hours during the non-office hours on weekdays and whole 24 hours on weekends.
For example, when a doctor is scheduled to be on-call on a weekday, he/she starts the normal working day from 8am to 5pm, followed by the on-call that starts at 5pm till 8am the next day, subsequently continuing with another working day till 5pm. In short, this doctor stays in hospital to work for more than 30 hours before going home the subsequent day.
When a doctor is scheduled to be on-call on a weekend or public holiday, his/her active call starts at 8am till the 8am of subsequent day, staying in hospital for at least 24 hours till the completion of that active call. These active calls can be challenging and exhausting at times especially when ones is working in a short-handed department or hospital. Most doctors are scheduled to be on active call duty once a week as well.
Recently, the Health Ministry has started collecting data and statistics from healthcare workers on road traffic accidents involving hospital staffs after work, presumably assessing the need to make adjustments to the system.
Any move to reduce the working hours and minimise exhaustion will be welcomed universally. However, what are the possible changes to the current on-call system and the respective implications? From my humble personal point of view, few modifications can be considered.
No1 - mandatory post-call off ie off day after an active call. Any doctor scheduled to be on active call duty on a certain day will be entitled an off day on the subsequent day when the active call ends at 8am.
This will offer adequate time - almost 24 hours to rest and recuperate before working again the subsequent day, with the hope of less exhaustion resulting in better safety on the road and better performance at work as we will have more well-rested doctors serving the public. However, doctors will no longer be entitled to on-call claim/compensation and our monthly income will easily shrink by 10-20 percent.
Moreover, there will be less manpower during normal hours despite the workload and patient load being as heavy as usual. The quality of our works and quality of care provided to public may be affected. If there is no adequate staff to cope when emergencies happen, patient’s safety will be compromised as well. Furthermore, post-call off day will not be feasible in smaller district hospitals with less doctors thus less flexibility in redistributing manpower.
Some responsible doctors might stay on to work on the post-call days, to help out the team, to escort the transfer of ill patients of which the journey will take hours or even a whole day, yet they will not be able to claim for compensation for their work anymore.
No 2 - mandatory post-call PM off i.e. a half-day off on the post-call day. The post-call doctors will be allowed to leave by 1-2pm after the main bulk of works have been carried out by the team in the morning. Active call claim / compensation remains and doctors are entitled to extra few hours of rest after an active call. The similar challenges as mentioned above will be minimised as we will still be working on full force in the morning.
However, should any post-call doctor be required to work for full day till 5pm as needed by the team, an increment in the amount of compensation should be considered.
No 3 - autonomy to opt for post-call off day without on-call compensation or staying back to work on post-call days, either half day or full day, with appropriate compensation respectively. The system will be different from hospital to hospital, department to department.
The post-call doctors, departments and hospitals will be granted the flexibility and autonomy of making such decision while maintaining the quality of service provided, ensuring the normal functioning of the teams and smooth running of the departments.
No 4 - shift system for Medical Officers, either two shifts (AM and PM shift) or three shifts (AM, PM and night shift) per day. There will be no on-call. This will ensure that no doctor works more than 24 hours in a stretch, thus minimizing exhaustion. Doctors will be scheduled to work for a certain number of hour per week equally, even on weekends and public holidays.
This system, however, requires greater number of doctors for the flexibility of making such arrangement. With shift system, our critical allowance and on-call claim will all become irrelevant, thus our monthly income will shrink by 30-40 percent. Weekends and public holidays will be irrelevant as well as we will be working on these days too as scheduled without any compensation.
Shift system may be not feasible for now as all Medical Officer posts are saturated, yet with critical allowance and on-call compensation removed thus reduction of monthly salary of Medical Officers, healthcare budget can be spread out to create more posts and hire more Medical Officers, eventually making shift system possible.
The ministry will then be able to offer more permanent Medical Officer posts to the growing population of House Officers when they complete their housemanship training. However, the financial aspect of the profession will look even gloomier for doctors in the public service.
No 5 - nothing changes. Doctors have to be smart in taking care of ourselves, be accountable for our own health and safety. Avoid long-distance travel after an exhausting day at work, get some sleep before driving, carpooling with other colleagues, using public transports and so on. More designated rooms and beds can be prepared for the on-call and post-call doctors to rest whenever possible.
Doctors ourselves have to be compassionate and empathise with our post-call colleagues, helping each other to combat fatigue and exhaustion.
I believe all patients prefer to be managed by fresh, well-rested doctors who are more likely to perform better at work, be it the higher efficiency or higher quality of work and service provided.
I believe most doctors will welcome the move to minimize exhaustion at work, whether by capping the maximum number of working hour in a stretch or making other adjustment to the current on-call system without compromising the quality of our training nor the quality of service provided.
However, simply reducing the hours is not the only solution as we need to weigh the pros and cons of each possible change to the system. Improved human resource management will be necessary as well.
Personally I think the current on-call system is an essential part of good training, as long as we can cope with it. After all, generations of doctors have survived it and there is no reason why we can’t. At the end of the day, the benefits of patients, hospitals, departments and doctors ourselves needed to be taken care of with great justice.
There is no one simple solution to resolve all the issues while maintaining the balance. The courageous greater minds in the profession will have to make the tough call but voices of all should be heard as well. What say you?
SCHEE JIE PING is a Medical Officer.