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Petrie et al. examined the relationship between average weekly working hours and junior doctors' mental health (1). Common mental disorder (CMD) was assessed using a cut-off of 4 as a threshold on General Health Questionnaire 28-item scale score. Suicidal ideation (SI) was assessed with a single item. Adjusted OR (95% confidence interval [CI]) of working over 55 h/week against working 40-44 h/week for CMD and for SI were 2.05 (1.62 to 2.59) and 2.00 (1.42 to 2.81), respectively. I have some concerns about their study.
First, Soares and Chan described stress levels and the psychological wellbeing of current junior medical officers (JMOs) (2). They used the Short Form-36 and Perceived Stress Scale-14 (PSS14), and JMOs were more likely to have a high PSS-14 score or to have a low mental health score if they reported higher career anxiety. Working hours are closely associated to sleeping time and other lifestyle behaviors, and these factors should be considered for the risk assessment of stress and psychological wellbeing of JMOs.
Second, Rosta and Aasland conducted a survey to experienced doctors to examine the perception of working hours for postgraduate training doctors (3). The question is “How do you think that self-reported total weekly working 45 hours is too short, sufficient, or too long to meet the quality requirements of obligatory postgraduate training for junior doctors?” Although the majority perceived as sufficient for obligatory postgraduate...
Second, Rosta and Aasland conducted a survey to experienced doctors to examine the perception of working hours for postgraduate training doctors (3). The question is “How do you think that self-reported total weekly working 45 hours is too short, sufficient, or too long to meet the quality requirements of obligatory postgraduate training for junior doctors?” Although the majority perceived as sufficient for obligatory postgraduate specialist training, doctors of higher age, senior doctors and doctors working in surgical specialties perceived an average of 45 h per week for juniors too short. Although there were specialty differences in perception of sufficient training time, health support for mental disorder and suicidal ideation is indispensable by controlling working hours.
Additionally, Rodriguez-Jareño et al. surveyed the scientific evidence on the health effects of exposure to working hours for doctors (4). Although there is an association of percutaneous injuries and road traffic accidents with extended long working hours, the evidence was insufficient for mood disorders and general health. In addition, dose-response relationship and health risk threshold of extended working hours for physicians have not been determined. Prospective studies are needed for the management of working hours for medical specialists, including junior doctors.
1. Petrie K, Crawford J, LaMontagne AD, et al. Working hours, common mental disorder and suicidal ideation among junior doctors in Australia: a cross-sectional survey. BMJ Open. 2020;10(1):e033525. doi: 10.1136/bmjopen-2019-033525
2. Soares DS, Chan L. Stress and wellbeing of junior doctors in Australia: a comparison with American doctors and population norms. BMC Med Educ. 2016;16:183. doi: 10.1186/s12909-016-0693-2
3. Rosta J, Aasland OG. Weekly working hours for Norwegian hospital doctors since 1994 with special attention to postgraduate training, work-home balance and the European working time directive: a panel study. BMJ Open. 2014;4(10):e005704. doi: 10.1136/bmjopen-2014-005704
4. Rodriguez-Jareño MC, Demou E, Vargas-Prada S, et al. European Working Time Directive and doctors' health: a systematic review of the available epidemiological evidence. BMJ Open. 201;4(7):e004916. doi: 10.1136/bmjopen-2014-004916
Petrie et al. asks the interesting question of where optimal weekly work hours lie for junior doctors, which is ultimately the question policy makers and advocates want to answer, with the aim of safeguarding the wellbeing and promoting satisfaction of junior medical doctors. Having recently (Dec 2019) published a large study (n=4012) in Medical Education examining factors related to Australian specialist trainee doctors we thought that there were several points of discussion made that may be distilled by our findings.
There are a number of salient points to discuss:
1. Satisfaction and Mental Illness - Our study examined specialist trainee’s satisfaction rather than mental illness or suicidal ideation with the idea being that a shift in the drive for policy from illness avoidance to promotion of satisfaction may be considered. In our Australia wide study, we found that one in five respondents worked more than 56 hours per week and, corroborating Petrie et al., that they were 24% less likely to be satisfied than those working 45 - 50 hours (median working hours).
2. Optimal work hours - In contrast to the findings of Petrie et al. we found that those working 51 - 56 hours were the most satisfied group, 21% more satisfied than those working 45 - 50 hours (p=0.006). The demands and priorities of a trainee undertaking a specialist pathway, which include: taking time with patients to build a sufficient case load to become proficient, taking time to study,...
2. Optimal work hours - In contrast to the findings of Petrie et al. we found that those working 51 - 56 hours were the most satisfied group, 21% more satisfied than those working 45 - 50 hours (p=0.006). The demands and priorities of a trainee undertaking a specialist pathway, which include: taking time with patients to build a sufficient case load to become proficient, taking time to study, attending and contributing to department meetings. These responsibilities contribute to their training and may mean that they are not satisfied being restricted to a 40 hour working week. Further, as Petrie et al points out, simply putting on these restrictions may have other corollary negative effects.
3. Classification of Junior Doctors - Discrepancies between the findings of our study and Petrie et al. may exist because we captured different groups. Namely, Petrie et al. has studied a cohort that is all junior doctors vs our study which looks at specialist trainees. We would argue that within Australian junior doctors there are multiple sufficiently distinct groups and that they should be studied separately. First, interns and residents who do not have the stressors of examinations or specific learning courses and tend to be younger. Second, unaccredited trainees that are similar to junior doctors, but have added pressures of getting onto training programs and responsibilities of registrars without protections from colleges. Finally, specialist trainees who have the stressors of looming exams, lectures, study courses, applying for impending consultant employment, tend to be older and have a greater burden of family responsibility. The optimal working hours, ceiling threshold for working hours and its impact on satisfaction, wellbeing, and mental health may differ between these groups.
4. Effects of pay on the relationship between hours worked and satisfaction - while Petrie et al. controlled for a number of factors there were several confounders that were not included, particularly pay. We found that those working longer hours were generally paid more and those in the highest quintile of pay (>125k/yr) were the most satisfied group, although there was a ceiling effect (i.e. those earning >150k/yr were significantly less satisfied than those earning a median income). It may be that there is a particular effect on satisfaction or mental illness when there is significant amounts of unpaid overtime or if remuneration is inconsistent with the workload and difficulty of tasks performed.
5. Interpretation of causality - although the authors avoided making statements of causality in their study the second line of the media release from their study states “More than a quarter of junior doctors (JDs) are working unsafe hours that double their risk of developing mental health problems and suicidal ideation” (2). That the working hours “double” the risk of mental health problems is not demonstrated. There are many confounders that need to be considered. For example, it is just as plausible that those who score more highly on the GHQ-28 tend to be more anxious, conscientious and try to do a more comprehensive job at work which is why they work longer hours.
Dr Matthew Lennon, MD
Dr Claire Mok, MD
The authors had no declarations to make.
(1) Lennon, MJ, McGrail, MR, O'Sullivan, B, et al. Understanding the professional satisfaction of hospital trainees in Australia. Med Educ. 2020; 00: 1– 8. https://doi.org/10.1111/medu.14041