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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