Will the end of long shifts mean better care for patients?

HEALTH AFFAIRS: After weeks of protests, junior medical staff reach agreement with the Health Ministry.

MEDICAL RESIDENTS demonstrate for better work conditions, in Tel Aviv earlier this week. (photo credit: TOMER NEUBERG/FLASH90)
MEDICAL RESIDENTS demonstrate for better work conditions, in Tel Aviv earlier this week.
(photo credit: TOMER NEUBERG/FLASH90)

When she was a young girl, Dr. Adina Lashansky used to be very impressed by her grandfather’s stationery.

“He was a physician and on his table he had a very nice penholder that said ‘Dr. Budeau,’” she said. “Seeing this, I decided that when I grew up, I wanted to be a doctor, just like him.”

As she got older, additional elements started to attract her to the field of medicine.

“The more I learned about it, the more I realized how fascinated I was by learning how the human body works and how much I enjoyed the work,” Lashansky noted. “This way, a little girl’s fantasy about being like her grandpa became something more.”

Years later, the 34-year-old is a pediatrician and a resident at Sheba Medical Center in Tel Hashomer. As the representative for the residents union Mirsham in her hospital, she has been at the forefront of the weeks-long battle demanding to abolish the 26-hour shifts that junior doctors are required to serve several times a month.

 MED STUDENTS demonstrate in Tel Aviv in support of doctors, interns and residents who resigned in protest of 26-hour-shifts and heavy workload in hospitals, October 17, 2021 (credit: MIRSHAM) MED STUDENTS demonstrate in Tel Aviv in support of doctors, interns and residents who resigned in protest of 26-hour-shifts and heavy workload in hospitals, October 17, 2021 (credit: MIRSHAM)

“I am just back from a shift, and I have already done six of them since the beginning of October,” Lashansky noted.

The issue of the length of the residents’ shifts has been debated in Israel for several years.

While most senior doctors in the hospitals work between 8 a.m. and 4 p.m., every day a number of residents cover the rest of the hours until the following morning at 10 a.m. – with the last two hours devoted to handing over the patients to the next shift. Normally, the young medical staff is required to be back at the hospital again the next day, less than 24 hours after.

The length of the shifts is not unique to Israel. Medical residents in the US and Canada also often work shifts as long as 24-28 hours.

In the European Union however, the law requires that young medical staff has at least 11 hours of rest per day, even though official exceptions or unreported longer shifts do occur. Also in Australia and New Zealand, residents usually work shifts between 16 and 18 hours long.

For most of Israel’s history, the shifts were even longer – 38 hours in a row, then reduced to 32 until the beginning of the 2000s.

For years medical research has shown the damaging effects of such a taxing schedule.

“Many studies on resident physicians have demonstrated that extended work hours are associated with a negative impact on well-being, education and patient care,” read a study published in the academic journal Sleep Health in 2016 by three Yale University scholars.

On Wednesday, Mirsham reached an agreement with the Health Ministry to cut the shifts to 18 hours over the next four years.

According to the plan, the first phase will come into effect on March 31, 2022, when shifts are going to be cut short in 10 hospitals in the periphery.

By November 30, 2022, the reform will be applied also in the internal and emergency medicine departments in two hospitals in the center of the country.

By March 30, 2023, residents in the same departments in all hospitals nationwide will start working in reduced shifts.

A further expansion applying the reform to more residents and hospitals, which will be decided upon at a later stage, will be implemented by November 30, 2023.

By 2025, all residents, interns and students in Israel will work 18-hour shifts.

In addition, as part of the framework agreed upon by the ministry and the residents, young medical staff will not be able to work more than six long shifts per month nor more than a total of 63 hours a week.

LASHANSKY DESCRIBED the difficulty of working 26 hours straight.

“There are times when you do not have five minutes to sit, let alone an hour to sleep,” she said.

As part of her residency, she serves in various units connected to pediatrics.

“We are about 50 pediatric residents, and each night one of us is responsible for one of the nine pediatric stations,” Lashansky remarked. “For example, there are times where I’m working at the delivery ward, which means that I’m in charge of some 200 newborn babies in the nursery.”

In such a situation, her duties include taking care of unexpected events and emergencies, but also examining every single baby that is born, to make sure that they are in good health. At Sheba, there are some 30 or 40 deliveries per day.

“There are times that are not so stressful, but also days where the workload is really huge,” the doctor remarked.

Lashansky recounted a particularly difficult shift she went through recently.

“There was this one night that sits like a stone on my heart,” she confessed. “Babies kept on coming, and there were some emergencies to take care of. At some point, I thought that I was completely caught up and I would go sleep for an hour, but then I realized that in the meantime another eight babies were born and needed to be checked, which meant at least another hour and a half of work.

“I was angry at them,” she said. “I resented those babies just because they were born on a busy night. I feel so ashamed of it today.”

Lashansky stressed that she knows it was not really anger but, rather, “exhaustion, tiredness, the feeling that my legs were cramping up because I had to stand and run around for so long.”

However, she pointed out that this episode embodies the problem with serving such long hours.

“If, at 4 a.m., I need to make a quick decision about whether a newborn can stay with his mother right after delivery or needs to be taken away to be checked and helped, I want to be able to do it with patience, with the mental energy to explain to his mother why we need to do this, in the same way we would do it at 4 p.m.

“Instead, I often need to focus all my attention to actually do what is needed for the baby, because that is all I have left.”

As the residents have been emphasizing in their demands for shorter shifts, the issue is not just about their personal well-being, but about the care offered to patients.

“After I’ve been working for 12 hours, I do not feel up to driving a car, but at the 25th hour of my shift I might find myself required to make a crucial medical decision about someone’s health,” said Dr. Uri Rozen.

Rozen is doing his residency in family medicine and currently works in a clinic of a healthcare provider in Tel Aviv, but he also spent two years as a resident in internal medicine at Wolfson Medical Center in Holon. He also served in a corona ward for a certain period of time – where shifts were generally limited to 12 hours to limit the exposure of medical staff to the virus, as well as in light of the high demands of the work in terms of wearing protective equipment and patient care.

“I decided to study medicine because I like the combination of working with people and focusing on social skills, as well as working in a broad database of knowledge,” he said.

In internal departments, a resident can be in charge of dozens of patients, and more can be admitted quickly, coming from the emergency room.

“You cannot miss anything – medical history, sensitivities – anything you overlook can be dangerous,” Rozen said. “If you have been awake since 6 a.m., at 9 p.m. you start to be a little tired and impatient, but things are still under control. But by 1 a.m. or 2 a.m. the situation becomes ridiculous: you are completely tired and impatient, you doze off, and then you find yourself running to take care of a resuscitation, which can take a long time. And then, when you are done, there are three more admissions to do, which require a high level of focus and accuracy.”

“These are the times when you are not only miserable, but you make all the mistakes,” he remarked.

IN SPITE of the fact that in theory all agree that making shifts shorter is important, the medical residents’ struggle has raised more than an eyebrow in the medical establishment.

After Mirsham rejected a first outline proposed by the ministry at the beginning of the month, describing it as too vague and criticizing the lack of a clear timeline and budgetary commitments, some senior doctors criticized the aggressiveness of the residents’ protests, including the threat to quit.

A few dozen residents did end up presenting their letters of resignation to the hospitals where they work, but they withdrew them after the agreement was reached.

“The campaign by Mirsham is violent and demonizes all senior doctors,” Dr. Yaron Bar-Lavie, chairman of the Israeli Society of Critical Care Medicine, said on October 13, according to KAN News. “We do not kill patients or harm them, as they claim.”

Even after the agreement was reached on Wednesday, the criticism did not abate.

According to the Hebrew site Ynet, on Thursday the Government Hospital Directors Forum sent a letter to Health Minister Nitzan Horowitz denouncing how the outline was reached without consulting with them, and that as those responsible for implementing it, they will face several difficulties.

Israel suffers from a chronic lack of medical staff.

There are currently 7,000 medical residents in the country, in addition to 2,000 interns – a year of internship is required of all medical graduates after their degree and before they can start their residency – and 4,000 medical students.

Over the next four years, the shortening of the shifts is expected to create an additional 1,250 positions to fill. The ministry has insisted on a longer road map to shortening shifts to be able to increase the available manpower.

“The solution is wrong and the price will be paid by the patients,” Prof. Idit Matot, director of the surgery division at the Tel Aviv Sourasky Medical Center, told Ynet.

In addition, Dr. Yoram Kluger, director of the division of general surgery at Rambam Health Care Campus and chairman of the Surgeons Association, resigned from his position as a member of the National Council for Surgery, Intensive Care and Anesthesia, calling the solution political and not professional.

The residents reject the criticism.

“Many of our teachers, tutors and heads of departments understand the situation and recall that when they were young physicians in the 1970s, the situation was terrible and many mistakes were made. Others treat us like spoiled children,” Rozen said. “But I am not a kid; I am almost 40. I am an officer in the army and in charge of people. We all know that serving such long shifts means being used and abused, and it should not happen anymore. Most countries in the world have already changed their rules.”

In addition, most current residents know that the new outline will not make an impact on their personal lives, since the shifts will not be cut short in time for them to benefit from it.

“We have not done this for ourselves but, rather, to protect the next generations of physicians in a way that we were not protected, as well as for the benefit of the Israeli public and the medical care they receive,” Lashansky concluded.