Monday, July 22, 2013

AN ARTICLE- MAKING A CHANGE THROUGH ADVOCACY

 Amy Huai-Shiuan Huang
Amy is a second-year medical
student at the National
Taiwan University, Taiwan.

AND,
Heng-Hao Chang
Heng-Hao is a final-year
medical student at the
National Taiwan University,
Taiwan. He is a former
Secretary General of IFMSA
and NMO President of FMSTaiwan

Efforts made to reduce resident work hours in Taiwan
A wave of shock swept over Taiwan one evening in 2011.
“A medical intern, Yeng-Ting Lin, was discovered dead in
a bathroom after 36 successive hours of work on April
27th. Investigations are being done to confirm whether his
death was due to overwork.” The correspondent on television
went on, “According to a study, overworked doctors
are no more sober than a drunk person! If the situation
does not improve, who is going to guarantee that you are
not the next one to suffer from medical errors made by
overworked doctors?”.
During the previous three years in Taiwan, 9 cases of
doctors dying from being overworked had already been
reported. But it was only after the tragic event of the intern
on April 27th that the general public became aware of
doctors’ abysmal working conditions in the country. It
had never been clearer that action needed to occur to
improve the situation.


In Taiwan, medicine is considered to be a sacred
profession; seemingly omnipotent doctors are imagined
to have endless devotion, and seen to never get sick, let
alone suffer from long work hours. Indeed these beliefs
are even shared by many senior doctors - to them, medicine
is a responsibility to which they dedicate their whole
lives. They think they have the power to escape bodily
weakness in spite of unbelievably long work hours. But
the facts now come to light
.

According to research, the average number of
hours worked per week by residents in Taiwan is about
111.87[1], and the maximum shift length is an average of
33.5 consecutive hours. This is well beyond the regulations
proposed by the Accreditation Council for Graduate
Medical Education (ACGME) which recommends that
US resident doctors not work over 80 hours a week, and
that the maximum duration of work shifts is kept below
16 consecutive hours[2]. Furthermore, statistics show that,
after 18 successive hours of work, ICU residents are five
times more likely to commit serious medical errors[3]; and
that the mental state of someone who has been awake for
this long resembles that of a person with a blood alcohol
concentration of 0.05%[4]. As we can see, the well-being
of patients is under threat.

Recently, a resident doctor in Taiwan conducted
a study focusing on how long work hours can affect
residents both physiologically and mentally[5]. Despite
the significance of the topic, the thesis was turned down
by many well-known medical journals in Europe. The
editorial boards wrote back, stating they simply could not
understand how residents could cope with the work hours
stated, thus questioning the reliability of the study.
On May 1st 2011, four days after the intern’s unfortunate
death, came Labor Day, when workers of all professions
marched to defend their rights and to raise awareness
about unreasonable working conditions. A group of
medical students, assembled via the Internet, joined the
march to arouse the media and the public’s attention to
the unforeseen consequences of overworked doctors on
patient safety.

Following the demonstration the medical students
came together again and held their first formal meeting
on October 10th 2011. This was the birth of the Doctor
Working Condition Reformation Group (referred to as the
Reformation Group in the following passages).
The Reformation Group, now comprised of around
30 active medical student and resident doctor members,
aims at improving the working conditions of doctors. In
Taiwan, almost all professions are under the protection of
the Labor Standards Act, which contains regulations on
work hours and compensation of occupational accidents.
Doctors are not included on the list, however - allegedly
due to the “unpredictable” nature of medicine.
But doctors’ rights need to be acknowledged, and by
no means sacrificed, as they are human beings after all.
Through various endeavors, the Reformation Group has
teamed up with FMS-TAIWAN and is trying to put an end
to this abuse of human rights. The following approaches
that have been taken are useful for us as medical students
to think about when it comes to advocacy:
1. Lobby government officials and legislators
For the past two years, Reformation Group members
have attended the public hearings held by Congress.
FMS-TAIWAN spoke up there and also hosted several
press conferences, stating the urgent need for residents to
be included in the Labor Standards Act in order to ensure
the implementation of work hour restrictions. We recommended
that work hours be reduced to less than 80 hours
a week; that the maximum shift duration not exceed 30
hours; and that the frequency of on-call nights not exceed
one every three days.
The Reformation Group also met with several legislators
and officials from the Department of Health to bear
witness with regards to the severity of this issue. In spite
of its long-standing reluctance and procrastination, the
Department of Health finally admitted the necessity to
regulate residents’ duty hours. Promises were made to
establish duty hour regulations in teaching hospitals by
employing a standard contract. The Reformation Group
was invited to draft this contract pending further negotiation.
Although the Department of Health has not yet taken
explicit action, we believe this is an optimistic start and we
will continue our efforts to ensure the implementation of
these new regulations despite the likelihood of objection
from hospital administration boards.
2. Raising awareness through campaigns, media and
networks

We made ourselves seen and heard through the
media. The Reformation Group took part in a number of
marches - on Labor Day, and on Doctor’s Day - and participated
in the demonstration launched by the National
Labor Union. The publicity associated with this provided
the opportunity for us to gain broader public support and
to get the word out about the predicament residents are
facing. Awareness about the possible threat to patient
safety and healthcare quality began spreading through
the media’s reports.
In addition, members of FMS-TAIWAN and the
Reformation Group submitted editorials to noted magazines
and newspapers, responding to inaccurate doubts
and criticisms. The Reformation Group also formed networks
with organizations from different disciplines, such
as an NGO for patients’ rights as well as the newly established
Nurses’ Union. Furthermore, social networking sites
such as Facebook were well utilized to promote a more
sustainable strategy of health workforce management.
3. Influence Our Peers by Education
Most importantly, medical students themselves
need to be aware of the problem. In order to educate
them about the seriousness of excessive work hours, the
Reformation Group held numerous lectures in medical
schools around Taiwan, including during FMS-TAIWAN
events, where publications about the working conditions
of doctors were issued. Furthermore, the Reformation
Group members met regularly to evaluate their progress
and to exchange ideas, keeping themselves abreast with
regards to future plans.
There is a saying that when fire is set in a room full of
sleeping people, the few that are sober should try to wake
up as many of the slumbering as possible. If some are left
to sleep on, this is the dead end; but if they are not, a way
out may be found together. The moral of the story is that
the power of unity can be enormous.
The challenges we face and what we can do in the future
In Taiwanese culture, advocacy has never been
considered very important by young people. Medical students
are more absorbed in achieving good grades than
changing the face of the medical environment they will
one day work in. FMS-TAIWAN and the Doctor Working
Condition Reformation Group went against the grain in
trying to strike up a revolution. We believe there is no one
who should be more concerned about the problems of
the healthcare system than healthcare workers themselves.
One big challenge we face is the lack of participation
by many residents. It is known that some of them believe
the problem will resolve itself with time, however if we can
get to know more of their thoughts about the current working
conditions, we can better evaluate the situation and
thus make improvements in the right direction.
Presently, medical associations are particularly concerned
that the training of junior doctors may be impaired
with the reduction of duty hours. However previous studies
have shown that reducing working hours to less than 80 a
week has not adversely affected training outcomes in the
US[6]. We understand it is prudent to create supporting
policies to ensure a better system in which training quality
is not sacrificed, and believe this ideal can be achieved by
assigning a rotating group of doctors for overnight shifts;
introducing supplementary personnel; and focusing on
efficient skill training.
Conclusion
We medical students should recognize advocacy
as one of our responsibilities. Medicine is a profession
that has the well-being of billions of people in its hands.
After identifying the elements that need to be changed,
we need to have the courage and passion to tackle the
challenges. Take the example of work hour reduction, for
instance. This is not just about interns and residents; it is
about each and every one of the people living in Taiwan
who seek medical assistance or who have loved ones under
medical care. If the situation does not improve, many
will suffer. Our ultimate goal is to create a better system
overall to improve the quality of healthcare. With a heart,
a will to contribute, a positive belief and continuous effort—
let us bring positive change to our medical environment!


1. Yang M.S. , Li Y.F., Wei S.L. An Analysis
of the Work Hours and Related Factors
Associated with Attending Physicians and
Residents in Teaching Hospitals. J Med
Education. 2007; 11(3).
2. Accreditation Council for Graduate
Medical Education. 2011 Duty Hours:
ACGME Standards [Internet]. 2011 [cited
2013 Jan 12]. Available from: http://
www.acgme-2010standards.org/pdf/
monographs/jgme-monograph.pdf
3. Landrigan C, M.D., Rothschild J, M.D.,
Cronin J, M.D., et al. Effect of Reducing
Interns’ Work Hours on Serious Medical
Errors in Intensive Care Units. N Eng J
Med. 2004; 351: 1838-48.
4. Laura K. Barger, Ph.D. et al. Extended
Work Shifts and the Risk of Motor Vehicle
Crashes among Interns. N Eng J Med.
2005; 352(2): 125-134
5. Lin, Y.H., Kuo, B.J., Ho, Y.c., et al.
Physiological and psychological impacts
on male medical interns during on-call
duty. Stress. January 2012; 15(1): 21–30.
6. Moonesinghe SR, Lowery J, Shahi N,
Millen A, Beard JD. Impact of reduction
in working hours for doctors in training on
postgraduate medical education and patients’
outcomes: systematic review. BMJ.
2011;342:d1580
References
{ Advocacy }
medical students

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