Give me a break
Authors: Ian Gurney
Publication date: 19 Aug 2006
Hungry, angry, late, or tired? You're heading for trouble says Ian Gurney
Last week a nurse summoned me to tell me that a patient on our assessment ward hadn't passed urine for four hours. Not an uncommon occurrence, but it set me thinking because neither, as it transpired, had I. In fact, I hadn't felt the need to visit the toilet since I'd arrived on duty seven hours earlier. I don't have some renal or urological pathology though, or at least I don't think so. It is really quite simple—if you don't drink you don't pee.
For many of you this will be an all too familiar tale. Anecdotally at least, junior doctors seem particularly prone to skipping lunch. Many of you will have done so today. A straw poll of 50 juniors working with me showed that three quarters of them rated as “frequently” the number of times that they go through a day of work without 20 minutes of uninterrupted rest. This is important. As time rushes on towards 2009 and the 48 hour working week, many of us will become shiftworkers, and for many people the old predictable pattern of the working day will become a memory. The days of being greeted by the ward sister with a cup of tea in the morning before later retiring to the sanctuary of the doctors' dining room for lunch will be as much a part of medical history as the iron lung. But so what? If we choose to slog on through the day without a break then surely the only people losing out here are us (and possibly the local cafe owner). Perhaps not. What if our misguided martyrdom is putting patient care at risk? As total hours decrease, the intensity of your working day is likely to be greater, with the risk of errors through tiredness or hunger just as great as in the bad old days.
Prompted by a number of tragic accidents and near misses during the late 1970s and 1980s the airline industry took stock and investigated the root causes. Of the critical incidents attributable in some way to human error, investigators found that in a large portion the cause could be pinpointed to the pilot or aircrew being hungry, angry, late, or tired—HALT. Simple personal factors, some of which were unavoidable, although many were not, were responsible for some of the worst aviation accidents in history.
Fatigue management for high flyers
Current practice in the airline industry for long haul flights is to have three or four pilots on deck, with only two flying at any one time—a working pattern of two hours on then one hour's rest. For particularly long flights an entire second crew is often on board. Although the Civil Aviation Authority (CAA) does not impose strict legislation regarding rest breaks in flight (as it does with total hours flown and rest between flights), a CAA spokesperson confirmed that fatigue management was a priority for the industry. Airlines are acutely aware of the effect of hunger and tiredness on concentration, so much so that international airline Qantas is funding research into the issue. Although allocating rest periods in flight is left to the responsibility of individual captains, at least one airline I spoke to monitors breaks taken. Should consultants similarly be expected to order their juniors to lunch? Before we come back down to earth it's also worth noting that strict CAA rules for airtraffic controllers force them to take 30 minutes' rest every two hours.
Up trees and down mines
Should we need convincing further, research in the forestry industry demonstrates that more accidents occur with fewer or poor quality breaks, and the mining industry recognises that insufficient rest is a major risk factor for employee safety. This makes sense. In parliamentary debate regarding the European Working Time Directive (EWTD),  politicians argued that working without regular rest is equivalent to working “under the influence” as far as concentration levels are concerned.
Back to school
Educational theorists have long understood the need for regular diversion and adequate sustenance on the learning brain, giving rise to the classical daily pattern of school and college life, with short mid-morning and mid-afternoon breaks in addition to an hour long lunch break. Consider then that with two 20 minute breaks and a decent lunch a teacher at the school down the road from your hospital may have more rest time in a day than you often fail to take in a week. Is our performance really so immune from the need for rest?
Give me a break
Over the last few years extensive restructuring of medical working practice has been witnessed to ensure doctors' compliance with the EWTD and the New Deal, which limits the amount of hours that junior doctors can work. Although we have gone to great lengths to make sure that we do not work more than our permitted weekly hours and have sufficient rest time at home, however, little attention has been spared for what we do while we are at work. According to the directive, for any period of work exceeding six hours you are entitled to an uninterrupted rest break of not less than 20 minutes, to be taken during the work period, not at the beginning or end. Uninterrupted means no bleeps or phone calls, and lunchtime meetings are not technically “rest.”
Twenty minute mockery
Missing lunch but going home 20 minutes early makes a mockery of the health and safety reasons behind the directive. Employers must make sure that workers can take their rest, but are not required to make sure they do so, a situation where it is not unlawful to voluntarily forgo your entitlement. This loophole led the European Commission to launch legal proceedings against the UK government in 2004 about its interpretation of the directive. Could this be the reason for our poor compliance? Although legal uncertainty clouds the issue it is natural that our personnel departments will focus their efforts on monitoring our total hours and leave the rest up to us.
No such things as a free lunch break
Perhaps it is unfair to imply blame on the part of our administrators. In discussing this topic recently a colleague told me about a brief trial that was carried out in the emergency department of the Edinburgh Royal Infirmary a few years ago. Doctors arriving for a shift were allocated a set time to go for their “lunch” break, and compliance was audited. During the study, take up was good, staff were well rested, fed, and happy, and patient care didn't suffer one bit. As soon as auditing ceased, so did lunch. What does this say about us as a profession? Have we chosen to forget the nutritional realities of life that we are so keen to preach to others?
One group who have never forgotten the importance of lunch are our peers in the business world. Students on Masters of Business Administration courses are taught of the potential pitfalls of carrying out negotiations in the late morning when concentration levels are on the wane and energy levels dip as the fuel supplies from breakfast are exhausted. Although only legally entitled to the same 20 minutes, common practice in officebound professions is for a contractual entitlement to one hour for lunch, to be taken between 12 pm and 2 pm. Shiftworkers who trade stocks and shares on the global financial markets (a “time critical” occupation matching medicine in stress levels) still regularly manage a one hour lunch break (even if it is taken at their desks) according to a trader from UBS Warburgs who I recently discussed this with. The National Institute for Occupational Health and Safety, a US think tank, advises that employers should encourage regular breaks.  They detail the benefits of taking lunch for decreasing stress, dissatisfaction, and staff illness, and the positive influence on productivity and staff retention that regular breaks can produce. Even though lunch isn't what it once was in the city—increasing work and time demands are driving more workers to shorter breaks—it is rarely missed altogether.
Colleagues offer the excuse of being too busy, of not having time to fetch or eat food, or that compared with our deskbound peers, eating on the job is inappropriate. I wonder if many of us are guilty of feeling too important to be away from our patients. The lesson is there to be learnt, however, from our closest working colleagues. Long before Europe imposed rules on working, the nursing profession was self regulating workers' breaks, aware of the potential harm for their own and their patients' health and wellbeing of overtired or hungry nurses. From the most junior student to the ward or department manager everyone is expected to take a break. “Too busy” is never an accepted excuse. ■
- Department of Health. European working time directive . London: DoH, 2006. www.dh.gov.uk/PolicyAndGuidance/HumanResourcesAndTraining/WorkingDifferently/EuropeanWorkingTimeDirective/fs/en (accessed 11 Jun 2006).
- National Institute for Occupational Health and Safety. Overtime and extended work shifts: recent findings on illnesses, injuries and health behaviours. 2004-143 . 2004. www.cdc.gov/niosh/docs/2004-143 (accessed 15 Jun 2006).
Ian Gurney registrar in emergency medicine Prince of Wales Hospital, Sydney firstname.lastname@example.org