Who should police dangerous hours worked by locums?

The recent debate in Ireland over doctors' hours has brought back some not so fond memories of my own internship in Scotland. My record shift was 57 hours straight with about 1.5 hours sleep. I actually fell asleep whilst walking down the corridor to write up a paracetamol order.

Doctors have always been a bit unusual in their acceptance of such dangerous work conditions, made all the more bizarre by the fact that it puts the end-user, the patient, at such danger.

One of the problems with normalizing antisocial hours for junior doctors is that it becomes a mind-set that is hard to shift in later years. We see this frequently in the locum world. Locum doctors lock in attractive shifts knowing that there will be competition for them. They work out the logistics later - juggling this with their regular work or other locum shifts that they have booked, before or after. This can lead to absurdly long periods of continuous work with bouts of tiring travel in between.

So who is responsible for managing the hours of locums to ensure that no-one is working dangerous back-to-back shifts without adequate downtime in between?

• The Employer? Employers are not necessarily privy to what a locum has in their agenda before and after they do a stint in their hospital or practice. They can ask the question before they arrive but an adjacent shift can be booked in 5 minutes after the question is posed. Asking when they start the locum is a bit too late - who is going to stand down a locum with no hope of a replacement?
  
  
• The Locum Doctor? The locum themselves should, of course, exercise some responsibility - they are the only ones who know exactly what is in their diary. But then they have been institutionalised to think they can work long hours without a break by the very system that is now suggesting that they shouldn't.
  
  
• The Recruitment Agent? Locum agents sometimes have the clearest view of doctors' work hours - they are certainly in contact with the candidate more than anyone else. However this presupposes that the agent is cognizant of the dangerous hours problem, has a system for dealing with it, is intrinsically responsible, and has exclusivity with the locum. In reality it is rare for all four factors to line up. Also - not every locum is arranged through an agency.
  
  
• The Government? Where a void of self-regulation exists the law often steps in. But which government (state or federal) and how do they track all the locums out there?
  
  
• The Regulatory Authority? Should AHPRA impose restrictions on working hours, police them and impose penalties when regulations are breached? Again - how?

As you can see it is not an easy knot to untangle. The mobile and 'free agent' nature of locums makes them very hard to keep track of. It would take enormous effort and resources to enforce any regulations no matter who took it on.

I don't see any coordinated efforts to tackle this problem in Australia at present. Sadly, this usually only occurs in response to some crisis that attracts lots of media attention. The recent case in Scotland of a doctor dying in a car crash as a result of shift work fatigue is a case in point. If and when it does, you can be sure it will create a lot of additional paperwork in an already highly regulated area.

All suggestions gratefully received. In the meantime 'personal responsibility' is probably the best we can hope for.

Written by Dr John Bethell, Director of Wavelength International