The medical profession is amongst the most altruistic of career paths. There is a commonplace understanding that becoming a doctor involves dedicating one’s life to the passion for saving the lives of others. The true extent of the dedication required is however a lesser known reality. Public health care practitioners face rigorous working hours rendered unlawfully exploitive in most other sectors. Young medical graduates bear the bulk of this burden, obliged to deal with these despotic working conditions in their two-year internship and further year of mandatory community service in order to complete their qualification.
These young doctors-in-training are contracted to an obligatory 80 hours of overtime per month, which are served as ‘on call’ hours attached to regular shifts. While on call, interns are required to be available to act as medical practitioners under the supervision of senior doctors. This translates to shifts routinely being around 18 to 26 hours long; and on occasion requiring up to 30 or more consecutive hours of work. Breaks for meals or possibly sleep come at a premium, with interns getting three hours of sleep if they’re lucky - or simply nothing at all.
These draconian working hours pose a serious threat to the health and safety of our armada of young life-savers. This was highlighted in early June this year when a young doctor veered into oncoming traffic on the N1 in Paarl after working a shift over 24 hours long at the obstetrics unit at Paarl Hospital. The Junior Doctors’ Association of South Africa (JUDASA) had last year received complaints about excessively long working hours from medical interns working in this very unit. A 2010 study published in the International Journal of Occupational Medicine and Environmental Health showed that after being awake for 24 hours, one’s cognitive faculties are impaired comparable to that of someone with a blood-alcohol level of 0.10 percent - representing nearly twice the level of SA’s legal driving limit.
This issue is matter of public concern, as such fatigue puts patients at risk. Senses crucial to patient care (hand-eye coordination, decision-making abilities and memory) deteriorate when sleep deprivation reaches the 24-hour mark. Interns admit to a reduced ability to focus towards the end of their shifts, with tasks then taking up to five times longer out of fear of making errors due to sheer exhaustion. Even more disturbing are the reports of unsupervised call duty, where inexperienced interns (who are years away from being certified as doctors) have served as the sole medical practitioner in emergency room units. Senior management are said to dismiss complaints of such abuses by proclaiming the experience to be positive and beneficial to the training process. This wilful ignorance by managers of our country’s hospitals is driven by immense staffing shortages - making the task of filling up rosters very difficult. The problem is however being dealt with in a way that is seriously compromising the delivery of quality public health care.
The elephant in the room is that these inhumane working conditions seem to operate largely within South African law. Guidelines by the Health Professions Council of South Africa (HPCSA), the statutory body with whom all health practitioners are required to register, allow for medical interns’ shifts to be up to 30 hours long. How can it be possible, in a country known for its robust labour laws, for a worker to be allowed subjugation to such gross exploitation? Section 23(1) of South Africa’s Constitution bestows its citizens with the right to “fair labour practices”. This much-acclaimed declaration is ratified by the Basic Conditions of Employment Act, regulating employment contracts to ensure that this right is universally enjoyed. There is, however, an earning threshold, as per ministerial determination, exempting those earning more than R205 433.30 per annum from chapters 9 to 18 of the Act. These chapters deal with regulation of ordinary hours of work, overtime, meal breaks, daily and weekly rest periods, and other provisions that protect an employee’s rights as per the Constitution. Medical interns have an entry level salary of roughly R420 000 per annum, and are thus exempted from being able to legally demand these basic conditions of employment.
Earnings above the threshold usually imply seniority, adequate work experience, or skills that are in high enough demand that such workers would be able to negotiate favourable contract terms. It also would typically mean that there are sufficient employment alternatives if negotiated conditions fall below expectations. This is not the case for medical interns who are without any negotiating power, as they have to work for the state for three years in order to receive certification to practice medicine in South Africa.
The mass shortage of doctors has led to an institutional submission of the profession being associated with harsh working hours. This should not however cause us to disregard the obvious dangers that excessive working hours pose to both doctors and patients. Moreover, vulnerable medical interns cannot be allowed to be callously browbeaten in order to fill the gaps of a health sector in crisis. It is worth noting that those with an income above the earning threshold are still covered by chapter 7(b) of the Basic Conditions of Employment Act, which states that employers must regulate working hours with due regard for the health and safety of employees.
Shorter, more frequent shifts, are amongst the possible short-term solutions. Ultimately, government needs to step up efforts to increase the number of doctors in the public health system and ensure that our hospitals are properly resourced. Present HPCSA guidelines urgently need to be revised. While our armada of life savers may have limitless dedication, they are human beings with very human limitations. Inhumane working hours are rendering them drunk behind the wheel - whether it be on the road or in the emergency room.
By Mogamat Dayaan Salie: Intern, FW de Klerk Foundation
*This article was written independently by an intern of the FW de Klerk Foundation and represents the views of the author. It does not necessarily represent the views of the Foundation, its staff or members of its Board. The Foundation is, however, committed to a broad public dialogue aimed at the promotion and protection of the values, rights and principles enshrined in the Constitution.