End of 24-hour institutional on-call duty in Quebec

Scientific evidence

The first reason is linked to the arbitrator’s ruling of June 7, 2011, 4 years after a grievance was filed by a Quebec medical resident contesting the legitimacy of Section 12 of the collective agreement of Quebec’s federation of medical residents, the Fédération des médecins résidents du Québec (FMRQ), which allowed 24-hour call duty. The grievance stated that Section 12 was in violation of Section 7 of the Canadian Charter of Rights and Freedoms and Section 1 of the Quebec Charter of Human Rights and Freedoms. The grievance went to arbitration, but deliberations did not begin until April 26, 2010, nearly 3 years after the grievance was filed. The decision rendered by arbitrator Jean-Pierre Lussier 1 year later was challenged by the McGill University Health Centre, which submitted an application for judicial review and a motion to stay the application of the ruling, scheduled for December 2011. However, in January 2012, after the new collective agreement for Quebec’s resident physicians was signed, extending the deadline to July 1, 2012, these applications were withdrawn.

Researchers’ position

The experts whom we consulted confirmed the importance of reducing the number of consecutive working hours for physicians. Professor Roger Godbout, the director of the Human Sleep Laboratory at Hôpital Rivière-des-Prairies and coordinating psychologist at Clinique spécialisée d’évaluation diagnostique des troubles du sommeil (a clinic specializing in the assessment of sleep disorders), describes the consequences of 24-hour calls during his testimony before the arbitration panel hearing the grievance about on-call duty on April 28, 2010: “A single night without sleep results in a less structured method of processing information; interferes with the ability to remember material learned just before the night; and decreases an individual’s ability to remember and identify details. Memory of places and people seems to be the only brain function that is resistant to lack of sleep [unofficial translation].” A rather troublesome finding for the medical profession!

Dr Charles Czeisler, professor emeritus and researcher at Harvard University, cited his studies on sleep during his testimony before the arbitration panel hearing the grievance about on-call hours on April 29 and 30, 2010. According to these studies, “medical residents are 2.3 times (168%) more likely to be involved in a car accident after a 24-hour in-house call [unofficial translation],” not to mention other drivers who could be involved in these accidents. “They are also twice as likely to fail to pay attention during their in-house calls; they make 36% more serious medical mistakes; and they are nearly six times more likely to make serious diagnostic errors (464%) than when they do 16-hour calls [unofficial translation].” With these data in hand, it is difficult not to reach the same conclusion as the arbitrator.

New collective agreement

The second reason involves the signing of a new collective agreement by the FMRQ on September 17, 2011. It confirms a reduction in the number of consecutive institutional working hours from 24 hours to 16 hours and orders the restructuring of on-call duty in all training settings in Quebec, based on models adapted to different departments, by July 1, 2012. In fact, several departments in Quebec’s health institutions, including family medicine, have already adopted 16-hour call schedules, and the response from medical residents and supervisors has been very positive. Medical residents are now in a better position to learn. In some cases, continuity of care improved to such an extent that a decrease in the length of hospital stays was noted, as a result of the fact that medical residents knew their patients better and were better able to assess their progress. Lastly, overnight call schedules were eliminated, thereby increasing the presence of medical residents during the day.

Some medical residents will be disappointed to lose their “post-call” and others will fear working weeks of nights. Others will continue to criticize the change, maintaining that we need to increase the length of training of medical residents to ensure that they receive adequate exposure to different pathologies in their field. We believe that these statements, which are often based on the changes in working hours made by the European Commission working time directive, are completely false. Quebec’s medical residents will work just as many hours in a week, the only difference being that they will be distributed differently. While our European colleagues now work a maximum of 48 hours a week, medical residents in Quebec will continue to work an average of 66 to 72 hours per week, and some will work 80 or 100 hours. Of course this is not ideal, but medical residents continue to be professionals who have the best interests of their patients at heart. They care deeply about the quality—indeed the excellence—of the care they deliver.

An advance not only in physician health, but in patient safety

In 1984, the FMRQ waged a lengthy battle to reduce 36-consecutive-hour on-call duty to a maximum of 24 hours. At the time, we did not have access to scientific studies as advanced as those now at our disposal (Box 1). The current change represents an advance not only in physician health, but in patient safety.

Sixteen-hour in-house calls are now the standard in Quebec. We hope that the other Canadian provinces will follow suit and that future studies will lend further support to the working conditions of medical residents and those of their supervisors. The Canadian Medical Association has already suggested to the Royal College of Physicians and Surgeons of Canada that it include practising physicians in an upcoming survey on 16-hour call duty in Canada. The steps taken by the FMRQ have not changed the minds and hearts of medical residents; the FMRQ has simply supported the implementation of more optimal working conditions so that residents are at their best when they practise their profession.