This is the first study of its kind to examine the state-wide reality of duty hours and the compliance with European and national labor regulations of resident physicians in Spain. The main findings of the study are that a significant number of residents are not able to rest after a 24h on-call shift and that the vast majority of residents exceed the maximum number of working hours per week set by the European Working Time Directive. It is also the first European study of national reach which investigates EWTD compliance. Until now, the available literature had a regional, hospital or specialty scope.
With respect to this literature, all the studies show an overall picture of non-compliance with European working time regulations with subtle differences between them on regional and specialty variables. In this sense, our results are more alarming than what had been hitherto described. In the only study with a European scope, Goncalves-Henriques M et al. (2022) first approached the topic of compliance with European regulations in several European Union countries from the perspective of one specialty (gynecology). They concluded that only 17.9% of the countries respected European working time regulations. However, they did not describe the extent of noncompliance in each country. Brohan J et al. (2017) analyze this problem in the specialty of Anesthesia in Ireland, in this case up to 70% of resident physicians exceeded the working time limits. In our study, this figure rises to 80% across all specialties.
As for the results from the regional studies conducted in Spain our results show similarities with the figures of non-compliance with breaks after duty hours (Carrasco et al. 2020; Cerame et al. 2021). In this sense, a generalized phenomenon of non-compliance with labor regulations is observed throughout the country. However, there are significant geographical differences between regions, a situation which was not described in previous studies due to their regional lens. A similar trend to previous studies was observed when analyzing the underlying factors associated with non-compliance; namely the type of specialty (surgical specialties).
Compliance with weekly rests has an important margin for improvement in Spain. In spite of the existence of a clear legal framework and a Spanish Supreme Court ruling ratifying this rest period (TS 2022), several regions show significant non-compliance rates where up to 80,49% of residents were not able to rest for at least 36 hours per week. On the positive side of the spectrum, Primary Care and Other Clinical specialties group showed a high degree of compliance with the mandatory weekly rests.
An important problem which has been observed is that the Spanish regulatory framework establishes a minimum of four shifts per month to be able to attain the competencies of most specialties’ training boards, a figure which is incompatible with the 48 hours per week limit (BOE 2003). Therefore, we believe that the legal framework as well as scientific analysis should be based on the number of hours worked per week, as established by European regulations (EP 2003), and the maximum number of mandatory shifts should be adapted to comply with these regulations.
The situation which has been described could potentially create a high-risk situation for the health and psychosocial well-being of resident physicians and could lead to suboptimal patient care. There is a vast body of literature on the physical and mental health consequences of sleep deprivation and work overload in doctors compared to the general population: increased motor vehicle accident risk (Rodriguez-Jareño et al. 2014), higher rates of depression, anxiety, burnout, drug and psychiatric medication abuse (Chen et al. 2022), to name only a few. This link between working conditions and the mental health of resident physicians could potentially explain the observed differences between the mental health outcomes of certain specialties. In this sense, surgical residents, who work in the worst working and learning environments according to our analysis, are also the ones with the worst mental health outcomes according to some studies (Burhamah et al. 2021), although more information is needed to conclude clear differences by speciality.
Furthermore, both working in suboptimal conditions and the consequences it produces on the health of the residents could in turn pose a great risk to patient’s safety (Rodriguez-Jareño et al. 2014), when attended by these professionals who can spend up to 32 hours working non-stop. This situation is especially alarming in surgical specialties due to the fact that they are the ones with the worst results in terms of working conditions and mental health, and at the same time they are the professionals where it is probably most necessary to keep their cognitive capacities intact in order not to make critical errors that can be fatal for the health of their patients (Real Noval H et al. 2022).
In addition, some studies have explored the way in which excessive working hours could be detrimental to PGT outcomes insofar as learning could be significantly impaired. On the one hand, on-call shifts regularly take place in emergency departments and in understaffed periods of time (nights, weekends) which constitute extreme learning contexts without adequate supervision which generate defensive attitudes in professionals that may be counterproductive to their development in other health care settings and contexts (Dennis et al. 2015). On the other hand, the mental health toll derived from the lack of sleep and work overload makes it difficult to learn clinical skills (Eymann et al. 2014) and even more so interpersonal skills and attitudes such as communication, empathy and medical ethics (Wolfshohl et al. 2019).
In relation to surgical specialties, in the study by Carrasco et al (2020), a qualitative assessment was made by the residents on the reason for the lack of compliance with rest breaks. Although most of the reasons given were due to the overload of the service where they were doing their residency, a percentage of the residents cited the need for more time in the operating room as the reason for non-compliance. This situation is consistent with the literature published in the United States and Canada (Grabski et al. 2020) on the problems associated with time regulation for these specialties, and could be a possible explanation for the poorer results in our study of surgical specialties in our study.
Given the results described above and their place in the existing literature, there are several implications both at policy and research levels. On the policy level, there is an urgent need for changes in national regulations to bring them into line with European regulations and for measures to be taken to ensure compliance. For surgical specialties, due to the importance of spending more time in operating room learning contexts, it would be interesting to review and extend training times in order to mitigate this phenomenon as a possible reason for non-compliance with law. In the field of research, it is necessary to continue to carry out studies on the working conditions of health professionals. In this sense, it would be interesting to study in depth the causes of non-compliance with labor regulations and the consequences of exceeding the number of working hours, with both quantitative and qualitative studies, reflecting the personal experience of the resident and the power dynamics they produce in the healthcare field. In addition, it would be particularly useful to carry out studies that examine the association between non-compliance with weekly breaks for continuous care and the number of hours worked by residents, and the deterioration of training quality, the mental health of the professional and patient safety, as the existing studies have been carried out on other groups of healthcare professionals and not specifically on junior doctors.
The present study has several limitations. Firstly, there may be a response bias as it is a voluntary survey, in which residents with less compliance with the corresponding breaks are more motivated to answer the survey. Secondly, the type of data collection method, since the data was collected through a self-administered online survey, there is limited control over the quality of the data. This method of data collection can lead to potential biases, lack of standardization, and response errors. Finally, it was not possible to include resident physicians in Catalonia in the sample, since they use a system for managing their physicians' data which is independent of the centralized control of the Spanish Medical Organization making Catalan data unavailable.
In conclusion, the present study problematizes the working time of resident physicians and its compliance with working hours and rest periods. It is shown that the vast majority of residents exceed the maximum number of hours established by European regulations and a substantial percentage of residents do not take their daily rest after 24 hours of uninterrupted work nor the established weekly rest periods. There are certain differences at the regional level and marked differences depending on the specialty, with surgical specialties standing out as those that least comply with the maximum work hours and rest periods established. All this is detrimental both to health and to the learning process, so measures are suggested at both the legislative and research levels.