The 24/7 debate … from a 3/5 viewpoint

As I write, the Press is busy negotiating its U-Turn over the ‘weekend effect’ and the ‘doctors-must-work 24/7’ debate.

The University of Manchester ¹ has released the astounding news that people who are admitted at weekends perhaps don’t die of neglect. They’re just sick in the first place. Their huge analysis of more than 12.5 million A/E attendances and 4.5 million admissions suggested that stricter admission criteria meant only the sicker patients are admitted at weekends, so the (percentage) mortality goes up.

Of course, doctors said that from the start. Well, not exactly. My simplistic view was that people with nothing much wrong with them don’t come in at weekends when they’re having a good time, while others with serious illness often wait until Monday before troubling the medical services. Either way, it’s not ‘6,000 avoidable deaths every year’. ²

And not all doctors, of course. It depends on your remit. Early in the story, I attended a national meeting where a young registrar presented her Unit’s ‘(holiday) weekend data’. Sure enough, the percentage mortality of patients coming in on a public holiday was higher. But during questions she interpreted this sensibly, mentioning the caveats above. Fewer patients were admitted. The actual number (not %) who came in on a weekend day and later died was lower than on other days. When you think about it, there is no obvious reason for that. One could speculate wildly … maybe fewer admissions to look after at weekends results in better management! We agreed it was all very complex.

The following week, the papers interviewed her senior authors extolling the virtues of the results, and happily inferred that a lack of doctors at weekends was the culprit. They later hailed the RSPSG’s symposium to debate how doctors could fulfil the 24/7 remit. The great and the good were quoted as ‘strongly supporting’ the notion, stating it was ‘illogical that you have fewer doctors … on certain days of the week’. ³ No one wanted to look as if they were anti-progress.

It’s all about bandwagons.

And now that it’s ‘official’ that there’s no difference, should we join that bandwagon? It might be too good to be true. Let’s face it, there must be some disadvantage in having less staff and facilities at weekends. Clearly, making weekend days the same as any other makes sense …

… or does it?

I retired earlier this year. Editing the SMJ seemed a nice way to fill my time. I hadn’t realised the interregnum had built up a backlog of 150–200 submissions, with authors regularly battering the email door of a largely unattended submission service (For which situation, all at the SMJ apologise to both our readers and writers.). Soon my ‘spare-time’ activity occupied a number of hours every day. So the first thing I did? I made a point of not working on Saturday or Sunday. Of ‘having a weekend’. I needed it. I needed some sort of structure to my week. Maybe that’s why I had wanted some outlet in the first place.

I was reminded of my parents – ‘devout’ (never their word) Catholics who, after retirement, found themselves going to mass on weekdays, plus the recently introduced Saturday evening ‘vigil’ mass. But it didn’t work for them. Their week lost shape.

Their accidental solution was intriguing. Parishioners attending vigil mass were not ‘obliged’ to go to mass on Sunday – just like Christmas!

So they stopped going on Sundays.

They went to mass everyday except Sunday. It gave their week ‘shape’. In the best of traditions, Sunday was their ‘day of rest’.

I think we all need shape to our week. It doesn’t have Mother Nature’s insistence, like the hours of the day or the seasons of the year. Apparently it’s all down to the Ancients; five visible planets, plus the sun and moon. But numerous civilisations throughout the centuries have separately come up with the same format. It’s a sensible time-period to have an ebb and flow.

Sometimes, in fanciful mood, I used to see my hospital almost as a living organism – each part doing its own job, but existing as part of the whole. And just maybe that organism needs a shape to its week; it can’t function the same way day-in day-out, year-in year-out, for evermore.

It needs its day of (relative) rest.