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European Working Time Directive and doctors’ health: a systematic review of the available epidemiological evidence

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      To summarise the available scientific evidence on the health effects of exposure to working beyond the limit number of hours established by the European Working Time Directive (EWTD) on physicians.


      A systematic literature search was conducted in PubMed and EMBASE. Study selection, quality appraisal and data extraction were carried out by independent pairs of researchers using pre-established criteria.


      Physicians of any medical, surgical or community specialty, working in any possible setting (hospitals, primary healthcare, etc), as well as trainees, residents, junior house officers or postgraduate interns, were included.


      The total number of participants was 14 338.

      Primary and secondary outcome measures

      Health effects classified under the International Classification of Diseases (ICD-10).


      Over 3000 citations and 110 full articles were reviewed. From these, 11 studies of high or intermediate quality carried out in North America, Europe and Japan met the inclusion criteria. Six studies included medical residents, junior doctors or house officers and the five others included medical specialists or consultants, medical, dental, and general practitioners and hospital physicians. Evidence of an association was found between percutaneous injuries and road traffic accidents with extended long working hours (LWH)/days or very LWH/weeks. The evidence was insufficient for mood disorders and general health. No studies on other health outcomes were identified.


      LWH could increase the risk of percutaneous injuries and road traffic accidents, and possibly other incidents at work through the same pathway. While associations are clear, the existing evidence does not allow for an established causal or ‘dose–response’ relationship between LWH and incidents at work, or for a threshold number of extended hours above which there is a significantly higher risk and the hours physicians could work and remain safe and healthy. Policymakers should consider safety issues when working on relaxing EWTD for doctors.

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      Most cited references 48

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      Occupational sitting and health risks: a systematic review.

      Emerging evidence suggests that sedentary behavior (i.e., time spent sitting) may be negatively associated with health. The aim of this study was to systematically review the evidence on associations between occupational sitting and health risks. Studies were identified in March-April 2009 by literature searches in PubMed, PsycINFO, CENTRAL, CINAHL, EMBASE, and PEDro, with subsequent related-article searches in PubMed and citation searches in Web of Science. Identified studies were categorized by health outcome. Two independent reviewers assessed methodologic quality using a 15-item quality rating list (score range 0-15 points, higher score indicating better quality). Data on study design, study population, measures of occupational sitting, health risks, analyses, and results were extracted. 43 papers met the inclusion criteria (21% cross-sectional, 14% case-control, 65% prospective); they examined the associations between occupational sitting and BMI (n=12); cancer (n=17); cardiovascular disease (CVD, n=8); diabetes mellitus (DM, n=4); and mortality (n=6). The median study-quality score was 12 points. Half the cross-sectional studies showed a positive association between occupational sitting and BMI, but prospective studies failed to confirm a causal relationship. There was some case-control evidence for a positive association between occupational sitting and cancer; however, this was generally not supported by prospective studies. The majority of prospective studies found that occupational sitting was associated with a higher risk of DM and mortality. Limited evidence was found to support a positive relationship between occupational sitting and health risks. The heterogeneity of study designs, measures, and findings makes it difficult to draw definitive conclusions at this time. Copyright © 2010 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.
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        Extended work shifts and the risk of motor vehicle crashes among interns.

        Long work hours and work shifts of an extended duration (> or =24 hours) remain a hallmark of medical education in the United States. Yet their effect on health and safety has not been evaluated with the use of validated measures. We conducted a prospective nationwide, Web-based survey in which 2737 residents in their first postgraduate year (interns) completed 17,003 monthly reports that provided detailed information about work hours, work shifts of an extended duration, documented motor vehicle crashes, near-miss incidents, and incidents involving involuntary sleeping. The odds ratios for reporting a motor vehicle crash and for reporting a near-miss incident after an extended work shift, as compared with a shift that was not of extended duration, were 2.3 (95 percent confidence interval, 1.6 to 3.3) and 5.9 (95 percent confidence interval, 5.4 to 6.3), respectively. In a prospective analysis, every extended work shift that was scheduled in a month increased the monthly risk of a motor vehicle crash by 9.1 percent (95 percent confidence interval, 3.4 to 14.7 percent) and increased the monthly risk of a crash during the commute from work by 16.2 percent (95 percent confidence interval, 7.8 to 24.7 percent). In months in which interns worked five or more extended shifts, the risk that they would fall asleep while driving or while stopped in traffic was significantly increased (odds ratios, 2.39 [95 percent confidence interval, 2.31 to 2.46] and 3.69 [95 percent confidence interval, 3.60 to 3.77], respectively). Extended-duration work shifts, which are currently sanctioned by the Accreditation Council for Graduate Medical Education, pose safety hazards for interns. These results have implications for medical residency programs, which routinely schedule physicians to work more than 24 consecutive hours. Copyright 2005 Massachusetts Medical Society.
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          Prognostic factors for duration of sick leave in patients sick listed with acute low back pain: a systematic review of the literature.

          The percentages of patients with acute low back pain (LBP) that go on to a chronic state varies between studies from 2% to 34%. In some of these cases low back pain leads to great costs. To evaluate the evidence for prognostic factors for return to work among workers sick listed with acute LBP. Systematic literature search with a quality assessment of studies, assessment of levels of evidence for all factors, and pooling of effect sizes. Inclusion of studies in the review was restricted to inception cohort studies of workers with LBP on sick leave for less than six weeks, with the outcome measured in absolute terms, relative terms, survival curve, or duration of sick leave. Of the studies, 18 publications (14 cohorts) fulfilled all inclusion criteria. One low quality study, four moderate quality studies, and nine high quality studies were identified; 79 prognostic factors were studied and grouped in eight categories for which the evidence was assessed. Specific LBP, higher disability levels, older age, female gender, more social dysfunction and more social isolation, heavier work, and receiving higher compensation were identified as predictors for a longer duration of sick leave. A history of LBP, job satisfaction, educational level, marital status, number of dependants, smoking, working more than 8 hour shifts, occupation, and size of industry or company do not influence duration of sick leave due to LBP. Many different constructs were measured to identify psychosocial predictors of long term sick leave, which made it impossible to determine the role of these factors.

            Author and article information

            [1 ]Catalan and Spanish Societies of Occupational Medicine, Barcelona, Spain
            [2 ]Department of Medical Sciences, School of Medicine, Universitat de Girona, Girona, Spain
            [3 ]MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
            [4 ]Healthy Working Lives Group, Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
            [5 ]CiSAL—Centre for Research in Occupational Health, Universitat Pompeu Fabra, Barcelona, Spain
            [6 ]Occupational Health Department, Epsom & St Helier University Hospitals NHS Trust, Surrey, UK
            [7 ]Clinical Institute of Occupational, Traffic and Sports Medicine, University Medical Centre, Ljubljana, Slovenia
            [8 ]College of Occupational Medicine, Portuguese Medical Association, Lisbon, Portugal
            [9 ]Helsinki City Occupational Health Centre, Helsinki, Finland
            [10 ]Occupational Health Service, Parc de Salut MAR, Barcelona, Spain
            [11 ]CIBER of Epidemiology and Public Health, Spain
            [12 ]UEMS Section of Occupational Medicine
            Author notes
            [Correspondence to ] Dr Evangelia Demou; evangelia.demou@
            BMJ Open
            BMJ Open
            BMJ Open
            BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
            7 July 2014
            : 4
            : 7
            25001394 4091509 bmjopen-2014-004916 10.1136/bmjopen-2014-004916
            Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to

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