Being deprived of sleep is not only experienced by the patient as discussed in the last post but also by those working within the hospital. This fourth of a series of short essays or reflections on aspects of what could be understood as forms of violence within the practice of medicine turns to the experience of working under those conditions.
Sleep deprivation, acknowledged by Amnesty International to be a means of torture, could be expected to occur in the regimes of long working hours required of early-career doctors, There is both quantitative and qualitative research on the impact of the working conditions experienced by early-career doctors on clinical outcomes and on the health and safety of the workers. On the one hand, a study of the literature by Isabella Zhao, Fiona Bogossian and Catherine Turner reported that the literature was unable to establish causal links between fatigue and work-related injuries. On the other, in a study where 36 emergency physicians were shadowed for a total of 120 hours, the authors, Australian medical academics Johanna Westbrook, Magdalena Raban and Scott Walker reported poor clinical outcomes evidenced by the failure to complete simple prescription tasks with what would seem to be the unbelievable statistics of a total of 208 prescribing errors in 239 medication orders. They attributed these errors to multitasking, sleep deprivation, and difficulty concentrating. Finally, a UK study of 2170 trainees in anaesthesia reported 84 percent had felt too tired to drive home at the end of shift and 57 percent had experienced a near-miss or car accident driving home from work.
The systemic or organisational violence proposed earlier by Shapiro could also be applied to the work practices specific to the training programs undertaken by young doctors. The Australian Medical Association in 2016 undertook an update of their Safe Work Hours Audit.  One of their strongly worded conclusions is that of their study respondents, of whom 80 percent were doctors in training, one in two was working unsafe hours.
Giving the last word to the voice of the doctor in training, a qualitative study by Australian and Scottish medical academics Victoria Tallentire, Samantha Smith, Adam Facey and Laila Rotstein, “Exploring newly qualified doctors’ workplace stressors: an interview study from Australia”, included several quotes from the study participants that allude to the stress of the workload and the systemic violence of the system:
You’re covering about 100 patients on your own and it’s just, your pager is full. Like, you’ve got 25 outstanding pagers, a few MET [medical emergency team] calls going, like, really sick patients. And it’s just that absolute sense of being totally overwhelmed and exhausted …
I didn’t know what I was doing and I called the registrar to ask for help and he said, ‘I don’t want to deal with this, you sort it out’ and hung up on me. And it’s, like, absolutely terrifying. It was my first week. I had no idea what I was doing with this patient … It’s not professional the way we’re spoken to sometimes, and, you know, it wouldn’t be allowed in any other workplace so it shouldn’t be allowed here. The bureaucratic system of requiring long hours per shift, rotations of those shifts, and the possibility of stress experienced in the real-world training model for postgraduate medical training could all be framed as an additional form of violence in medicine.
Amnesty International Defining torture https://www.amnesty.org/en/what-we-do/torture/
 J. L. Westbrook, M.Z Raban and S.R. Walter, “Task errors by emergency physicians are associated with interruptions, multitasking, fatigue and working memory capacity: a prospective, direct observation study.” BMJ Quality Safety (2018), 655-663.
 L. McClelland, J. Holland, N. Lomas, E. Redfern, and A. Plunkett “National survey of the effects of fatigue on trainees in anaesthesia in the UK,” Anaesthesia Vol 72. 9. (Jul 5, 2017) 1069-1077
 Shapiro, “Violence” in Medicine, 2-4.
 Australian Medical Association “Safe Hours Audit” 2016 https://ama.com.au/article/2016-ama-safe-hours-audit
 Victoria Tallentire Samantha Smith, Adam Facey, and Laila Rotstein, “Exploring newly qualified doctors’ workplace stressors: an interview study from Australia.” BMJ Open (2017),
 Victoria Tallentire, Samantha Smith, Adam Facey, and Laila Rotstein “Exploring newly qualified doctors’ workplace stressors: an interview study from Australia.” BMJ Open (2017)