Tuesday, September 26, 2006

BB's Darker Days

Barbados Butterfly has just finished a series of posts entitled "The Darker Days" which are revealing yet insightful posts as always. Like any other profession, medicine is full of unsavoury experiences, often exacerbated by the expectations and pressures that society places upon doctors and nurses.

Working hours are often excessive, and there is no doubt that ridiculous >24 hour waking shifts should be outlawed, as well as on-call shifts where it is fully expected you will be kept awake.

I worry, however, about the needle swinging too far in the opposite direction... the doctor who in 5 years time struggles to find 38 hours of work to do each week. Last week I met some second-year paramedics, and some ICU nurses. I realised that my hourly pay is less than each of theirs, and the only thing that maintains gross income parity is the long hours I work. Imagine halving your income and doubling your training period because of the reduced patient exposure!

In her athlete analogy: "Sometimes their frequent injuries prevent them from reaching the heights they dreamed of, or force early retirement."

I must add that sometimes doctors do not realise that they do not have to reach the pinnacle of medical seniority in order to lead a full and productive professional life. There are a multitude of hidden and secret pathways into a long term medical career short of completing specialist and GP training. Unfortunately the options that are readily visible (e.g. career hospital HMO) are financially and professionally unrewarding in our current salary environment. I think it is inevitable this will change, though it has major implications for the structure of the Australian hospital system.

Wednesday, September 20, 2006

Are Doctors Society's Dinosaurs?

Tanveer Ahmed from Sydney wrote in today's Age suggesting that changes in medical education have not kept pace with other changes in the wider community, and that it is "one of the last bastions of the Old World left in our economy and requires a genuine shake-up... It is the East Germany of our society, waiting for its wall to fall."

Dr Ahmed (I don't know whether to refer to Tanveer as he or she) challenges the role of "systems, through colleges and apprentice-style training, that have effectively been unchanged for decades."

Let me tell you, Dr Ahmed, decades are not a long time. Our political system has not changed for over a century - is it time for a "radical shake-up"? Human anatomy has not been re-defined for at least several hundred years. Is it time to revamp the textbooks? Should we ditch the apprenticeship model that trains your plumber, electrician, painter or mechanic because it is not keeping pace with modern society?

There are a number of reasons that medical education and health systems have not been torn asunder and rebuilt every few years (despite what the ACCC may want).

Firstly, it is because small, incremental changes are happening all the time. This is how change is managed. Minor changes and improvements are introduced. They are assessed. If they work out they are kept, and if they don't they are reversed (let us hope the dilution of anatomy teaching will be reversed). We are not fighter pilots. We are doctors. The training produces flexible doctors who can make use of new technology, new information, new health system structures, and adapt to suit community requirements as they arise. If you knew that you needed fifteen left-handed dynamic hip-screw inserters in five years time you could train for that, but in five years time the DHS might be obsolete. And so will be your specialist DHS inserters.

Secondly, you may recall the Latin phrase "Primum non nocere" (First do no harm). Tearing down the public health system and medical education in one fell swoop would cause a lot of harm, long before it did any good, especially when no adequate replacement is conceived or planned for.

Thirdly, my favourite saying: "If it ain't broke, don't fix it". As you say, the current arrangement of "cheap labour in underfunded public hospitals... suits many people in authority, both within the profession and in government". Well, let me tell you, it also suits the common citizen holding their Medicare card, who gets first-world health-care for 1% of their gross taxable income each year. As doctors we may grumble and bitch about our lack of pay, long working hours, lack of recognition, long training periods, and no social life, but aren't you the least bit proud that you are providing the majority of your patients with health care that is the envy of many countries around the world?

If anything, the most frustrating part about being a doctor in Australia is that given state and federal funding constraints we can only provide some of the services to some of the people some of the time, but of what we do deliver it is still top quality care. Yes, my pay after 16 years of training is paltry compared to my younger cousin who reprograms the ATM system for a major bank, or my recently-graduated friend who advises semi-private health insurance companies how to waste the wads of cash they make every second. But I have the satisfaction of a patient coming up to me and saying "Thankyou for improving or saving my life" every now and again, and that makes me proud of what I do, despite the fact that the public health system uses and abuses me.

My concern is that if Tanveer's opinion translates to a general perception that doctors are over-trained, then we are looking at the inevitable extinction of the traditional doctor. No longer will we have a health professional who is expected to deal with anything and everything that could possibly come through the door, and to have a good grasp of all the other facets of health care and medicine that affect their patients - we will have a workflow-oriented, productivity-driven, multidisciplinary team-based system with cannulation technicians, specialist nurse practitioners, phlebotomists, reporting radiographers, analytic biochemistry technicians, and diagnostic hygiene specialists who will hold a committee meeting every half hour to discuss why the patient in Cubicle 21 is deviating from the ingrown toenail clinical pathway. There will not be a doctor to be seen because they will be unnecessary. Is this what the Productivity Commission wants?

I might as well retire today. Perhaps we should not be reforming our health-care system or medical training, just our expectations of what it should deliver.

Thursday, September 14, 2006

Doctor Death - or Doctors' Deaths

It was only a matter of time before the papers wrote it up (Young doctors succumb to killing pressures on the ward, The Age 13/9/06) but it concerns me as always that the focus is on working hours (Young doctors' rest-deprived life, The Age 14/9/06). I have written about this before (Doctors get stressed too).

Yes, as hospital doctors we work long hours. Yes, most hospitals have little incentive to reduce working hours (despite the AMA's Safe Hours campaign - potentially flawed as it may be). But don't confuse long working hours with causing doctor suicides. It is a single factor among many others, including long-term responsibilities for patient care; work conflicts with other medical teams and other staff; mixed loyalties to patients, bosses, friends, colleagues, and families.

Personally, I believe that many of these stressors are offset by the rewards: that satisfying feeling of successfully fixing a patient's problem, and talking to a grateful patient and family; being appropriately remunerated for one's services; having a sense of standing within the community; spending fruitful and rewarding time with one's friends and family. I work long hours. I experience stress at work. But I experience the rewards and I do not mind. Some of my colleagues, however, are denied those rewards on a regular basis.

Stressors will not go away. To take them away requires a massive restructuring of our health system which is economically impossible, and despite a lot of empty rhetoric from state and federal governments, is not in their interests. We may whine on about reducing working hours (at the cost of prolonging postgraduate medical training), employing more junior hospital doctors (Where will they come from? Where will they go afterwards? Where is the career path for "hospitalists"?), buying more fancy equipment (equipment is cheap, people are expensive), but at the end of the day, it is all political pseudospeak.

You want to know what the real factor in doctor suicides is? Take a group of motivated, intelligent, organised people. Give them access to lethal drugs and the knowledge of how to kill themselves quickly and painlessly. A small proportion (just like the general community) will develop suicidal ideations. A smaller proportion still will attempt suicide. Unlike the general population, however, every single doctor will succeed. There are no "attempted suicides" among doctors. No random pill-swallowing. No jumping off rooftops. No lying in front of trucks. If a doctor tries to commit suicide, he or she will succeed. Unless they don't really want to.

If you want to make doctors feel better, and discourage them from committing suicide in the first place, then we need to improve the general mental health of doctors. Reducing work stress is part of this, but personally I feel that we need to fix the eroding status that doctors have in our society. We are not commodities to be traded from country to country. We are not bargaining chips to be swapped between government consortia. Talking down our salaries means talking down our value to the community. Make hospital doctors feel wanted, and they will want to stay. Make hospital doctors feel valued, and they will want to live.