In the same way that IT workers might flit from consulting contract to consulting contract, doctors are increasingly moving from locum position or locum position. Just as the mining boom is stealing young workers away from their apprenticeships, medical workforce gaps and locum positions steal young doctors away from their long-term training programs.
Why should you spend arduous years, giving up family time and being worked like a dog, when you can go somewhere in rural Queensland and be paid handsomely for something that you could do in your sleep?
Is There A Doctor In The House … At Any Price? - Australian Financial Review
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Is There A Doctor In The House … At Any Price?
The Weekend Australian Financial Review
August 25-26, 2007
Story – Deirdre Macken
They used to have status and money. They also worked long hours. But medicine is in transition and the public may pay the adjustment price.
At Malcom Parmenter’s first annual meeting as chief executive of a health-care group, he met a couple of former patients who had bought shares in his new company.
“I made the comment to them that they were paying me twice as much to look after their money as they paid me to look after their life.”
The former general practitioner runs the Independent Practitioners Network, which represents 90 medical centres, 700 doctors and the corporatisation of medicine. The shift from a physician’s life to a fiscal life was an obvious one for an entrepreneurial GP, but one that still troubles him.
“The overwhelming thought that goes through your head in a job like general practice is that the scope for financial reward is very limited. Having made the change, however, I’m still surprised that people are prepared to pay substantially more for you too look after their money than they are to look after their life.”
In an extended economic boom, when CEOs can earn $33 million, when young equity players get million-dollar bonuses and 26-year-old lawyers can earn more than half a million dollars in London firms, it’s easy to appreciate the frustrations of doctors, who were once top of the tree and now feel they’ve been hung out to dry.
But the medical profession hasn’t just lost its mantle as the highest-paid and highest-status job in the country. It is devolving into a well-paid pastime, where few want to commit to a practice, a hospital or even regular work shifts and where the rewards go to those who opt out of the mainstream.
A crucible of pressures has delivered this discomforting outcome. A profession regulated by not one but two layers of government has met the globalisation of the workforce as well as the changing lifestyle preferences of a younger generation of doctors. Then there are the perverse incentives that reward casuals and punish loyal staff. As a result, says Tasmanian Australian Medical Association president, Professor Haydn Walters, “doctors have come to regard themselves as well-paid casuals”.
Walters has been battling the federal government’s recent decision to takeover the hospital in the marginal Tasmanian seat of Braddon and restore services the state government had cut.
Fighting “political stuff-ups” such as these is just one of many skirmishes that medical lobbyists such as Walters engage in today to keep the profession viable. Walters believes two small hospitals on the east coast of Tasmania are not viable, for doctors or patients.
The crisis in the medical system has almost become a cliché in news pages. But the politics of today makes yesterday’s reporting of hospital waiting lists look like a very small picture indeed.
On Thursday, Labor leader Kevin Rudd made his own systematic assault. He pledged $2 billion to reform the nation’s hospitals by hitting on the hot spots: acute and aged-care beds; accident and emergency services, as well as dental, mental and disability services. He is also talking about somehow improving the interaction between the general practitioner – funded by the federal government – and the hospitals, which until this phony election campaign began, had been the exclusive preserve of the states.
On the same day Rudd made his announcement, it was revealed that the Royal Australasian College of Physicians had banned Shellharbour Hospital in NSW from training junior doctors because of the lack of supervision and heavy workloads.
“Trainees,” the RACP report said, “are currently operating in a fashion which compromises patient safety.”
The state of emergency rooms, the use of acute beds for the infirm and the transfer of GP after-hours care to hospitals are at the heart of concerns expressed by the medical community.
These systematic problems are the landscape inhabited by an already stressed profession, worried it is losing control of its working environment, losing power in the community and losing heart in its future.
While doctors are still among the highest paid workers, their relative pay has dipped, with medical specialists ranking sixth highest respected in society, they’re not so fondly regarded as they once were. According to a Roy Morgan survey on the image of professions, they’ve slipped from No. 1 position 20 years ago to third, after nurses and pharmacists.
A large part of this relative decline can be blamed on the two forces that routinely depress both wages and status – globalisation and feminisation of the workforce.
The mass entry of women into medicine over the past few decades has meant that one-third of practitioners are now women.
Their impact on working styles is a major topic of discussion in the profession.
The more recent influx of overseas-trained doctors into the system has brought the percentage of foreign doctors to 25 per cent overall and up to 50 per cent in regional and rural areas. Their impact is not so readily discussed.
Stephen Leeder, co-director of the Menzies Centre for Health Policy, says the shift to a part-time workforce “could be defended from a feminist critique of not clinging to the male model of work, but in reality working part time is not as respectable as working full time.
“You can’t have the same level of respect of the public, the community or patients if you’re a part-time doctor. And that lack of respect isn’t just directed at the doctor who works part time but at all the profession. Patients simply think that the doctor is less committed to them and to the profession.”
The tendency of female doctors to shun specialty training in favour of general practice, and then to work part time when they have families, has been compounded by the impact of generation Y men.
Says Walters, “the feminisation of the workforce meant that 50 to 60 per cent of graduates are not looking at their career pathways in the same way as previous generations. Now gen Y men have very similar attitudes to many women. They want lifestyle, flexibility, part-time work and they want to travel, and those aspirations are very unlike my generation.
“The norm when I trained was to expect to be stressed, work long hours, onerous rosters and continue working like that for 30 years. People are not going to commit to that anymore, so you need twice the number of people covering the work and you’re not going to get the same amount of training because doctors are working half the hours.
“So doctors are half as experienced as they once were, and there’s an intense shortage of doctors and that leads to other problems such as the increased reliance on locums,” he adds.
The move to part time is reflected in doctors’ average weekly working hours, which have fallen from 48.3 hours in 1995 to 44.4 in 2003 – despite the long hours that registrars and interns work in hospitals.
The fastest rate of decline was among male doctors, where hours dropped 7.4 per cent compared with 6.4 per cent for females. While part-time medicine has mostly dominated the GP end of the profession, it is now spreading through hospitals under the locum system, which has grown from a poorly regarded niche to a much-sought and well-paid career path.
Walters adds: “It’s now the norm for someone in their third year out to give up full-time work so they can work as a locum for three or four months and earn enough to travel for the rest of the year before resuming their fourth year”.
The gap year for young doctors is throwing emergency rooms into chaos, according to an ER registrar, Clare Skinner, who produced an academic paper last year on the use of locums and works with them at a major Sydney hospital. Her concerns were echoed in Kevin Rudd’s reform package.
Skinner says: “There are a lot of perverse incentives in the system at the moment and most of those incentives are driving people into the black market, leaving people in the mainstream under more pressure, which in turn encourages them to leave the system.”
In her report for the Greater Metropolitan Clinical Taskforce, Skinner found that locums now represent half the ER workforce in many small hospitals and are also appearing in major hospitals. Locums earn more, work fewer hours, have less responsibility and can pick and choose their shifts because of the chronic shortage of ER staff.
“It’s frustrating for permanent staff like me to work with junior locums who can earn three to four times as much as you do. I get $37 an hour and locums can earn between $100 and $150 an hour and because they pick whatever shifts they want, the permanent workforce ends up doing the left-over shifts that locums don’t want to do,” says Skinner.
The locum workforce is comprised of three main types of workers. Some are senior staff, close to retirement who generally pick up regular shifts and can earn a week’s wage - $1100 to $1500 – in one shift. Others are more junior trainees, who have decided to work a gap year as a locum. And the third group are overseas-trained doctors.
The foreign-trained locums, says Skinner, “often do it because there is no official credentialing and they can walk into an ER locum job even if their background is working in a Third-World hospital where they can only hand out Nurofen”.
The impact of locum work is not good for morale.
“When you turn up at work and supervise six to eight people who may not have worked in ER before and are earning four times as much as you do, it’s really difficult for permanent staff and it’s frightening from the patient’s point of view.”
A similar lack of commitment is re-engineering general practice and Malcolm Parmenter isn’t the only GP who has decided that lugging a little black bag around 24/7 is no longer a great career.
“It’s all about money these days,” says Parmenter. “Even though most graduates start off with those ideas of helping people and making a difference, they quickly realise the bottom line of general practice. And general practice is a narrow-margin business that’s increasingly low paid compared with other professions.
“I spoke at a general practice conference recently and one of the speakers asked the 50 or so registrars there how many of them wanted to own their own practice and just one person put their hand up.
“Obviously there are generational issues with younger doctors less willing to commit, more female GPs [who] want to work part time and many more guys who don’t want to work the 40, 50, 60 hours that their counterparts worked in the past.
“It’s a part-time industry and there’s a large group who went into medicine for the lifestyle, and motivation them with more money is not the answer because they either don’t want it or don’t need it,” he says.
While there are hints of generational conflict between those raised in the medical school of hard knocks and those who want a life, not just a job, the ageing demographics of the medical profession will accelerate the part-time work brigade. One in four doctors is over the age of 55 years and in the next few years many of those will be looking for the odd locum shift or a Saturday morning shift in the local practice.
The impact of foreign-trained doctors is both a moot and a mute point in the profession. Most acknowledge it as an unavoidable consequence of government decisions in the late 1980s and 1990s to reduce the number of medical graduates in Australia. In 1980, there were 1278 graduates, in 1990 it fell to 1030, and even in 2005 it had only risen to 1348.
As far as the practice of medicine is concerned, the presence of large numbers of doctors trained in foreign systems is having an impact. Says Clare Skinner: “It’s fair enough to discuss issues such as language and communication skills and their experience, or lack of it in the hospitals they used to work in. Also there are cultural issues; for instance, in some countries if you have to ask a question, it’s a loss of face – and yet in medical practice it’s obviously really important to ask questions if you don’t know something.”
Walters days overseas doctors are a consequence of a sick system not the cause of it, but he adds: “It will be another twist in the downward spiral. The fact that many have less English, are less qualified and harder to train in general will erode quality.”
If part-time preferences and the dumbing down of the profession isn’t enough, most doctors will mention several other negative influences on their working life – and most will speak for longer than the preferred six-minute billing unit on these subjects.
Walters, like many, cites the shift of resources from public hospitals to the private sector as a major concern.
“Our public hospitals have been the core of the profession, providing clinical excellence, teaching research and governance of a ‘learned’ profession. But this government has favoured the private sector, which emphasises lucrative procedural, fee-for-service work. That has devalued the public hospital system and the tradition of professional excellence. Academic medicine, in particular, is just disintegrating.”
Skinner laments the collapse of the after-hours GP visits, which has filled ER wards with chronically ill patients at the expense of casualty patients.
“It breaks my heart to see a 90-year-old in an emergency bed because she vomited in her nursing home and her GP wouldn’t make an after-hours visit; and then a 20-year-old comes in from a motorcycle accident and there’s no bed left so we have to send him to another hospital and that can take four hours to arrange.”
Stephen Leeder cites micro-management by bureaucracies, litigation and changing social roles, which “have changed the old relationship between a doctor and a patient because patients turn up with wads of pages fro Wikipedia and treat the doctor as a useful arbiter but not much more”.
In an era where a disgraced CEO can get a golden pay-off, doctors are upset that one mistake can destroy them.
Says Leeder: “Many are really irritated about the possibility of being sued and the kind of social thinking that goes with that. I’ve seen several careers terminated by involvement in these sorts of legal shenanigans.”
Parmenter nominates the dollar-driven rebate system, which penalises caring. “The dollar value attached to the time periods means seeing a patient every six minutes is worth so much more than longer consultants (sic), and if you see someone for longer than 50 minutes, you’re earning 40 per cent less for your time.”
The plight of Australian doctors is hardly local. Michael Moore’s Sicko documentary has indicted the American health system; UK doctors are under even tighter government control, and medical systems in the developing world are being abandoned by their own doctors for First-World salaries. (Stephen Leeder points out that there are more Malawi doctors practicing in Manchester than Malawi).
While a medical degree is still one of the most sought-after university qualifications for school leavers, and universities turn away thousands of hopeful candidates, some in the profession are asking “Who’d want to be a doctor?”
But the larger concern is that the way medicine is practised today is undermining both the value of the profession and the sustainability of the system.
As Walters points out: “Australia is still a pleasant place to work and that’s partly because doctors can manipulate the system to do what they want. Huge amounts of money are being used to patch up the system and doctors can see that. They can see that they can work at, say, Mersey Hospital and earn half a million a year and retire in a year or so; or they can spend a few months working as a locum and go travelling for a year. But none of that is sustainable for the system as a whole.
“We in Tasmania are the future. We’re ageing before other states, we have a lack of funds for health and a dispersed population and we were getting our act together as a state – and then John Howard comes in and undermines all that.
“Politicians have to realise it’s not about money, it’s about workforces and it’s about culture.”
Asked if he would choose to study medicine again, if he had the choice, 57-year-old Walters pauses then says: “Knowing the pressures that are ahead in the next 10 years, let’s say I’m very glad that within 10 years’ time I’ll have left the system.”
Skinner, at 33, answers the question with facts. Two years ago, she earned the same salary ($62,000) as a friend who was a teacher. In another year or two, she’ll earn $89,000. In 2½ years she’s had two weekends off.
“None of us have a normal life,” she says, “but I have a sense of pride in the work and I’m very communally minded, so I’d choose to do it again.”
Malcolm Parmenter has made his decision, although he admits he mostly enjoyed his days in practice. He says he’d probably choose it again, “but whether I’d choose general practice again, I don’t know”.*-*
Going Locum
Responses from doctors who have chose to work as locums from the survey by the Greater Metropolitan Clinical Taskforce:
”I was working long hours and not getting paid for it. I was getting home too tired to do anything else. I lost touch with my friends and didn’t have time for all my usual coping mechanisms.”
Man, 32, in postgraduate year 4
”I can choose where I want to go, what I want to do, when I do it.”
Woman, 29, in postgraduate year 5
”For the hours that I work, it enables me to earn the same money as I would full-time under award rates.”
Man, 28, in postgraduate year 3*-*
Key statistics
- Doctors in Australia: 58,000
- GPs: 40% of doctors
- Specialists: 42%
- Women doctors: 33%
- Overseas-trained doctors: 25%
- Doctors over 55 years: 25%
Historical figures
General practitioners
- In 2005, GPs were 15th highest earning professionals ($1626 a week)
- In 1986, GPs were third highest earning professionals ($620 a week)
Medical specialists
- In 2005, medical specialists were sixth highest earning professionals ($1986 a week)
- In 1986, no figures for medical specialists were available
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3 comments:
Thanks for transcribing that article. I enjoyed reading it. Why not put it up on PagingDr too? ;)
(But please put up a little warning that it is a very long article ahead)
Cheers
Thank-you for transcribing. Extremely interesting and scary read. As a wide eyed eager medical student to be - I found this article really prompted more thinking about my future should I successfully pursue a career in medicine.
It illustrated many truths about the public attitude towards medicine that I already see while working in a hospital. Coming from a female dominated profession, I am familiar with how part-time workers affects how the profession is viewed and valued.
I too, however, see myself as part of the problem in wanting a lifestyle in years to come rather that work a 60 or 70 hour week. I sincerely wish that there will be opportunities to enjoy the profession of medicine whilst achieving my other personal goals for family..........
Why does no-one point out the obvious potential benefit of having part-time doctors: that they're more likely to be satisfied, well-adjusted, not gulity that they never see their children, not socially isolated, and not - or so I hope - at such high risk of the predictable consequences of hard work, long hours, and social isolation: drug abuse, depression, and suicide?
Yes, the generation Y doctors are selfish in comparison with their forebears. We do want a life, and feel entitled to one. And despite the disservice I might do the country by not jumping immediately into private practice after qualifying, I don't feel even the slightest bit of guilt about it.
(Sheepish, I know this comment can be read as if it's directed at you; it isn't. Just at the issue in general.)
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