Bully for You, Bully for Me

Since the 4 Corners "At Their Mercy" episode this week, there has been some discussion about bullying over at PagingDr Forums, a great source of medical chat for those who are interested. Occasionally I go on a bit of a rant there, and obviously this issue has riled me up somewhat. Interestingly the 4 Corners episode was preceded by a very powerful and relevant episode of Australian Story on Retired Lieutenant-General David Morrison.

My last post was a rather personal piece, with relevant identifying features altered. It was about my experiences as a bully, but I have similarly experienced it differently as a victim. I have received some feedback that it does not help the cause of eliminating harassment and bullying from the workplace. I respectfully disagree, since I think that identifying and rehabilitating the bully is just as important as identifying and helping the victim. I also believe that there is a complex personal interplay in these situations which deserve more than a simple "I'm right. You're wrong" approach. That is a recipe for sudden, knee-jerk changes that can cause far more damage to a system than the benefits it may bring.

I can imagine the objections now, that medical bullies are heinous individuals that deserve to be stripped of their qualifications, their right to care for patients and to teach, and that they should be publicly named and shamed, or even executed. If you found out today that the surgeon who saved your life was a bully is that seriously what you would want to happen to them?

Also the other argument that is made is that the destruction of any career or the loss of life from suicide is tragic and that even if that happens once it is once too many, let alone four times in the space of a few months. Well that is absolutely true, and I agree completely, but we also accept that there is a road toll for the benefit of being able to zoom at speed around the country. We accept that there is a terrorist risk for all of the freedoms that we enjoy. Callous as it may sound, why do we now not accept that some people will not make it through training and might even be harmed in order for the general public to enjoy quality healthcare from highly-trained experts?

The question is how do we go about preventing those preventable incidents? What cost are we willing to bear in the pursuit of preventing them? These are hard questions, and they are questions that we as a society fail to answer, in the same way that we all want the best healthcare using the most expensive drugs and technology, but we also don't want to to pay greater taxes to cover the cost (currently ~9% of GDP).

This question was posed by an aspiring medical student over at PagingDr Forums:

I'd be interested to know how much infrastructure there is to teach doctor's working through the ranks leadership, mentorship and people managements skills... or even teaching skills? (Beyond observing those around them?). I realise doctor's are time poor but I wonder if formal development of these skill would go some way to improve things.

The Royal Australasian College of Surgeons runs training courses in professional and non-technical skills which encompass these areas of leadership, team communication and teaching.

• Non-Technical Skills for Surgeons
• Safer Australian Surgical Teamwork
• Supervisor Training Courses (SAT-SET)
• Keeping Trainees on Track (KTOT - to help struggling trainees)
• Training in Professional Skills (TIPS)

Some might argue that these should be taught earlier. Several other Colleges run similar programs.

Another comment was from a doctor:

An issue that came up was question/answer method of teaching, and that this was bullying. I must admit I do this all the time and never felt like I was bullying anyone. Are medical students saying that ANY questioning is making them upset or is it just contextual, ie. Don't ask me in front of patients/other people?

Speaking for surgery, the Q&A type teaching mirrors the format of the final surgical exit examinations. You are in a closed room with two examiners who basically ask you questions until either they run out of time or you give up (for more information see here). Even if you answer all their questions they think of more until the bell rings. It is not practical to simulate that scenario in private on a regular basis during a working job, so the scenario is simulated at the bedside, at the operating table, or in unit/department meetings. The questioning is not intended to be malicious or threatening, but they are intended to be challenging, to tease out lines of logical thought or consideration, to highlight areas of deficiency and to promote motivation to self-study.

Unfortunately generations of doctors have been brought up with this myth (perpetuated in the media along with lots of other bad work practices because, heck, it's entertaining) that the questioning (or "pimping" which I think is a terrible term) should be used as a chance to mock trainees on their errors, to get them to "harden the F(*#@ up" and that it is most effective if they are pushed to the brink. It is also easy to forget that it is a public forum in front of other co-workers and not a private one like the exams. Lastly if there is a power imbalance then the questioning/teaching process is an opportunity to reinforce that, which sadly some seniors find irresistible. This practice has become so much a part of medical folklore that it is seen as a bit of a joke.

Thankfully the vast majority of surgical teachers realise these limitations and are very sensible in how they employ this teaching strategy. A small number do not and need to read this article.

As for modern education theory that recommends that confronting trainees with their errors is wrong, and should be done in a safe, private, comfortable teaching environment after you have assembled a mountain of data about their errors and prepared a comprehensive performance management plan... well you can imagine the challenges of implementing that in a busy, service-oriented workplace.

The sexual component of the 4 Corners episode is what really kicked everything off, with Gay McMullin's rather inappropriate and deplorable comment that "What I tell my trainees is that, if you are approached for sex, probably the safest thing to do in terms of your career is to comply with the request". RACS has proactively worked to address bullying and harassment for many years, but the public seems to care more when it is sexual harassment, not just regular run-of-the-mill workplace bullying. This is very unfortunate because workplace bullying and harassment is a form of disruptive interpersonal conflict that is made possible by a power imbalance, and exacerbated by chronic and short-term stressors that develop amongst both the harasser and the harassee.

Remember that most definitions of bullying or harassment (and most certainly sexual harassment) is one that is based primarily on whether the harassee has taken offense or feels threatened. The intent of the harasser may not be relevant and harassment can be unintentional (see this Parliamentary document Section 1.55 "Intentional versus Unintentional Bullying"). Therefore factors that increase the harasser's aggressiveness and factors that increase the harassee's sensitivity will logically play into its manifestation. (I am trying to be polite here).

Sexual harassment is however seen as something that arises because of an innate "evil" within the harasser or workplace which is part of their nature and cannot be remediated. This is not a constructive way to view things. It is effectively shaming hard-working supervisors and teachers who have made a terrible mistake without offering them any form of salvation.

I think what is more relevant is the concept that there is occasional harassment that occurs in settings of heightened workplace stress (whether contrived or not) and there is harassment that occurs as a deliberate and repeated pattern of sociopathic behaviour. Regardless of whether there is a sexual component these are two very different scenarios which require two very different approaches. The former is a combined human factors and systems issue ("culture change" or changing the structure and methods of hospitals/teaching - realising of course that this could be very expensive both in terms of financial cost and time cost to surgical training and patient care systems) and the second requires identifying and rehabilitating the individuals involved (this may also involve punishment and/or compensation).

Ultimately the cases described in 4 Corners were tragic, but hopefully they represent a tiny number of the daily surgeon-trainee interactions throughout Australia and New Zealand. For those that are proven, they should not have happened. For those that are just allegations, they deserve to have their investigations completed without intererence. For the rest of us, it is a salient lesson in what not to do. More importantly it highlights what we should speak out about because as Ret Chief of Army Lt-Gen David Morrison said "The standard you walk past, is the standard you accept."

Clubs and Cartels

The big news this week has been that the ACCC is on the prowl again. Medical work practices are not new ground here - the ACCC has previously stoushed with the RACS over surgical training, as well as Queensland obstetricians and more recently Adelaide heart surgeons (my previous posts ACCC Strikes Again and Bleeding Hearts in Private Hospitals). In fact the ACCC has so much interest in the medical industry that it provides an Info Kit for doctors.

The new case now concerns medical accreditation practices at St Vincent's Private Hospital in Sydney, in particular, the practice of limiting appointment of new anaesthetists to those who already hold appointments at the nearby St Vinnie's Public hospital.

In general, most private hospitals have Medical Accreditation Committees that review the qualifications of any medical staff that wish to work at that hospital. The majority of private hospitals are quite keen to have as many doctors on their books as possible and to make the accreditation or credentialling process as simple as possible, because generally more doctors means more patients (and more business).

In the case of anaesthetists, they generally provide a service at the request of a surgeon. With the exception of staff anaesthetists who are paid directly by a private hospital to be available full or part time for urgent or emergency cases, the majority of private anaesthetists are paid fee-for-service by the patient or their insurance fund. Patients generally choose their surgeons but not their anaesthetists, and therefore the surgeon-anaesthetist team usually comes as a single package.

A surgeon will choose to work with a specific anaesthetist in the private setting because they are competent, they work well with the surgeon and his team (often having worked together for years), and they are available to do a particular set of cases at a particular time. Usually if a surgeon moves to another private hospital the anaesthetist will follow, rather than the other way round. Therefore it makes sense that if a private hospital wants to attract a new surgeon to bring work over that they encourage simple, rapid accreditation by the associated anaesthetists.

In contrast, in a public hospital the surgeon has no say who their anaesthetist will be. It could be a junior registrar, or a seasoned consultant. It could be someone they have never met or worked with before. We have to trust that somebody, somewhere (usually the public hospital's appointments committee), has decided that this anaesthetist is up to the job. In most cases, there are no problems as many aspects of anaesthetics are commonplace and transferable. Having a pool of staff anaesthetists makes it easier to roster for emergency cover, or to squeeze as much work as possible from a smaller group of staff - essential in any cash-strapped public hospital - at the cost of breaking up the regular surgeon-anaesthetist team. Obviously for more complex operations there will be more in-depth decision making and efforts to pair experienced and familiar surgeons and anaesthetists (as well as other theatre staff) together.

So what is going wrong here at St V's? Well, to the frustration of the hospital management and the surgeons, an arbitrary rule has been applied to limit the accreditation of new anaesthetists. This means that otherwise qualified and capable anaesthetists are unable to work at that hospital and surgeons who go to that hospital must choose from the anaesthetists who already work there. It is effectively a closed shop and keeps those anaesthetists who already have appointments busy with private work, and potentially allows them to raise their fees above what might be market rates at a hospital with a more liberal accreditation process.

Unfortunately it means that surgeons are forced to work with anaesthetists that they may not wish to work with, as well as discouraging them from bringing work to that hospital, much to the disappointment of hospital management.

Sadly, this is not the only private hospital in Australia that engages in this type of activity. Sometimes it is instigated by the medical staff, sometimes it is instigated by management as a business decision (usually if they employ the anaesthetists directly). Sometimes the ACCC gets it wrong, but by my reading this is one that they have got right and things clearly have to change.

Links:

• ACCC demands answers from St Vincent's - The Australian
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  ACCC demands answers from St Vincent's
  The Australian
  via AAP | August 17, 2009
  
  THE entire team of anaesthetists at St Vincent's Private Hospital is under investigation by the consumer watchdog for acting as a cartel.
  
  The Australian Competition and Consumer Commission (ACCC) last week demanded the group of 30 doctors, who are allocated nearly all the hospital's anaesthetic work, justify its membership rules, the Sydney Morning Herald reports.
  
  The investigation comes after the hospital applied to the commission last year to rule it could continue the practice of preventing outside anaesthetists from working in its operating theatres, even when requested by a surgeon.
  
  Individual doctors face possible fines of up to $500,000 if they are found to have breached competition laws.
  
  The private hospital's pool is restricted to anaesthetists who also work at St Vincent's Public Hospital.
  
  The process is supposed to be competitive and to benefit public patients, but has been criticised for being skewed towards doctors trained at St Vincent's.
  
  The hospital withdrew its application in December, but the commission is investigating fresh complaints from anaesthetists who say they are still locked out of work at St Vincent's.

  
  
  
• St Vincent's a closed shop, said leading anaesthetist - SMH
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  St Vincent's a closed shop, said leading anaesthetist
  Sydney Morning Herald
  Julie Robotham Medical Editor
  August 19, 2009
  
  THE anaesthetist representing doctors in the St Vincent's Private Hospital cartel investigation told professional colleagues that work allocation practices there would not change, despite a deluge of adverse submissions collected by the competition regulator during its initial, later abandoned, inquiry last year into the scheme.
  
  Minutes of a meeting of the NSW branch of the Australian Society of Anaesthetists, obtained by the Herald, reveal Gregory Deacon's resistance to the idea that closed-shop anaesthetic rostering might breach the Trade Practices Act.
  
  According to the minutes, from February, ''GD reminded committee members that St Vincent's Hospital is a privately owned business and therefore has the legal right to appoint staff, including doctors, as it chooses … GD felt the appointment process at St Vincent's Hospital was unlikely to change as a result of the application to the ACCC.''
  
  At issue is the practice of allowing only the limited number of doctors with an appointment at St Vincent's Public Hospital to work at the private facility. The private hospital argued this ensured adequate anaesthetic cover for the public hospital. However, NSW Health, which funds the public hospital, told the commission that claim was specious because there was a surfeit of anaesthetists in the eastern suburbs willing to work with public patients.
  
  Other doctors told the commission the real intention was to keep lucrative private work within a select group of associates.
  
  The commission last December dropped its first examination of the arrangement when St Vincent's withdrew its application to be exempted from the law.
  
  Now the anaesthetists - who as a formal association manage anaesthetic staffing for the hospital - are again under ACCC scrutiny, following new complaints from doctors excluded from working there.
  
  Dr Deacon, as the public officer representing them, must respond by Friday to the commission's questions regarding the group's history, policies and reasons for refusing work to qualified doctors. He refused to comment last night.

  
  
  
  
• Elite hospital old boys' network targeted by competition watchdog - SMH
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  Elite hospital old boys' network targeted by competition watchdog
  Sydney Morning Herald
  Julie Robotham Medical Editor
  August 17, 2009
  
  THE entire team of anaesthetists at St Vincent's Private Hospital - more than 30 doctors - is under investigation for acting as a cartel.
  
  The Australian Competition and Consumer Commission is moving to end what other doctors claim is a decades-long history of restrictive behaviour by an old boys' network which is bent on protecting its exclusive access to some of Sydney's most lucrative private operating lists.
  
  The ACCC last week demanded the group - a consortium of doctors employed as independent contractors but allocated nearly all the hospital's anaesthetic work - justify its existence and membership rules and defend how its members set patients' fees.
  
  Other doctors said giving anaesthetic shifts to a limited pool of specialists could also compromise patient care, barring surgeons from choosing anaesthetists experienced in particular operations.
  
  The commission's move could see individual doctors hit with fines of up to $500,000 if they are found to have breached competition laws. It comes after the hospital last year applied to the commission to rule it could continue the practice of preventing outside anaesthetists from working in its operating theatres, even when requested by a surgeon.
  
  The private hospital's pool is restricted to anaesthetists who also work at St Vincent's Public Hospital - appointed through what the hospital describes as a, ''competitive process '' intended to benefit public patients, but which others say includes a system of patronage skewed towards doctors trained there.
  
  The application prompted a huge backlash, as individuals and specialists' groups told the commission the closed roster was unjustified and unique in NSW.
  
  In its submission, NSW Health, which funds St Vincent's Public Hospital, said public patients did not benefit from the exclusivity arrangement, because there was no, "current or foreseeable shortage of anaesthetists," in the eastern suburbs, and, "indeed if anything there is an oversupply''.
  
  The hospital withdrew the application in December and is understood to have told the doctors, who effectively run the anaesthetic department and charge some of Sydney's highest rates, to change how they allocate work.
  
  But the commission is now investigating new complaints from anaesthetists who say they are still locked out of work at St Vincent's Private.
  
  Early this year the hospital's executive director, Robert Cusack, signed a rejection letter saying there was, ''sufficient anaesthetic cover within the existing cohort of anaesthetists,'' and the candidate therefore, ''did not satisfy a business need of the hospital.''
  
  Despite this, Mr Cusack is understood to be furious with the anaesthetists' position and to have told them he will not pay their legal costs or any fines.
  
  An anaesthetist, David Bollinger, told the Herald : ''I've had a professional relationship with a surgeon I've worked with for 15 years, and he moved to St Vincent's and they won't let me work there. It's … mean-spirited, and bordering on unethical.''
  
  Another anaesthetist refused work said: ''St Vincent's is very highly regarded in the community [but] the way they do things is not necessarily in the best interests of patients … it's in the best interests of themselves.''
  
  Gregory Deacon, public officer of the St Vincent's Private anaesthetists' consortium, declined to comment, saying the matter was being handled by lawyers. The hospital also refused to comment, citing the ACCC proceedings.

10 Year Challenge

Seasoned readers may recall my previous post "10 Years in Limbo" about the 10 year moratorium placed on overseas-graduated doctors.

The 10 Year Moratorium applies to New Zealanders as well, as despite their special visa status they are not considered permanent residents even when enrolled in Australian Medical Schools, and the only way around this is to obtain permanent residency prior to commencing Medical School in Australia.

Well, Dr Mike Belich wants to do something about that, and he has challenged the validity of the 10 year lockout and is currently going through the courts, as reported in The Australian. To be honest, I don't really understand his argument for seeking an exemption from the current rules... but I guess this is how precedents are set.

No doubt all the New Zealander's over at Paging Dr will be all excited. I better go let them know...

GP goes to court fighting country duty - The Australian
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GP goes to court fighting country duty
The Australian
Adam Cresswell, Health editor | August 15, 2009

A NEWLY qualified general practitioner has launched a David and Goliath legal challenge to the head of Medicare, filing a Federal Court action over a ruling he says will force him to abandon his home and partner and spend the next 10 years working in the bush.

Byron Bay doctor Mike Belich passed his postgraduate exams to qualify as a GP three months ago but is on borrowed time in the northern NSW coastal resort because of a retrospective ruling by Medicare that he was an overseas student when he enrolled at the University of NSW in 1999.

The ruling means he is subject to a moratorium set up by the Howard government in 1996 that forces overseas-trained or foreign-origin doctors to work for 10 years in the outback before attaining the right to practise where they like under Medicare.

Belich could not apply for permanent residency when he first moved to Australia with his family at age 14 because as New Zealanders they were considered to be, effectively, permanent residents already. He became an Australian citizen while at university, but later found out that the day he started medical school was the cut-off point used to classify him as an overseas student. He's challenging the ruling as unfair and beyond parliament's original intentions.

If successful his case, lodged with the NSW registry of the Federal Court this week, could affect up to 100 other doctors of New Zealand origin who, it is understood, may be in a similar position.

Belich tells Weekend Health that while at university he was treated the same as a local student, to the extent that he graduated with a HECS debt.

He was first informed of Medicare's decision to classify him as an overseas student when he applied to join the GP training program, more than a year after he had qualified as a doctor and when an Australian citizen.

He says his case is a fight for "natural justice and transparency".

"They have gone against the intention of the law, and have acted in a way to get me and 100 other people into a 10-year binding contract where we had no idea (this would apply)," Belich says. "I'm not going to work where they want me to work ... the government has spent all this money training me as a GP, they are short of GPs and they need a GP here in Byron."

Belich, who has recently bought a house with his partner in Byron Bay, says subsequent attempts to overturn the decision - including direct appeals to then federal health minister Tony Abbott and his successor Nicola Roxon - have brought sympathetic noises but no practical concessions.

The situation has been in limbo during Belich's four-year period of GP training, when he was allowed to continue working in Byron Bay under a temporary exemption from the 10-year rule.

But with his GP fellowship secured, the exemption is due to expire on October 19. Belich says he cannot comply with the 10-year rural service order because his partner is unable to leave the area under the terms of a Family Court order granting her former partner access to their two children.

Belich's solicitor Adam van Kempen, partner with the Byron Bay law firm Bottrill van Kempen, says Belich is asking the Federal Court to make a declaration that Belich is not a former overseas medical student under the terms of the Health Insurance Act.

Further, the case, which cites the chief executive of Medicare Australia as the respondent, seeks a declaration from the court that the act does not prevent Medicare benefits being paid in respect of services Belich provides.

Other doctors who may be affected by the outcome of the case will be New Zealanders who study in Australia under the same conditions as Australian students but who later are told by Medicare that different rules will apply, van Kempen says.

"The contention is that the legislation has captured this group of people and it was an unintended consequence of the legislation," van Kempen says.

Given the October 19 deadline, van Kempen says he expects there will be an application for the case to be heard urgently.

In a letter sent by then Royal Australian College of General Practitioners president Michael Kidd to Abbott in July 2006, Kidd says it is "evident ... that the Department of Health and Ageing's classification of Dr Belich as a 'former overseas medical student' appears to be a contradiction to the information publicly available" from the Department of Family and Community Services,

Department of Education, Science and Training, Department of Immigration and Multicultural Affairs and other agencies.

Kidd concludes that the college believes the moratorium should not apply to Belich and requests Abbott "use (his) ministerial discretion ... to overrule this restriction and allow Dr Belich to practise freely".

A Medicare Australia spokeswoman says it would "not be appropriate ... to comment on foreshadowed legal proceedings".

What Waiting List? A followup.

I received an insightful comment from Anonymous in response to my post on Waiting Lists. My reply follows.

Anonymous said...
I disagree with the assumption that waiting list manipulation doesn't change how long patients wait for operations.

If we use a lie (using stats) to say there is no waiting list problem then additional resources will not be allocated and ignore attempts at increasing real efficiency. This means that real waiting times may increase along with losses in quality of life, patient productivity, increased complications and increased cost of care. It’s not just the usual cost of the operation but all the related costs before and after that don’t show up in the hospital stats.

Differences in the delay of processing of forms will change the order when patients are seen.

Dear Anonymous (why are there so many people called Anonymous???),

I would agree wholeheartedly with you if the statistics were actually used for resource planning - unfortunately as far as I can tell they are only used as a political football. I am not saying that sitting on waiting list forms is a great thing to do, just that we live and work in a pragmatic world and have to get on with things.

I remember clearly in a chat with a friend who was a government lackey a few years ago why we don't look at more useful KPIs - the response was that there was no interest in measuring a KPI unless it was a number that could be improved upon and promoted in a media release.

Efficiency is squeezed to its limit already - there is no efficiency gain to be realised. Our driver at the coalface is the desire to treat patients as best we can, not to meet arbitrary targets or make the Minister look good. The only thing that can be improved upon is more capacity by capital investment - and this will never happen because placing a chokehold on capacity is the only way to limit ongoing costs! Just like the logic that if we have fewer doctors the health budget will be smaller. Bugger the patients.

As for differences in delay of processing forms... all the forms for our specialty went through me. It didn't matter how long I sat on them, or when I put them on the list, or when I received them. I filled out the forms, I submitted the forms, I reviewed the waiting list, and I booked and scheduled patients into theatre where I then operated on them.

Patients were prioritised by me on the basis of firstly clinical need, secondly resource availability, and waiting time came a very distant third. The patients were more frustrated by delays and cancellations on the day of operation than an extra week after 2 years of waiting. This is what happens every day in every hospital I have worked at. How about yours?

I Don't Understand the NHS

This is probably the domain of Dr Crippen but the more I read about the NHS the worse it seems to be.

What does the NHS Centre for Involvement do?


And do they really really need a National Knowledge and Question Answering Service?. I thought that's what AskJeeves, Universities and libraries were for. Before you know it there will be a Ministry of Truth.

Too bad the NHS' Jargon Buster service doesn't explain what "Involvement" and "Question Answering Service" mean, because it sure as hell has redefined what a Spine is!

Perhaps it is a function of the fact that the NHS is one of the largest employers in the world (over 1.5 million) that they have to find pointless activities for people to do? I vote that they shut down one of these departments and hire more doctors and nurses.

Nurses Need Hospital Training

Does this sound strangely familiar?

Hospital bottleneck stymies nurse plan
Siobhain Ryan | April 20, 2008 - The Australian

GOVERNMENT needs to put the brakes on plans on massively boost nursing numbers until they solve the worst shortage in hospital training places the profession has seen, John Daly, Chair of the Council of Deans of Nursing and Midwifery (Australia and New Zealand), said.

Professor Daly, speaking on the sidelines of the 2020 Summit in Canberra, said in some states such as New South Wales, nursing undergraduates were already unable to do the hours of practical clinical training in hospitals required to complete their courses.
"This is the worst we’ve seen it, and it’s not just in NSW. The Deans of Nursing and Midwifery are saying it’s a problem across the country," he said.

The Rudd Government’s health policy relies heavily on its promise to ramp up the number of nurses and other health workers, announcing last month it would train up to 50,000 new frontline health professionals.

Pre-election, it also committed $81 million towards putting 9,250 extra nurses into Australia’s hospital system.

But Professor Daly said governments had to address existing bottlenecks in supervised clinical hours in hospitals, and expand training opportunities for undergraduates in GP practices and community health, if it was not to exacerbate the crisis.

"Let’s be very cautious before we rush to increase them any further before we resolve this clinical training problem," he said.

Firstly, this is what happens when you take training out of the hospital system for nurses - when they realise it is a good thing, they can't get back in.

Secondly, student nurses could get plenty of clinical training on-the-job if they returned to working junior nursing positions, but that sort of makes universities redundant - what would you do with all the clinical educators and nursing preceptors?

Lastly, this sounds like exactly the same issues that postgraduate doctors face in getting their specialist experience! Doesn't anyone ever learn?

NB This diagram is a little out of date but nonetheless relevant.

Walking backwards, slowly.

I have been following, on and off, a thread on Paging Dr about how to "Survive First Year". After three pages of posts it is a bit muddled about the first year of what, but all the talk about work-life balance has raised the hairs on the back of my neck.

Now don't get me wrong, I am not against doctors having a social life and being able to wind down away from work. Heaven forbid, my family would be very unhappy if I completely ignored them to work all day and all night.

But this concept that doctors (and medical students) are entitled to a fun and enjoyable experience during their work or study irks me. Medical school is meant to get you trained up as a decent doctor... but it just so happens that all the students want it to be fun and enjoyable. Being a doctor is about treating patients as best as you can, and drawing appropriate reward (personal satisfaction is a form of reward) from doing so.

There are many previous generations of doctors who chose to let (or failed to stop) work taking over their lives. 50 years ago it was normal to eat, breathe and sleep medicine all day every day while you were a RMO or Registrar. Even as a GP in a solo practice it was normal. And your patients appreciated it. Doctoring was not a job, it was a lifestyle.

These days, nobody (in any profession) wants to make any personal sacrifices for the sake of work. We all want to clock off at the end of our shift, turn off our pagers and forget about work. And by that I don't mean just doctors, but everyone in the wider community. No longer is the community expectation "8 hours work, 8 hours rest, 8 hours sleep" (care of the trade union movement) but so is the 2 week overseas holiday, investment property, beach-house, private school education, 4WD, and token sustainable garden. Are we becoming a society of spoilt brats?

I increasingly see it in the surgical trainees (and I must confess that I am and was no exception). They don't want to move out of town for rural rotations, let alone interstate or overseas, for fear of disrupting their personal or family arrangements (neither did I, at that stage). They want to claim every single dollar of their award entitlements (as do I), though obviously this eats into the budget for treating patients. There is a cost and a benefit to each of these decisions - though self-interest increasingly outweighs that of community-interest.

But back to the point - if you want to give up your social life you will make significant professional and educational advances. If you want to prioritise your social life you will suffer some impediment to your career or study (in comparison to those geeks who don't sleep and talk med all day long). You may well live longer as well. BUT IT IS YOUR CHOICE.

Some people like to blame "the system" for making medicine stressful and demanding. Blame it all you like. "The System" is the way it is, and if you want to go into medical politics and change it for everyone else, it will have community-wide ramifications (not necessarily all for the better). A plethora of large and small organisations from the AMA to the DRS push their views on how to improve the health system and also working conditions for doctors.

Sometimes I don't know whether reform of the medical profession or medical employment is for the better or worse. I find it a rather ego-centric view that we have to demarcate roles, engage professional industrial representatives, or wage public campaigns in order to maintain wages and conditions for doctors.

It feels like we are stooping to a lower level, and that it demeans us as a profession that we have to engage in underhand tactics, or play hardball in order to maintain conditions. Every "victory" over some measly little payment or benefit seems to degrade my professional self-respect even more. Perhaps it says more about our government, our industrial landscape, or our lawyers. Most of all, it sickens me that the time spent on this detracts from what I want to do - treat my patients well.

I'd like to see someone stand up and say "Good Job, Doctors. Here's a pat on the back, a few days off, and a pay rise because you deserve it." But I know I'm just dreaming.

10 Years in Limbo

As a follow-on to a recent discussion thread over at PagingDr, I had cause to review the effect of the 10 Year Moratorium on Medicare Provider Benefits.

This has been a big deal because it effectively limits non-Australian Citizens or Permanent Residents from gaining access to Medicare Provider Benefits.

You may recall from the first instalment of my Mind the Gap Series that outside of the public hospital system the Federal Government funds medical services via the Medicare system (including the PBS and the Commonwealth Medical Benefits Schedule [CMBS]).

This renders the Federal Government extreme power and influence over who delivers medical care to the community via the allocation and restriction of Provider Numbers, and also how that care is delivered via limitations, restriction and conditions placed upon services before they are eligible for reimbursement via Medicare.

Note that this is a relatively roundabout method of control over medical practitioners. The Federal Government does not tell doctors what to do. They merely tell doctors that unless they do things in a specific way, satisfying Medicare guidelines and Ministerial Determinations, that their patients will not be able to have their medical costs reimbursed.

Therefore in theory it is not the doctor who is being punished, but the patient. Unfortunately, the doctor is the one that the patient sees face to face. The bills and invoices carry the doctors name. If the patient can't get money back from Medicare or their insurance company, it is the doctor they complain to, not the 17 year old counter chick at the Medicare office, or the faceless call-centre operator on the end of the phone line.

And if you are unfortunate enough to be one of the 90% of doctors that do not get payment upfront then you end up unpaid because the patient can't get their Medicare reimbursement.

What does this have to do with the 10 Year Moratorium?

Well, the 10 Year Moratorium is one of the limitations (along with Bonded Medical School Places) that the Federal Government applies to restrict access to Medicare benefits. It's purpose is to encourage doctors to enter and remain in the public hospital system, or to work in "areas of need" as defined by Medicare, brought in as part of John Howard's 1996 Provider Number reforms (More Info).

It applies to Overseas-Trained Doctors who migrate to Australia as well as non-citizens and non-permanent residents who commence studying medicine in Australia.

Basically if you fall into the target population, patients who see you in private (in your clinic or rooms) or on whom you operate in a private hospital will not have their medical costs reimbursed or subsidised by the Federal Government. In a system where patients are accustomed to paying little or nothing out-of-pocket this is tantamount to shutting these doctors out of the market, unless you do what the Government tells you to, and work where they tell you to work.

Fine, it's primary purpose is to encourage doctors into "areas of need". But what about non-resident doctors who gain their medical qualifications in Australia? These include full-fee paying students from overseas, as well as New Zealanders (who are on Special Category Visas) who study medicine in Australia. These students take up valuable medical school positions, but are discouraged from working in Australia for 10 years after their graduation, when they have careers they can easily go to in New Zealand and elsewhere.

Furthermore, they aren't banned from working in Australia - only from working outside the public hospital system. That means that they are free to pursue their specialist qualifications and postgraduate degrees (but GP trainees have to enter the Rural Training Program). After this, however, they have to go overseas or off to the bush (which increasingly means outer metropolitan urban fringes) to bide their time.

It seems a colossal waste of university and hospital resources to train people who can easily avoid the rest of their Provider Number limbo by heading overseas (and most likely never returning).

But then again, maybe the Department of Health knows what it's doing...

Exemption guidelines for doctors need fixing: report - The Australian
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Exemption guidelines for doctors need fixing: report
The Australian
Sean Parnell | November 17, 2007

THE much-criticised system of regulating overseas-trained doctors has been dealt another blow, with the Department of Health and Ageing confirming the existence of a damning internal report on its distribution of Medicare provider numbers.

Two years after the furore over the alleged criminal malpractice of foreign doctor Jayant Patel in Queensland, which prompted a concerted reform push across Australia, the commonwealth is under fire over its use of overseas-trained doctors to fill gaps in primary care and private practice.

Section 19AB of the Health Insurance Act stops overseas-trained doctors receiving Medicare benefits for 10 years, unless, as temporary residents, they agree to serve in an area of need known as a District of Workforce Shortage. At the end of October, 4148 overseas-trained doctors had been given exemptions -- double the 2004 figure.

More of Australia is being classified by the department as a District of Workforce Shortage and, with the staffing crisis now reaching into the suburbs, its own research has found Section 19AB exemptions are considered vital to filling outer metropolitan GP vacancies.

But a report commissioned by the department last year pointed to serious flaws in the Section 19AB process, which has existed since 1997 and is now covered by six-year-old guidelines.

A department spokeswoman confirmed doctor Eleanor Long, a renowned Australian medical education consultant, had used her report to recommend the guidelines undergo "major revision".

According to the spokeswoman, Long wants the validity of the guidelines improved as they apply specifically to GP numbers through an overhaul of the District of Workforce Shortage process.

Long believes more attention should be given to the factors leading to shortages, and how the department should assess District of Workforce Shortages and applications for an exemption from Section 19AB.

The spokeswoman said Long also wanted the department to improve the reliability of the guidelines through the development of a proper assessment tool, in effect doing away with a largely discretionary process.

Yet despite the findings, the spokeswoman said the guidelines were only being monitored and a statutory review of Section 19AB was not due until 2009-2010.

Her comments suggest a review has been considered and delayed, given a department spokesman in July said a review of the guidelines would be undertaken within a year "with input from medical professional peak bodies".

Efforts by Weekend Health to obtain a copy of the otherwise secret report have failed. Long is restricted by a confidentiality agreement, and a freedom of information application was rejected on the grounds that a review may yet occur and the information contained in Long's report might undermine the system.

David Dennis, assistant secretary of the department's Workforce Distribution Branch, ruled "to the extent that the document exposes weaknesses or 'loopholes' in the current scheme, disclosure could compromise the integrity and viability of the decision-making process in granting or rejecting exemptions".

Dennis warns of a premature public debate on the issue if the report is released. "This has the potential to disrupt the policy review process, delaying the important reforms which are intended to improve the operation of the legislation; and disclosure could disrupt the strong public interest or faith in the policy-making process leading to the allocation of Australia's medical workforce, particularly in relation to districts of workforce shortage."

But it appears both overseas-trained doctors and Australian-trained doctors have lost faith in the department's short-term response to the doctor shortage.

Surgeon Russell Stitz, chairman-elect of the Committee of Presidents of Medical Colleges, says the District of Workforce Shortage process is "flawed" and hides problems in the system. Stitz says the colleges should be involved in the assessment process to determine why Australian doctors are not filling vacancies and whether, for example, it is due to a lack of support staff or infrastructure.

Andrew Schwartz, from the Australian Doctors Trained Overseas Association, says the Section 19AB guidelines are also discriminatory in that they favour temporary residents over permanent residents.

"Australian Governments all favour temporary residents because they can be more easily restricted to where they work, and kept out of the private market," Schwartz says, again accusing the colleges of market protection.

But Stitz says the colleges acknowledged the doctor shortage and believed there would continue to be scope for overseas-trained professionals to work in Australia.

He says the Section 19AB exemptions should not allow doctors to bypass Australian Medical Council assessments and all overseas-trained doctors should first work under supervision to learn the system, the culture, and where they could seek help.

"What happens with area-of-need specialists -- and you must feel sorry for them -- (is) they get brought in, often very rapidly put through the system, and sent to an area where they have no support and are expected to function in a very difficult environment."

GP shortage in outer suburbs: report - The Australian
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GP shortage in outer suburbs: report
The Australian
Sean Parnell | November 14, 2007

JOHN Howard's bid to upstage Labor with a promise of after-hours medical clinics has been undermined by a federal government report, which reveals suburban GPs are already struggling to meet demand and unable to recruit enough staff.

The confidential report, which also damages Labor's policy, was written by Woolcott Research and delivered to the Government in August.

It advises the incentives it offered general practitioners to work in outer metropolitan areas had only limited success and 68per cent of clinics felt they were still short-staffed.

"These outer metropolitan practices indicated that they were trying very hard to recruit doctors ... by various methods, but often these methods were unsuccessful and ineffective," says the report, obtained by The Australian under Freedom of Information laws.

The Prime Minister has vowed to establish 50 Family Emergency Medical Centres, half of which would be open around the clock.

Health Minister Tony Abbott argues the centres would complement existing clinics, unlike Labor's plan for GP superclinics on predetermined sites, which he claimed would compete with established practices.

But while training more doctors has bipartisan support, GP shortages will continue for several years.

The Woolcott Research report and the decline in bulk-billing indicates policies that congregate GPs at certain sites will only force patients to travel further for treatment.

The report questions the Government's ability to address the maldistribution of doctors in outer metropolitan areas. Three initiatives are used to fill outer metropolitan vacancies: pay Australian-trained doctors a Relocation Incentive Grant of up to $40,000; force GP registrars to undertake a six-month placement in those areas; and offer to fast-track overseas-trained doctors into areas of need.

"Whilst these initiatives have been successful to a degree, with relatively high numbers of doctors relocating to or increasing their hours in outer metropolitan areas as a result of the Relocation Incentive Grant, as well as the placements of registrars for their six-month periods, evidence suggested that they had not been fully subscribed, and that more recent uptake of the RIG in particular was declining," the report finds.

GPs surveyed for the report found the RIG initiative was "viewed more in terms of being a retrospective bonus, and was not necessarily seen to offer sufficient incentive in itself to initiate the relocation of a GP."

Australian General Practice Network chairman Tony Hobbs - who raised concerns over the Coalition's plan for 24-hour services - said after-hours clinics would succeed only if they had enough staff.

Dr Hobbs welcomed any policy that fostered a team environment.

"What we really need, though, and it's a big call, is an over-arching primary healthcare policy in this country," Dr Hobbs said.

"What we've had is a piecemeal policy approach from both sides - something about clinics, something about practice nurses, something about dental care - but it virtually operates in a policy void without long-term, structured planning."

• Doctor Connect on Provider Number Restrictions for OTDs
  
• Health Insurance Act 1973 Section 19AB
  
• Student Doctor Forums (US) Discussion Thread
  
• Dept of Health & Ageing - Medicare provider number eligibility (section 19AA) - Temporary residents
  
• Dept of Health & Ageing - Medicare provider number eligibility (section 19AB) - OTDs
  
• GP Registrars Australia Website on the 10 Year Moratorium
  
• Tropical Medicine Training Website (source of image below)

Clinicians Speak Out

I was recently alerted by Dr Clare Skinner (who features in this article in the AFR) as to the existence of this website, Clinicians Speak Out. To be honest, I am not 100% certain what the purpose of the website is, as it is set up like a blog, but seems to act a little like a noticeboard and a discussion forum in one. Nevertheless, the premise behind the organisation running it is straightforward - public hospitals need to be run with a clear vision and purpose. Underlying issues need to be defined and addressed, and covering up one crisis after another does not solve these issues. Attention needs to be paid to long-term planning, not short term politics.

Kudos to those brave health professionals who are willing to speak out and put their names to their concerns about the public health system. Bravo to you, and may you have a positive influence on the administration of public health. I most certainly do not have enough courage to shelve my anonymity at this time.

While the predominant focus is on public hospitals in the Sydney area (no doubt all the controversy about RNSH has brought this to the forefront, as well as the basic fact that the current NSW Health system is one of the most rundown, bureaucratic, paperwork-driven, responsibility-shedding and accountability-avoiding administrations I have every had the sad privilege of working in), every other public hospital system in Australia deserves the same attention.

So congratulations, doctors, nurses, and other health professionals at Clinicians Speak Out, may you continue to fight the good fight. I am sure that when you have some content worth reading, medical web-surfers will flock to you... in the meantime, I'll just try to boost your pageload stats because I know how good it feels. (smile)

Medical Students are not GPs!

Will they never learn? Kevin Rudd announced a commitment to build Family Healthcare Clinics for Defence Force members and their families. That doesn't bother me one little bit. Go for it, Kev.

This statement, however, left me frustrated that both major parties continue to fail to appreciate how the medical workforce works, and illustrates the simplistic concepts that seem to underpin major decision making amongst politicians and high-level government.

He denied it would be difficult to attract staff to the new medical centres, saying Labor would also invest in more medical places at universities to boost medical workforce numbers.

Labor in health bid to retain personnel - The Australian, 13 Nov 2007

Every time the lack of doctors to staff new facilities is raised, the same response is trotted out: recruit more medical students. It sounds good. It doesn't make sense.

John Howard is not innocent of this. I have previously pointed out the problems with the Howard Government's approach to the training of doctors, but this was typical of statements at the time in February 2006:

Prime Minister John Howard's February 10 announcement of a new health package at the Council of Australian Governments (COAG) meeting has drawn both criticism and praise in its addressing of the ongoing shortage of qualified doctors.

At what Prime Minister Howard described as "an unbelievably successful COAG meeting", a package of health reforms were agreed upon by state, territory and federal leaders.

In addressing the shortage of trained doctors COAG announced that there would be 25 per cent more university places made available to train new doctors but that they would be full-fee paying university places. As a part of this, incentives are to be made to increase the number of qualified doctors which includes raising the loans cap for full-fee paying medical students from $50,000 to $80,000.

More Doctors but not via HECS - Epoch Times, Feb 14 2006

Putting aside the qualifications that are always involved in these pronouncements ("money is being provided - but it's up to universities to implement them", "money will be invested into innovative new training schemes", "private sector training will be explored") keep in mind that many of these places will be full-fee paying (i.e. only minimally subsidised by the Government) and that they could well be occupied by overseas candidates (i.e. ones that do not contribute to the Australian Workforce).

The lag time between recruiting a medical student and producing an independently practising doctor is significant: a minimum of 4-6 years before an intern is produced. Such an intern cannot staff a GP clinic. It takes another 4-6 years to do that, assuming that there are enough accredited training positions.

Depending on the specialty, such positions are limited by State Government funding of public hospitals (such as for surgery, medicine, and all of those hospital-based specialties), or by the Federal Government (via Vocationally Registered Provider Numbers for GP Trainees).

Furthermore, Provider Number and Medicare limitations means that unless a doctor completes a training program and achieves specialist recognition (including completion of GP training), they are effectively unable to service patients in the public sector. The 1996 Howard Federal Government hobbled its own ability to fill the need for GPs in its overexuberant attempt to reign in Medicare expenditure (Link 1, Link 2).

Of course, the traditional response is that training numbers are limited by Specialty College intakes, lining the pockets of specialists along the way. In reality, the Colleges go out of their way to accredit as many viable training positions as possible, but such positions can only be worthwhile if there is enough funding to treat patients and maintain throughput.

This is and will continue to be the bottleneck limiting the production of independent medical practitioners. Long-serving readers may recall that I have written about this before and while the terminology is being superceded by SET and PreSET, the basic principles remain the same.



There is a lot of talk about the impending "medical student tsunami". There is no doubt that we are turning out record numbers of medical students. Hospitals are also absorbing record numbers of Interns and RMOs, due to the enforcement of safe working hours, and the desire of these new generations of doctors to have a life outside work. These doctors are typically employed, however, in non-training positions.

Despite the best efforts of specialty colleges to approve more training positions, they are stymied by hospital and Medicare's Vocational Registration infrastructure. New graduates (and governments) are developing an expectation that they will come out of medical school and go straight into a training program, emerging as a specialist in the minimum amount of time possible.

Unless the incoming government realises that they will not be able to adequately staff these GP clinics without stealing GPs from other parts of the medical workforce, or they address all the rate-limiting steps in medical training, then we will continue to see short-sighted, short-term, sound-bite based health policy and workforce planning in Australia. We don't need politicians and political parties that make knee-jerk decisions and can't see beyond the next press conference. Unfortunately, that is all that we have to choose from.

Labor in health bid to retain personnel - The Australian
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Labor in health bid to retain personnel
Patricia Karvelas, Political correspondent | November 13, 2007

THE spouses and children of defence force personnel living in remote areas of Australia will have their medical and dental bills paid under a Labor plan to help retain troops.

Unveiling Labor's defence policy at the Lavarack Barracks in Townsville yesterday, Kevin Rudd committed $33.1 million for 12,000 ADF spouses and children to access free health and dental care at 12 Defence Family Healthcare Clinics.

The first two clinics will be at the Lavarack Barracks, in the marginal Liberal-held seat of Herbert, providing services for about 4000 spouses and children, and the Robertson Barracks in Darwin, which will cover 3650 spouses and children.

"This is the first time free medical and dental services are being extended to the spouses and kids of defence force personnel," Mr Rudd said.

He denied it would be difficult to attract staff to the new medical centres, saying Labor would also invest in more medical places at universities to boost medical workforce numbers.

"This policy ... is an important step forward in providing a better standard of living, a better quality of life to continue to attract people to join the defence force and to stay in the defence force," Mr Rudd said.

In 10 of the clinics, the GP will work half a day, five days a week, with a full-time nurse five days a week. A dentist and dental nurse will work five days a week.

Labor defence spokesman Joel Fitzgibbon said the health plan could be rolled out more broadly if it was successful.

"This is very much a retention initiative designed to put something on the kitchen table as defence families are considering whether to take an offer outside the ADF or stay within the ADF," he said.

Mr Rudd said that in recent years the structure of the defence force had been "torn in multiple directions".

"There had been an absence of clarity of strategic purpose, including asking our force structure to be able to maintain simultaneously hot operations in the theatres far from Australia as well as other operations near to Australia in our own immediate sphere of strategic importance here in the Southwest Pacific and Southeast Asia."

Mr Rudd said the ADF needed direction on what was expected of it in the future.

Labor was committed to all current defence projects but would ensure a new defence white paper returned discipline and strategic coherence to the Defence Capability Plan.

He said federal Labor would ensure defence was adequately funded through a commitment to at least 3 per cent real growth in spending each year.

Labor would also commission the defence white paper if it won government, with Mr Rudd asserting that defence procurement under the Howard Government had become a "rolling scandal".

"We are determined in Government to ensure that we've got the processes in place to make sure there is rational long-term planning for our equipment requirements ... which is in turn consistent with a strategic doctrine laid down in the white paper," he said.

"When you look at the long-term force structure, quite apart from immediate operations here in our own region and war-fighting operations currently occurring in various parts of the Middle East, it's very important that clarity is achieved in a new defence white paper, and that the full structure evolves from that."

More Doctors but not via HECS - Epoch Times
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More Doctors but not via HECS
By Sandra Keaton, Epoch Times, Australia Staff | February 14, 2006

Prime Minister John Howard's February 10 announcement of a new health package at the Council of Australian Governments (COAG) meeting has drawn both criticism and praise in its addressing of the ongoing shortage of qualified doctors.

At what Prime Minister Howard described as "an unbelievably successful COAG meeting", a package of health reforms were agreed upon by state, territory and federal leaders.

In addressing the shortage of trained doctors COAG announced that there would be 25 per cent more university places made available to train new doctors but that they would be full-fee paying university places. As a part of this, incentives are to be made to increase the number of qualified doctors which includes raising the loans cap for full-fee paying medical students from $50,000 to $80,000.

The Australian Industry Group (Ai Group) has said that it is confident these reforms will help assist the skills shortage currently facing the nation.

"COAG has taken important steps in helping the alleviation of skill shortages by agreeing to this raft of reforms," Ai Group chief Heather Ridout said.

Queensland Premier Peter Beattie is "delighted", as he says his state's health system will benefit – he has been lobbying for more than 300 new doctor training positions in his state.

Meanwhile Australian Medical Association President Dr Mukesh Haikerwal told the ABC that the increase in university positions will help the current shortage of Doctors. He said that it is important that enough doctors are trained but he said for that to be on a fee-paying basis is against the principles of university training and the principles of equality of access in education.

Dr Haikerwal foresees medical degrees costing students as much as $250,000.

"You know, you could have an awful lot of well-qualified people that could do medicine and do it well, having to give those places up because they can't afford this sort of money. If government is serious about getting doctors into the system and is serious about training doctors, then they need to pay for those places under the HECS system as they currently do," said Dr Haikerwal.

Doctors Reform Society President Tim Woodruff was also critical of the proposals. He said the full fee-paying medical student places were offered "to produce doctors who aren't good enough to qualify for HECS funded places".

Australian Vice Chancellors Committee CEO John Mullarvey, says he would have preferred the places to have been fully-funded by the Government.

Opposition spokeswoman Jenny Macklin saying that only government-funded university places would have helped.

"At the University of New South Wales, a medical degree costs $216,000. That leaves a huge gap for students to have to find," she said.

"We want to make sure that our doctors get there on merit not on how much their parents have got in the bank."

The Opposition also claims that Australia's university sector is being "Americanised".

The commonwealth will contribute $666 million to the health plan while another $479 million will come from the states and territories.

With AAP

Pay Them, and They Will Come

I came across this article in the Financial Review a few weeks ago. Unfortunately it is not online, so I have had to transcribe it manually. It raises a lot of issues - the declining status of doctors in our society, the hotch-potch of remuneration packages needed to fill gaps in medical staffing due to poor workforce planning, the loss of job satisfaction and thus the reducing amount of dedication to the job amongst new doctors.

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”.

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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

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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

By the way, I can't vouch for the accuracy of the figures given at the end of this article.

I'm Moving to Australia!

According to Deborah Powell from the New Zealand Rabid Dogs Resident Doctors' Association, Australian doctors are paid well above that of New Zealand doctors.

Apart from the fact that New Zealand doctors have working conditions and education allowances that doctors in Australia regularly salivate over, have no need to worry about medical indemnity insurance, work with nursing staff who in general are far more co-operative than Australian nurses, and otherwise live in a beautifully scenic vista, they have clearly drawn the short straw.

I don't know where this job in Australia where an intern is paid $75 an hour is, but I'm moving there once I find out!

Hospital crisis looms
By STEPHEN FORBES - Western Leader | Tuesday, 23 October 2007

An ongoing shortage of junior doctors is a threat to the delivery of services at Waitakere Hospital.

That's the message from the New Zealand Resident Doctors Association.

Spokeswoman Deborah Powell says too many of country's medical students are leaving our shores as soon as they graduate.

"This year we've lost 20 to 30 graduate doctors straight to Australia," she says.

"They aren't even starting practice here.

"There's no point producing them if they don't start to practice here.

"We can't continue to deliver services if we don't have the doctors to do it."

Waitakere Hospital falls under the jurisdiction of the Waitemata District Health Board where the vacancy rate for junior doctors is 34 percent.

Mrs Powell says remuneration is a factor, with the health boards offering a 3.3 percent pay rise over the next year.

She says that is not enough to attract young doctors.

"We're getting to the point where there won't be a doctor available to see you when you need one."

Mrs Powell says international recruitment is not the answer because New Zealand's pay rates are too low to compete.

She says resident doctors start on $23 an hour here, compared to $75 an hour in Australia.

"What we have to do is retain our own doctors."

Rachel Haggerty, the health board general manager of adult health services, says the problem is nationwide.

She says Waitemata is working closely with the Auckland district and Counties Manukau health boards to address the issue and reduce the workloads now faced by junior doctors.

"The problems we are facing are no different than any other hospitals around the country," Ms Haggerty says.