The reason so many young doctors (and a few of us oldies) are willing to endure such terms in exchange for extra money is because the difference in money is substantial. In case anyone thinks it is not an issue primary of pay, let me point out that Waitakere hospital has all but closed its ED in the evenings because they cannot staff it, yet there is a 24 hour Whitecross A&M just down the road that appears to be managing to staff the place just fine, despite the current shortage of locum doctors. The only difference is about a 60 dollar an hour difference in pay scales.

In addition, there is not much of a disincentive for junior doctors to locum. As the report points out, the junior doctors in hospital positions, work long, dangerous hours, get little continuing medical education and even less in-house training. So, apart from sick leave provision, hardly a big concern for fit, healthy young doctors, the DHBs are offering nothing except markedly lower pay.

And then they wonder why junior doctors leave and become full-time locums.

The report  then goes on to suggest a single employment agency for junior doctors, essentially suggesting that the clinical training agency becomes a provider of doctors instead of merely overseeing their on-the-job training. The report goes on to say:

The commission is critical of health boards for too often giving precedence to work over the training needs of RMOs (house officers and registrars).

“For RMOs to be treated primarily as an in-training workforce requires changes to a system that relies on them as a frontline workforce.”

I’m dubious that this will solve the problem. The main reason why junior doctors don’t get the training they need is that there are not enough of them. You could devolve some of the responsibilities of the junior doctors on to the nursing staff, but there are not enough of them either. A major part of the reason why there are not enough doctors is that their pay scales are inadequate. Having a single employment agency is not going to help. And using the single agency to prevent the use of junior locums will find all those junior locum doctors leaving the country in droves, swiftly followed by the collapse of our health system.

We doctors like to obfuscate about money. We like to suggest that we are motivated by other things. While that is partly true, the reality is that remuneration is by far the most important thing to most of us. If you bumped up the hospital doctor’s salary by 30%, you would solve your doctor shortage within a year or two and the locum industry would mostly evaporate. And with sufficient doctors, revitalising the training scheme would be easy, even for the DHBs. It doesn’t need yet another monolithic bureaucracy for junior doctors, it just needs the application of dollars.

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3. Night Shift

It is clearly not optimal to have a junior doctor on, unsupervised, overnight. Not only is this unfair on patients, but also the house surgeon. A serious mistake could not only harm or kill a patient, it could also potentially destroy a doctor’s career. 

You need to understand that most real world medicine (as opposed to all the theoretical stuff learnt at medical school) is learnt through experience. Experiential learning is, essentially, learning by mistakes. A junior doctor relies on his/her senior colleagues to catch his/her errors and correct them. When this feed back mechanism is not available, mistakes are not corrected and can then become compounded. Medical school gives you enough to stop you making huge mistakes, but small mistakes, one on top of the other, eventually form one large one.

Thus the situation of junior doctors alone at night is exactly the opposite of what it should be. Only senior doctors should ever be in this position.

Least you think that smaller hospitals do this because they can’t afford senior doctors, it should be pointed out that money is not the problem here. It would probably cost a hospital like Timaru an extra $200-$300 thousand a year to staff the hospital with seniors at night. I would guess Timaru’s total budget is at least $10 million a year and DHB budget overall is an order of magnitude higher. The additional amount is trivial.

The real problem is that senior doctors don’t want to work nights. Most locums willing to work nights are 2-5 years out of medical school. Doctor’s with families quickly become less and less interested in night shift, despite the better pay rates. Senior non-specialists in their forties and fifties, the safest category for night work of this nature, are basically uninterested in working nights.

Unfortunately for hospitals like Timaru, there is no pressure on senior doctors to work nights. There is plenty of other work for them that does not involve night-work. Any DHB attempting to force it’s seniors into compulsory night work would soon find itself without senior non-specialists. Even ED consultants refuse to do anything beyond being on-call after midnight.

I suspect this problem is essentially unsolvable. The problem can be relieved slightly by insisting on rather more experienced juniors (say three or more years out of med school), but these are in short supply as most have joined training schemes in the teaching hospitals. It is likely that any attempt to use more experienced staff in the smaller hospitals will only exacerbate the severe shortage of experienced staff countrywide, leading to shortages elsewhere.

In the meantime, hospitals will continue to be a dangerous place at night.

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3. Bullying Doctors

“In such an environment it would be common for performance feedback to be misinterpreted as bullying rather than a misguided attempt to improve performance.”

The Auckland District Health Board said last night it had “zero tolerance” of bullying and had processes to ensure all staff were treated with dignity and respect.

Both statements are complete tripe. Intimidating junior doctors neither improves their performance nor does it help them to learn. Doctors and nurses who do this are simply bullies and like to exercise power in their petty domains. Excusing it as a “misguided attempt to improve performance” only encourages the bullying and can hardly be called a policy of ”zero tolerance”.

There is a long-standing, worsening shortage of senior doctors and nurses in New Zealand. Because of this, unacceptable behavior in these people is often excused and the reporting of their misdemeanors is discouraged. After all, a junior doctor has only to tolerate the offending person for a short “run” of three to six months. If things become unbearable, management may swap them into another “run”. They will rarely discipline the senior doctor or nurse.

I know of a surgeon who does not tolerate non-kiwi doctors on his team and persecutes them unmercifully until they complain and are swapped to another “run”. This bullying behavior and racism are condemned by his colleagues, but he has never been held to account. Another surgeon treats all of his junior staff with complete contempt, so much so that he once nearly did not attend a critically ill patient, because the junior doctor was too nervous to insist he come. Had I not stepped in and demanded his immediate attendance, the patient may well have died. The surgeon in question refused to speak to me for the three years I remained at the hospital!

Fortunately, this type of childish behavior is rare. Most senior doctors are at least civil to their junior colleagues and nursing staff, even if they are very demanding. There is no excuse for rudeness, belligerence and intimidation at any time and these attitudes should not be tolerated. Nurses and Junior doctors should be encouraged to complain about misbehavior and management should not be seen to be inert on this matter. If one or two of my senior colleagues are eventually dismissed or retire early (the majority of maladjusted doctors are over sixty) then so be it. New Zealand will be a better place in which to work and we will be one step closer to eliminating the shortage of junior doctors – by creating a more pleasant working environment.

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3. The Union Division

The ASMS consists of specialists and senior non-specialists working in the public sector. These are older doctors who have established families with kids at high school or university. They are paid two to three times as much as their younger colleagues and have paid off their student loans. Many of the specialists augment their income in private practice. They often stay at the same hospital for many years.

The RDA comprises of younger doctors who are either finishing their house surgeon years or studying to become specialists. They have young families and are invariably up to their eyeballs in debt. They move from hospital to hospital, sometimes moving every year.

Just a quick glance at the two profiles should tell you something immediately. The junior doctors are not only far less fixed, but have much more to gain by moving to Australia than their older colleagues. Their salaries will virtually double and often their working conditions will improve. It is therefore no surprise that Deborah Powell has no difficult in persuading them to strike.

Although the ASMS often posture about specialists disappearing to Australia because their conditions are better, this is not really the case (its a very big move for a settled family). It is, in fact, the RDA members who are most likely to move, which is why the shortage of hospital doctors is right where you expect it to be – between the end of the compulsory training years and the end of the specialist training years. This is precisely the area that hospitals battle to fill.

Although I am not a fan of doctor’s strikes, I see why they happen. And unless the government realistically address the gap in salaries and working conditions between here and Australia, they will continue to strike.

Hat tip: Kiwiblog

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