Croakey has previously reported on the crisis engulfing senior medical staff in Queensland. As the turmoil continues, the knock on affect of a potential mass exodus of medical staff on junior doctors and medical training is coming into focus. Many thanks to Dr Gemma Robertson for this personal perspective on the loss of senior doctors in Queensland.
I remember my first day as a junior doctor vividly. That first shift is, all at once, terrifying, exhilarating, and mortifying. I spent it as an intern in the emergency department of the Royal Brisbane and Women’s Hospital: terrified, as I approached my first patient, a young man with severe inflammatory bowel disease, hoping he wouldn’t see me as the fraud I surely was; exhilarated, when my patient with kidney stones wrote a letter to the hospital thanking me and the nursing staff for the care he received; mortified, when the wife of a patient with pneumonia congratulated me on my pregnancy. I never did wear that dress again.
Working life as a doctor, while challenging, frustrating and tiring, is immensely rewarding. What becomes apparent early on, however, is just how far you have to go. As you progress through medical school, graduation looms in the distance like Everest. At the peak, when you don gown and cap and grasp hands aloft, you smile at each other as I’m sure Hilary once smiled at Sherpa Tenzing.
Internship teaches you that you just barely made it to base camp.
In the five years since that first humbling day I’ve managed not only to claw my way into my third year of specialty training, but to uproot myself 1358km north. I love it here in Townsville, and I can confidently say I’ve received some of the best training in Australia since moving here, but the decision to move away from my friends and family was daunting.
Despite my reservations the choice was straightforward: if I stayed in Brisbane, I would be unable to train in my chosen specialty. It’s a choice that hundreds, if not thousands, of junior doctors make each year. Relocation is one of the many dues you pay as a trainee. There are strained relationships, missed birthdays, long nights of study after work, untold hours of lost sleep. It’s not martyrdom. It’s repayment for the state’s investment: the patients, who have watched you fumble and learn, pretending that clumsily inserted cannula doesn’t hurt; the senior doctors, who spend thousands of hours, many of them unpaid, teaching, mentoring and cleaning up after you; and yes, even the health system, the heaving beast that provides the infrastructure to make it all possible.
Junior doctors in the public hospital system know from quite early on that work stability is not assured. We apply for new jobs every 12 months, and for those competing for highly sought after specialty positions, it may be years before acceptance into a training program is achieved. Once there, we rely on our bosses to train us, to mentor us; not only to deliver safe and appropriate care to our patients, but to also fulfil the strict requirements of our training colleges.
In the past two months the dispute between Queensland Health and the state’s senior doctors over the introduction of individual contracts has descended into acrimony. Briefly, the government has, in part, justified the introduction of individual contracts in order to address the findings of the Auditor-General’s report into the Right of Private Practice (RoPP) scheme. The report concluded that, while “the scheme appears to have been successful” with respect to “salary supplementation to achieve the … objective of recruitment and retention” it, cost “…at least $804.24 million over the past decade”. A subsequent report into senior medical officer (SMO) conduct, tabled in February, targeted 88 SMOs who were thought to be at high risk of abusing the private practice scheme. The report concluded that “… allegations of improper billing were able to be substantiated [against] eight SMOs” and that “seven of the 88 SMOs …investigated appeared not to be at work during their rostered hours…”.
Senior doctors, of which there are over 3000 employed by Queensland Health, have raised concerns that the terms of these contracts do away with conditions contained within the current Medical Officers’ Certified Agreement 3 (MOCA3), a contract valid until July 2015. The concerns about the contracts as they were originally proposed included the ability of the health service to: move a doctor’s place of work within the service; change rostered hours to include shift work and extended hours; and introduce key performance indicators that could be changed without agreement from the doctor, despite being tied to remuneration. Other concerns included legislative changes rescinding the right to access the Queensland Industrial Relations Commission for dispute resolution and appeals against termination, and allowing the Queensland Health Director General to issue directives which prevail over the signed contracts.
Since then, the Government has attempted to address the concerns of doctors, including issuing an addendum to the original contracts and proposing a repeal of the legislative changes to the Hospital and Health Board Act. Despite this, reservations regarding the employment provisions remain. The day after the addendum was released, a meeting of over 1000 doctors unanimously decided to reject the contracts and the addendum. The doctors’ unions, the Australian Salaried Medical Officers’ Federation (ASMOF) and Together, have since been coordinating a mass resignation strategy for those doctors who feel they cannot enter into the contracts as they stand.
In the two weeks since that meeting many senior doctors have publicly resigned, with others quietly ending their contracts or submitting paperwork to the unions for use in the mass resignation strategy. These resignations will profoundly affect the training of junior doctors. Despite this, I support any senior doctor who feels they cannot sign this contract in its current form. And I’m not alone. On March 27, a meeting of over 350 junior doctors across Queensland unanimously passed a resolution stating that “Queensland junior doctors support senior doctors who choose not to sign the proposed senior doctor contracts”. The conditions they are fighting for are the conditions that we will one day be working under.
Junior doctors are a fairly disparate group of young professionals, but we are bound by our varying requirements for senior supervision. As an intern, fresh out of medical school, you sit at the very bottom of the pecking order. Every day is a learning experience, and that learning is accredited to ensure you receive an appropriately broad level of training, provided by senior doctors, in your first year. Following internship, you become a resident medical officer (RMO), a two or three year junior doctor purgatory of sorts, where the knowledge and skills required to advance in your career are acquired. Progression to registrar level requires acceptance into a specialty training college, such as the Royal Australasian College of Surgeons, a process that variably necessitates extracurricular research, glowing collegiate references, entrance examinations, and multiple interviews. Once accepted, the real work begins, and you develop a relationship with your supervisors bordering on the pathologically dependent. Life as a registrar is the first opportunity for many junior doctors to undertake a role that is less about the routine of ordering blood tests and x-rays, and more about the holistic management of the patient sitting before you. It is now your decision whether that patient needs surgery, your decision how to treat the patient having a seizure in front of you, your decision what dose of propofol to administer. It’s harrowing stuff, but it’s manageable because behind you, twenty-four hours a day, is a senior doctor to give advice. To encourage, to teach, and to step in when you’re out of your depth. It’s because of senior doctors that junior doctors can even exist, because from the very first day you walk through the doors of medical school, to the day you receive fellowship with your specialty training college, they are guiding you down a path where mistakes can mean the loss of life.
Come April 30, there is every possibility that Queensland Health will experience the most dramatic loss of senior medical staff in its existence. The implications are grave, but for a government that has assured the public it will “… recruit people from interstate or overseas”, I fear they may be missing the bigger picture: without senior doctors, junior doctors cannot exist. Strict supervision and accreditation requirements dictate the number and qualifications of senior doctors who oversee junior doctor training. If our seniors leave, we may have no choice but to leave with them. Without supervision, we cannot deliver safe and appropriate care to our patients. Without supervision, the training positions we fought tooth and nail for will evaporate.
Almost every Australian specialty training college has written to the Health Minister, the Hon Lawrence Springborg MP, outlining in the strongest possible language their concerns for junior doctor training in this state. I wish to add my voice to the fray.
Minister Springborg, please come back to the negotiating table. The future of healthcare in this state is counting on you.
Dr Robertson is a microbiology registrar at The Townsville Hospital and an AMAQ member. Her views are her own and should not be interpreted to represent those of Queensland Health.