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| Journal of the New Zealand Medical Association,
22-November-2002, Vol 115 No 1166
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Time to revisit Ashburton? Junior hospital doctor employment
in New Zealand 1985–2002
Canterbury District Health Board RMO Advisory Committee and
Stephen Child
The death of young Libby Zion in a New York teaching
hospital in 1984 led to a grand jury review of hospital processes in that city.
Although the precise cause of death was never established, the grand
jury’s attention became focussed on the hours worked by junior
doctors.1
Whilst some claimed that the grand jury had confused
professional incompetence with hours worked, it was recognised that change was
necessary.2 A review of sleep deprivation
studies by Asken and Raham had supported the common-sense expectation that
fatigue could impair performance. With few exceptions, behavioural and
psychomotor performances deteriorated with sleep deprivation, and psychological
and emotional indices deteriorated even more.3
At the time of the study, some junior doctors were working up to 60 hours (a
weekend on call) without sleep.
Throughout the world, these long hours were customary. How
did they come about? In 1988, Asch and Parker summarised some of the prevailing
explanations. “Some believe the tradition is maintained by inertia, in a
bow to medicine’s historic foundations. Others believe that it is a rite
of passage that tests residents’ worthiness. Still others claim that the
long hours are essential to proper training – that an understanding of the
evolution of many acute cases can be gained only through the observation of
affected patients over time. Finally, some argue that residents are an elastic
source of physician labour and that extended hours are a concession to the
economic realities of fiscal
temperance.”2 As long as juniors looked
after patients, the senior doctors could devote more time to their private
practice or research, without losing control over their
patients.4
The Libby Zion case catalysed dramatic changes in the
practice of clinical medicine in America and around the world. The magnitude of
its impact has been likened to that of Karen Quinlan’s persistent
vegetative state.5 Controversy persisted with
the legal actions resulting from the case and with the Bell Commission of
Inquiry that followed. The medical system was severely criticised. The State of
New York legislated to limit junior doctors’ working hours and enforce
adequate supervision with defined lines of responsibility. (General Surgery
programme directors refused to comply and were eventually granted an
exemption.5)
As a result of this legislation, the average hours worked by
that State’s junior doctors declined within two years from 105 to fewer
than 80 hours a week. “Work hour limitations and augmented supervisory
requirements changed the patterns of training...with uncertain impacts on the
quality of education and patient care.”5
There was a substantial augmentation in the number of trainees – Internal
Medicine and Paediatric trainees increased by 20–30%, in contrast to
General Surgery where the numbers shrank by
2.5%.5
The actions that became focussed on working hours remain to
this day as the single biggest pressure on hospital services and a powerful
stimulus for change.6,7
Change in New ZealandThe winds of change soon reached New
Zealand – with gale force. In 1985, the so-called M10 determination
changed forever the way in which junior medical officers (RMOs) were employed
and remunerated.8 This change, from an annual
salary with no restriction on hours worked, to salary bands based on hours
worked with penalties for non-compliance, was a response to the general
perception that RMO employment conditions were debilitating and stressful for
junior doctors and potentially dangerous for patients. It must be noted that
whilst some countries used legislation to initiate change, in NZ it largely came
about through employer/employee contract negotiations.
The immediate consequences of changing hours of workWithin a year, RMOs’ working
hours had dropped to an average of 57 a week and only 10% of house surgeons and
13% of registrars were working longer than 72 hours in any one
week.9
The change was costly. Scott-Deloitte Ltd estimated that
those compensatory payments necessitated by M10 added 50.4% to the basic salary
in 1986 and that overall salaries for RMOs in Canterbury were 46% higher than
before the change.10 (That these were high
inflation years accounts for some of the rise.)
The Ashburton WorkshopThere were insufficient staff to
fill the new rosters, and service problems arose when the junior staff were no
longer available to provide so much of the continuity of care, or hitherto high
levels of service. These problems led to a workshop held in Ashburton in
1987,11 convened by Dr George Salmond (Director
General of Health) and led by Professor Geoff Brinkman. The workshop identified
the following problems:
The immediate problems for hospitals were:
The positive changes from M10 for RMOs were acknowledged.
Previous practice was considered exploitative and sleep deprivation possibly
harmful to patients and doctors. It was believed that ultimately M10 would be
the impetus for comprehensive change in the deployment of medical
practitioners.
The workshop explored the pros and cons of options for the
future. These options were:
The long-term consequencesIncreased
staff demands In the intervening seventeen years, the “do
nothing” scenario has prevailed to the extent that the “vast”
increase in RMO numbers by 1987 pales in comparison with the increases that have
followed (Figure 1). Factors other than the conditions of RMO employment have
also increased the demands on all staff. These include increased numbers of
admissions to acute hospitals, shorter stays and increased inpatient
acuity.
 Figure 1. Total RMOs (registrars and house surgeons)
employed in Christchurch
Imbalanced staff
ratios The Senior Medical Officer (SMO)/RMO ratio has become inverted.
Whilst the Medical Council and the Clinical Training Agency place increasing
emphasis on the responsibility of SMOs for the supervision and training of
junior staff, there are proportionally fewer of them to undertake these tasks.
This illustrates how attention paid to the hours worked by one group can impair
the effectiveness of others. Some SMOs feel close to the position taken by the
surgeons in New York.
Inflexible
employment Inflexible standard employment contracts for RMOs have been
enforced on services whose functional characteristics are very different. This
can have bizarre consequences. For example, a low-volume, high-acuity, largely
elective service, can sometimes have more doctors than patients. This situation
arises through attempts to attain roster compliance for out-of-hours hospital
cover. The service-specific balances that are critical include:
Systems able to provide care 24 hours a day, seven days a
week, with specific attention to the above particularities, together with
congenial working conditions and good educational systems are complex design
challenges. No single model is likely to suit all environments. Flexible types
of employment will be necessary. For example, in emergency and intensive care
departments, where the doctor–patient relationship is defined by acute
rather than longitudinal needs, shift work makes
sense.2
Inflexible working
conditions The fixation on hours can make it difficult for hospitals to
improve other important working conditions such as:
Loss of service
tradition The tendency to abandon a professional tradition of service,
for an industrial work ethic, seems to be encouraged by employment contracts
based on hours.
Shift of workload
SMOs believe that an “upward
shift”12 of workload has occurred as
continuity of care becomes increasingly provided at the consultant level.
“In the early part of their career they [SMOs] worked long hours to
maintain the service while their seniors had a pleasant lifestyle. Now they work
long hours to maintain the service while their juniors enjoy a pleasant
lifestyle”13 Anecdotes like this may be
no more representative of reality than RMO feedback about seniors who never
teach, but the observation provokes wry smiles.
Employment
conditions There is full employment for RMOs, with the following
conditions of service:
 Figure 2. Christchurch RMO salary bands
Discontinuity of patient
care To comply with these conditions, night and study leave rotators are
required. Since someone else must provide relievers’ day duties, the
discontinuity of patient care is increased. Dr George Dunea eloquently expressed
the frustration experienced by SMOs with the frequent junior staff changes that
result.14
Continuation of the “do nothing” scenario is not sustainableTo argue that continued augmentation
of RMO numbers is the only way forward is to risk augmentation of the
dysfunction that has been summarised above.
However, even if further augmentation is considered
acceptable, is it feasible? As hours of work are reduced worldwide, all
countries are seeking more RMOs. Hitherto, the UK has provided about one third
of our junior staff. Mainly on temporary registration, these young doctors
usually come for overseas experience and return to Britain for specialist
training. However, in the UK an agreement referred to as ‘The New Deal on
Junior Doctors’ Hours’ has been reached between the Health
Departments and the British Medical Association. Eventually, a European
Parliament statute called the ‘Working Time Directive’ (EWTD), will
affect the working conditions of doctors. The New Deal provides premium rates of
pay for junior doctors who work more than 56 hours per week – a change
made in New Zealand in 1985. The ambitious aim in the UK is to attain an average
of 48 hours a week for all doctors in salaried employment by 2009. General
practitioners, who in the UK are independent contractors to the National Health
Service, are responsible for their own and their employees’ working
arrangements.
The New Deal, with its augmentation of RMO numbers may
diminish our source of supply, although doctor dissatisfaction as a result of it
could have the opposite influence.15 Note that
the augmentation argued for in the Scottish
report6 came about years ago in New
Zealand.
Since it takes seven years to produce a new graduate,
increasing the input of students to NZ medical schools is not a short-term
solution. Hospital services may well have developed more effective skill mixes
within that time. Postgraduate training must continue in proportion to the
projected needs of the workforce rather than for the provision of
labour.
A vision for the futureThe issues raised here have received
thoughtful consideration in Scotland. The report to the Minister, ‘Future
Practice: A Review of the Scottish Medical
Workforce’6 has a single conclusion
– one that is equally applicable to New Zealand’s medical workforce:
“The medical workforce in Scotland is under pressure. Service demand is
rising and will continue to rise; the capacity to respond is already limited and
will be further restricted as the Working Time Directive is applied across the
workforce and as practitioners seek and expect less demanding hours of work.
The service will only survive with
change.”
The report has ten key messages, summarised in Table
1.
Table 1. Key messages of the Scottish
report6
ConclusionInternationally, it is increasingly
recognised that the twenty-first-century health delivery vehicle has been driven
by a nineteenth-century staff mix. As long as the gaze of the drivers was firmly
fixed on the rear vision mirror, a crash seemed inevitable.
New Zealand was one of the first countries to provide humane
hours of work for junior doctors, with incomes that are competitive when the
cost of living is taken into account. When the inevitable problems appeared, the
Ashburton Workshop provided for consultation and a range of options about
potential solutions. The similarities between these and the ten key messages
from the recent Scottish report are remarkable. However, a “do
nothing” scenario prevailed and the problems have been
compounded.
Those with hindsight may choose to apportion blame to the
failure to develop the ideas of 1987. A fairer assessment might be that neither
the politicians nor the professionals of that time perceived the challenges
lumbering over the horizon as clearly as did George Salmond and Geoff
Brinkman.
A revisit to Ashburton is long overdue.
Author information:
RMO Advisory Committee, Canterbury District Health Board; Stephen Child,
Director of Clinical Training, Auckland District Health Board. Members of the
Committee: Nanette Ainge, Professional Development Coordinator, Department of
Nursing; Michael Ardagh, Emergency Medicine Specialist; Michael Jamieson, Human
Resources Manager; Kelvin Lynn, Chief of Medicine and Committee Chairman; John
Thwaites, Physician and Director Medical Education and Training Unit; Jim Magee,
General Manager, Christchurch Hospital; John Morton, Medical Adviser, RMO Unit;
Karen Schaab, Manager, RMO Unit; Andrew Vincent, Orthopaedic Surgeon.
Correspondence: John
Morton, RMO Unit, Christchurch Hospital, Private Bag 4710, Christchurch. Fax:
(03) 364 0897; email: john.morton@cdhb.govt.nz
References:
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