Hospitals must change to staunch flow of staff

October 2005

Australian Breaking News Headlines & World News Online | SMH.com.au

THE rising use of casual doctors reflects the workforce shortage facing the health system, with chronic vacancies across the system.

The public has been slow to recognise that this lack of medical, nursing and allied health staff is behind the so-called hospital bed crisis, poignantly illustrated in a recent episode of the ABC TV drama MDA in which Bill "Happy" Henderson, suffering from chest pain, wanders through wards full of empty beds while waiting to be seen by an unsupervised intern.

The shortage is both absolute and relative: we do not train enough doctors and, once trained, doctors are not working in areas of greatest need.

Demand for hospital services is rising. As the population ages, the burden of chronic disease grows. The public expects 24-hour, immediate high-level care. Lack of timely access to general practitioners and aged-care services diverts patients to hospital emergency departments. The allocation of doctors and infrastructure to outer-metropolitan and rural areas has lagged behind the demographic shift. Overlaying this, the threat of litigation looms large, with "defensive medicine", in which simple problems are extensively investigated, becoming the clinical standard.

The medical workforce has also changed. Postgraduate medical programs introduced in the mid-1990s mean that graduates are older and are likely to have family commitments when they begin internships. Research by the Australian Medical Workforce Advisory Committee shows doctors are seeking flexible work options and are unwilling to work the long hours and involuntary secondments expected in the past.

Medical graduates from the HECS generation have high levels of debt and baulk at high costs associated with specialist training. Most importantly, the present crop of junior doctors has more options than ever before.

Casual locum work is a flexible and well-paid alternative to permanent hospital employment. Unlike earlier generations, today's junior doctors are aware of their rights and are willing to vote with their feet.

Is any doctor better than no doctor at all? Smaller hospitals rely heavily on locum staff, who have variable skills and experience and are not subject to credentialling and performance review mechanisms applied to regular hospital employees. A substantial proportion are recent medical graduates choosing to forgo specialist training for the flexible working hours and generous remuneration offered by casual work.

The challenge is attracting them back into the mainstream workforce, rather than forcing them out of medical practice.

The core here is changing the culture of hospital medicine. Despite improvements in clinical and organisational technology, work and training practices have changed very little in the past 50 years. The apprenticeship model fails because junior doctors are too busy doing paperwork to be involved in more complex clinical assessment and decision-making. The clinical hierarchy is firmly entrenched, creating a communication barrier between junior doctors, patients, nurses, allied health professionals and senior medical staff. Specialist training programs are restrictive and trainees (average age 32.5 years) have little control over their working lives. A culture of blame and embarrassment still exists when dealing with adverse patient outcomes and medical errors.

Low morale in public hospitals must also be addressed. Clinicians at the coalface bear the brunt of "system issues" such as waiting lists and bed shortages yet feel they have no power to address the problems. The goals of administrators and clinicians are disconnected, with key performance indicators such as length of stay driving patient flow, often at the expense of patient care. Patients and the media are quick to criticise following recent high-profile hospital incidents.

Public hospital clinicians work long hours, often in extreme circumstances. We need to work out how to better recognise their efforts and make them feel valued before more of them disappear.

Dr Clare Skinner is a registrar in emergency medicine and the author of the recent Greater Metropolitan Clinical Taskforce report Meeting the Medical Locum Challenge.