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AMSA Conference Brisbane - 10 July 2003 - AMA President Dr Bill Glasson - Bonded Doctors - Shaken and Stirred

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BONDED DOCTORS - SHAKEN AND STIRRED

Good afternoon Australia's doctors of the future.

These are indeed interesting and challenging times to be pursuing a career in medicine.

In times past, your family would be promoting and revelling in your quest to be a doctor with the support of the community and the government.

You would be filled with optimism and the knowledge that at the end of your study and training, you would have the freedom to practice the specialty of your choice in the place of your choice.

Today there are more hurdles than helpers. Today your freedom of choice is being eroded.

The Government not only wants to make you all salaried employees of the Government - or de facto employees - they want to tell you how to practice and where to practice.

We have got to stop this intervention. We have got to stop this control.

As the proverb goes, you can take a horse to water, but you can't make him drink.

This whole matter of Government intervention is wrapped up neatly in the issue of unfunded bonded medical places - the most inept, ill-conceived and ill-directed piece of health policy in recent memory.

Really. Who are they kidding? If they seriously think this is going to solve Australia's medical workforce shortage they are dreamin'. I mean, they can't get the horse to water, because the horse has already bolted.

You cannot train a medical workforce overnight. Everybody in this room knows that. But the Government doesn't.

Forcing doctors to practice where some bureaucrat in Canberra thinks is a good idea is a bad idea.

They have got it all so horribly wrong.

The AMA - with AMSA - will go the full fifteen rounds on this one. The towel will not be thrown in - not by us anyway.

If we can't get the policy dumped, we'll work to at least get it fair, equitable...workable. Acceptable. We can't have medical workforce policies that are built on social engineering.

We will continue to point out the flaws in their thinking on this.

If they don't change, we will be faced with a situation foretold by H.G. Wells: 'human history becomes more and more a race between education and catastrophe'.

Our Government will have introduced a medical training environment that will worsen the situation they thought they had set out to repair. The medical workforce will have further diminished.

I will talk more on bonding shortly. I just needed to let off a bit of steam first. This issue gets under my skin.

It is a priority for the AMA to ensure that our medical students can look forward to rewarding and satisfying careers in our great profession.

That is why the AMA and AMSA work together as a team.

The AMA knows the challenges, excitement and rewards of medical school - and those times when none of it seems to go right - and is happy to welcome medical students into the fold.

You are our future as well as the profession's future. Your advocacy starts now.

That is why the AMA provides financial support for AMSA and why the AMSA President - Nick Brown - is on the AMA Federal Council, our governing body.

AMSA also has a seat on the AMA Council of Doctors-in-Training, our national peak body for all doctors from Interns up to the time you become a Fellow of a medical College.

Why is that important? Because as young people on or near the threshold of a professional career in medicine, there are many things you will gain as members of Australia's peak organisation for medical practitioners.

The AMA has a loud and respected voice nationally in health policy and funding, public health issues and placing the interests of doctors and their patients firmly on the agenda of governments and legislators.

In most states, the AMA or associated organisations provide industrial representation for hospital doctors and negotiate their salaries and employment conditions so that there is a full range of integrated services.

The more young doctors join their professional association, the more we can all be assured of having a strong and vibrant organisation that works for all of us - works for all of us on issues such as bonded medical places.

Yes, I've got my breath back and I'm ready to have another spray on bonding - this time ore scientifically.

As you are now no doubt aware, the AMA opposes the Government's proposal to make the additional 234 publicly funded medical school places subject to a bond without any balancing benefit such as a scholarship or other financial aid.

It is also important to make sure that new medical school places are accompanied by infrastructure changes so that the existing expertise and resources are not simply spread more thinly across a larger number of medical students and new medical schools.

Working with AMSA, we have expressed our views strongly to federal politicians of all parties in Canberra and in our submission to the Senate Inquiry into Medicare. We will continue to do so.

Bonding HECS based medical student places represents a fundamental change to the higher education system.

Unlike past bonding arrangements in other professions or the bonded places offered by the military, bonded medical students will not receive a scholarship or other benefit. They will have to pay HECS and they will be bonded to return of service obligations that commence many years after completing university.

The proposal does not offer assistance to the student to meet the costs of vocational training in a specialty or general practice after graduation, despite requiring completion of this training before recognising service that discharges the bond.

Programs to attract doctors to areas of need should be incentive driven. More carrot and less stick would be more effective in addressing doctor shortages in specific areas - and would be a lot fairer for medical students.

And remember - people your age will be asked to tie themselves to a life situation a decade down the track.

No thought for personal relationships. What if your future spouse or partner has other priorities? What if you have kids? What if there is an opportunity to work or study overseas?

Pay out the bond, they say. Sure.

As I said earlier, we want this system abolished. If they won't abolish it, change it.

At the very least, the following changes would be required to make the bonding proposal in any way reasonable or acceptable:

  • make the bonded positions "HECS free";
  • shorten the bond period to four years;
  • start the return of service period after the Intern year, when doctors attain full registration as a medical practitioner;
  • amend the Health Insurance Act to guarantee that there will be no Medicare ban for breaching contracts. This provision applies to rural bonded scholars; the AMA opposes it for anyone.
  • place a cap of 234 on bonded medical school places and progressively convert the bonded positions to regular HECS places;
  • allow sufficient flexibility in the bond contract to accommodate emergent and unforeseen personal needs of the student.

I urge you to take the time to fill out the joint AMA/AMSA survey on this issue.

The information will be used in both AMA and AMSA oral submissions to the Senate Inquiry...and in all our lobbying efforts to right this wrong.

In the meantime, the AMA will continue its work in other areas to help you throughout your medical careers.

One area is providing a safer and more comfortable work environment.

Safe Hours

You've probably already observed that junior hospital doctors work long hours, often in patterns that make their working hours unsafe.

There is a tradition and culture of long working hours for doctors which flows through to all elements of the medical profession.

There is an expectation in hospitals and in medical Colleges that doctors will work long hours and that's just the way it is.

Rosters and on call arrangements tend to reflect this expectation. The temporary nature of hospital assignments for junior doctors helps to lock it in.

The AMA believes it's time to change this culture of unsafe working hours.

The medical graduates of today have different expectations and value a healthy balance between their work and personal lives.

The volume of knowledge required of young doctors is enormous and growing.

The range and complexity of clinical interventions and shorter hospital stays for patients add extra pressures which need to be reflected in the education, training and working arrangements of junior doctors.

In consultation with stakeholders, including hospitals and Colleges, the AMA produced in 1999 the National Code of Practice - Hours of Work, Shiftwork and Rostering for Hospital Doctors.

The Code now stands as the accepted standard for safe working hours for hospital doctors in Australia.

A cultural change of this kind takes time, but the issue of safe hours is now on the national agenda and progress is being made. For example, the AMA will soon launch a best practice rostering kit to educate hospital staff in safe rostering.

Also, the Australian Council for Safety and Quality in Healthcare has established a Safe Staffing Task Force in recognition of the link between safe hours and the quality of patient care.

Another major change program affecting young doctors is the AMA's Work Life Flexibility project.

Again, this national project aims to respond to changing needs and standards by freeing up the attitudes and practices that impose rigidity on medical education, training and work arrangements.

Research commissioned by the AMA confirmed that medical students and young doctors place a high value on a well-rounded life in which a professional medical career is an important, but not the only, part.

We have worked with stakeholders in the profession and the hospital sector to demonstrate that greater flexibility in medical education, training and work arrangements is the way of the future.

Colleges and hospitals that are unable to adapt their systems to accommodate part-timers, career breaks and the personal caring responsibilities of doctors will find themselves unable to attract or retain doctors in a competitive environment.

The AMA held a national Work Life Flexibility forum in Melbourne in November last year and is participating in a range of activities to promote flexibility, including development of a web-based resource network and tools to help managers implement flexible practices and to assess progress.

We will continue to promote flexible practices in the interests of doctors, their families and their patients.

You will all know that, in order to enter private medical practice, you will need an unrestricted Medicare provider number so your patients can claim Medicare rebates for your services.

To get a provider number, you will have to complete a vocational training program and gain a Fellowship of one of the medical Colleges.

So it is important that vocational training options be available and that they have fair and open selection, adequate educational support, trainee input into decisions affecting them, flexibility to accommodate individual needs, and reasonable costs.

All of these things are central to the work of the AMA Council of Doctors-in-Training.

The AMACDT has several representatives on the Medical Training Review Panel, established by Parliament to monitor and review the operation of the 1996 legislation that restricts Medicare provider numbers to holders of College fellowships.

The AMA campaigned against the provider number restrictions and lobbied hard to retain the sunset clause in the legislation that would have caused it to lapse in 2002.

We didn't win those battles, but that was not for want of trying.

The AMA has influenced the production of selection guidelines for entry into vocational training, national guidelines for junior medical officers in postgraduate years 1 and 2, numbers and definitions of vocational training posts, and continuing biennial reviews of the operation of the provider number restrictions and training of junior doctors.

We campaigned successfully against the use of psychometric tests for entry into GP training and are working to ensure that all Colleges use fair, open and valid selection processes.

We have consistently pursued opportunities for GP experience and other out-of-hospital practice prior to committing to a vocational training program.

The AMACDT, backed by the Federal Council and Executive, has pursued trainee concerns with a number of individual Colleges and with the Committee of Presidents of Medical Colleges.

We have published information on College training costs, questioned the level and inconsistency of training costs, and pushed for trainee representation on Colleges' decision-making bodies.

All of this work does make a difference. But there is always more to do.

Everyone knows there is a national shortage of doctors in Australia.

The federal Government finally acknowledged this late last year, but only after the AMA commissioned Access Economics to produce a report on the GP workforce demonstrating that, whatever way you looked at it, there was a shortage of GPs - and not just a maldistribution.

The AMA continues its input to the Australian Medical Workforce Advisory Committee, which advises governments on medical workforce issues and influences decisions on the numbers of student places, vocational training places and overseas trained doctors (OTDs).

The AMA analyses government workforce initiatives such as the More Doctors for Outer Metropolitan Areas and provides feedback to government based on consultation with members.

We have established a bilateral Workforce Liaison Committee with the federal Department of Health and Ageing and use this mechanism to raise and debate issues around the medical workforce, including evaluation of various government initiatives to address specific workforce shortages.

The AMA is strongly opposed to geographic provider numbers and any other form of conscription of doctors to work in particular areas.

That is why we have taken our strong position on bonding. What goes around comes around. I'll end where I started.

As you all enter the exciting and challenging world of medicine, I wish you well.

One thing you can be sure of - the AMA will be fighting for what is best for doctors, their patients and the health system.

I'll leave you with a thought about learning and scholarship - about being a student.

I think the words of the philosopher-poet, Ralph Waldo Emerson, from 1849 still hold true - especially when bonded medical places hover menacingly over the future of our profession:

"Free should the scholar be - free and brave. Free even to the definition of freedom, 'without any hindrance that does not arise out of his own constitution'."

Thank you. I'm happy to take questions.

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