AMA President, Dr Kerryn Phelps to the Dr Michael Rice Symposium, Adelaide

There would be few people who have seen more of this change - or been a part of it - than Michael Rice.

In a long career, he has given so much to patients in the South Australian public hospital system, particularly children with cancer and their families.

I can't offer you Dr Rice's personal insights. Mine will be a more clinical and medicopolitical overview.

Prior to the introduction of Medibank in 1974 and the Medicare system in 1984, 80 per cent and 65 per cent respectively of the Australian population held private health insurance.

In return for the use of public hospital facilities, private medical practitioners provided services to non-insured public patients for free under "honorary medical officer" arrangements in most States.

At the time there were not as many full time employed senior doctors in the public hospital system as there are now.

The trend since the early 1980s - with the introduction of the Medicare scheme of universal health insurance - has, until the last couple of years, been for a dramatic and consistent decline in the proportion of privately insured patients.

We have seen it drop to as low as 30 per cent of the population in 1998.

This trend precipitated a significant expansion in the public hospital sector to respond to the increased demands for public hospital services.

For visiting medical practitioners, the period saw a significant growth in the proportion of public patients formerly treated for free.

This prompted the development of common service contracts for visiting doctors and issues over payment.

Current Responsibilities

The ensuing years have seen a significant evolution of the relationship between the medical profession and public hospitals.

The number and proportion of full time salaried medical positions in hospitals has grown by 75% in the twelve years to 1999 to over 16,458 doctors.

State governments, which have major obligations under the Medicare agreements, require doctors to be much more closely integrated in the day to day operations and functioning of the public hospitals.

The Medicare principles oblige States to ensure patients:

have the choice to receive public hospital services free of charge

that they have access on the basis of clinical need

that services are available to people regardless of their geographical location

that information on available services is accessible to patients

and that improvements in efficiency, effectiveness and quality of services are continuously sought.

All this in a hospital system that is chronically underfunded, always in the media spotlight, and now required to cater to the whole Australian population irrespective of their individual means.

For doctors this has meant an even greater focus on:

teaching of undergraduate and postgraduate students

research

planning of clinical services

administration

clinical audits

clinical practice protocols

benchmarking against international best practice

quality programs

and a range of other managerial responsibilities.

Hospitals are among the most complex organisations known to man. The logistics are mind-boggling.

Hospitals involve the delivery of everything from specialist dietetic meal services, hotel services, running complex management information, computing and medico-technological systems, laundries, sterilisation and infection control systems…and, of course, medical, nursing and the full range of allied health services.

There is now much greater focus on the regulation of hospital systems.

The requirements for accreditation of facilities have become more onerous as the accreditation bodies, such as the ACHS, have progressively raised their standards.

Clinical departments are assessed more rigorously by prevocational and vocational training bodies for their suitability to undertake training of junior doctors - in terms of the supervision available from senior doctors and, more recently, the suitability of the working environment,

Clinical incident reporting systems have been developed and a whole new quality and safety movement has evolved - with the establishment of Quality and Safety Councils at State and Federal level rolling out a range of initiatives.

These include:

new emerging systems for medication management

infection control procedures

new clinical data collection systems

standards for open disclosure

credentialling of medical appointments

safe staffing initiatives

and moves to introduce vocational registration for specialists, to name just a few.

Scrutiny by governments has never been greater - State governments are faced with meeting public expectations of 24 hour/7 day availability of top quality medical care in all regions in a health financing environment that sees the Commonwealth and States seek to shift both costs and blame to each other.

Patients are better informed than ever before about how their health is being managed…and paid for.

Hospitals are political footballs these days, and front page fodder for the newspapers.

These developments have all contributed to dramatic changes in the hospital workplaces and the demands on the staff working within them.

The Workplace

Let's look at some numbers to prove the point.

Available beds in public acute hospitals fell from 59,273 in 1994/95 to 50,113 in 2000/01.

Separations in public acute hospitals have risen from 3,420,000 to over 3,850,000 in the same period.

The average length of stay in public acute hospitals declined from 4.6 days in 1994/95 to 3.7 days in 2000/01.

The range of available medical interventions and the sheer volume of knowledge that doctors and other health professionals are required to absorb has increased significantly.

And the volume and intensity of hospital work continues to increase from a clinician's perspective.

Restrictions on funding and the never ending attempts by governments to stretch the health dollar further place doctors in the unfortunate position of having to ration health care - something the Governments have sought to avoid being seen doing themselves.

Current Senior Medical Workforce

Let's look at the make-up of the medical workforce.

in 1998, 72% of all employed doctors were male and 28% female

in 1998, 28% of male doctors were over 55 years of age compared to 10% of females

84% of specialist clinicians were male and 16% female

50% of all female doctors worked in general practice, 19% as specialist clinicians, 7% in non-clinical roles, and the remainder as trainees or CMOs

Over 22% of male specialist clinicians worked in excess of 65 hours per week compared to 10% of female specialist clinicians

The senior medical workforce is predominantly male, and males as a group are older and work longer hours than their female colleagues.

New Entrants to the Medical Workforce

But this is changing, albeit slowly and slightly.

Women entering medical school now outnumber men, increasing from 43.6% in 1989 to 52.7% in 1999

Graduate entry medical programs are now accounting for a significant total of the student population, ie students are generally older and are more likely to have family commitments as they enter the workforce

Medical school entry numbers have been static for the past decade - 1,392 in 1991 and 1,334 in 1999

There is greater use of aptitude testing as part of the entry process for both graduate and undergraduate medical degrees - and we are now seeing a much wider range of life experiences among the medical students commencing their studies today.

In interviews conducted by the AMA as part of its Work Life Flexibility initiative, the Deans point to a more vocal, less accepting attitude in their students than ever before.

Gender Mix and Vocational Medical Training

We are also seeing an accelerating feminisation of the medical workforce.

Almost half of vocational trainees are now female, with the majority training in just three disciplines - general practice, psychiatry and adult medicine.

Interestingly, these three disciplines account for over three-quarters of all part time training available in 2002.

The number of medical graduates commencing work as interns has remained static over the past five years, while we rely on an ever-increasing number of temporary resident doctors to fill the void.

Summary of workforce

So, a quick snapshot of the changing medical workforce would look like this…

Females are replacing males in absolute numbers, make up the majority of new entrants to the medical workforce, and are concentrating in a small number of disciplines

Both male and female entrants are older and may have changed attitudes.

And the number of Australian graduates entering the medical workforce each year has remained static, accompanied by an increased reliance on temporary resident doctors.

Changed Attitudes and Workplace Ethos

But what is contributing to changes in attitudes and workplace ethos among doctors?

Lifestyle and flexible working practices are key issues for many staff in the hospital system - and not just for females

Young doctors perceive a resistance to change by consultants, medical colleges and hospital administrators in a work environment that is family unfriendly and where the junior doctors must go through a 'baptism of fire' to secure a training place.

It's the old 'it's been done this way for decades, why change now' or 'if it was good enough for me, it's good enough for you' attitudes.

But times have changed and work practices have changed.

Limited working hours and greater part time opportunities are seen as the key to delivering a more flexible workplace for all employees.

Lifestyle/working conditions

Young doctors are less likely to accept the adage that 'medicine is more than a career - it's a life'.

As one doctor responded in a recent AMA survey:

"People are now not seeing medicine as a life, just a part of it. Twenty years ago it was your life, and your family either lived with it or left you."

Lifestyle and working conditions are key factors for most hospital employees - however, it appears more important for males with children, and females.

Younger males (without children or partners) are also heavily influenced by lifestyle flexibility for social, sporting and travel pursuits.

As revealed in AMA surveys of doctors-in-training, there are specific aspects of work that are perceived by young doctors as important in relation to lifestyle/working conditions.

The ability to work part-time or have flexible hours is one.

According to one young doctor:

"Psychiatry is good for part-time work - you can have 0.8, 0.75 and even 0.5 positions."

Set working hours - 9 to 5, 5 days a week or discrete shifts - are another priority.

As another doctor says:

"The hours I work are important to me, that is why I like emergency medicine because you work set hours - you can hand over and there is no on-call."

Limited on-call/after hours requirements is another prime consideration.

Yet another young doctor proclaims: "I have done lots of on-call jobs and without fail you get called. Haematology is interesting but it is not worth it for the disruption on your life."

Perhaps top of the wish list is the ability to spend time with family, children, partners or friends.

A doctor with a young family says:

"I thought it would be unfair to my children, and my family is a priority."

Training requirement/conditions

Training requirements, too, have a huge effect on workplace and lifestyle.

Requirements that impact on working conditions and lifestyle include:

- Opportunities for part-time work or job sharing

- The length of time required to gain qualifications

- The ability to take time off during training program

- And the overall impact on lifestyle.

As a surveyed doctor explains:

"Registrars doing exams have to sacrifice their lives for a year. The exams are in March and they can't even go out for dinner now."

Other factors are:

- Exam difficulty

- and the impact on the timing of having children.

According to another surveyed doctor:

"I wanted to have children within a couple of years of finishing my intern year. You don't want to start a family when you are 35."

Medical students and junior doctors are not prepared to devote their lives entirely to their medical career.

Just like other hospital staff, they see a healthy balance between work and personal life as vital.

There is increasing pressure for the provision of greater flexibility in relation to training and work practices.

As mentioned earlier, young doctors are challenged by the established mindset of consultants, the medical colleges and some hospitals.

As one says:

"You almost feel like you have to apologise for having a life."

Young doctors, according to AMA surveys, resent the 'I had to do it, so do you' attitude. They see it as a reluctance to embrace change.

One young doctor complains:

"A consultant said to me, 'In my day, we had to wake up before we went to sleep.' Very Monty Python!

Young doctors perceive a prevailing negative attitude from their seniors about attaining greater workplace flexibility.

They perceive a strong lack of commitment because that's not how things were done in the past.

They say there is no evidence of support for the 'new' way. Do it yourself is the only advice, they say.

Clearly, there does exist real scope for adapting our medical training systems to the new ethos.

AMA commissioned research into the vocational training system as part of our Safe Hours campaign found that, while we train excellent doctors greater flexibility and shorter hours do not of themselves compromise the training process.

The quality of the training provided is critical - with many of the excessive hours by trainees worked in the early hours of the morning, alone in the hospital, without supervision, and without the scope for feedback that completes the clinical learning loop.

There is growing pressure for greater flexibility in the training process - but the workplace and training systems still respond to these pressures in individual terms.

One young doctor's experience was:

"The college said we support you but you have to find someone to job share with."

Ensuring working hours for doctors are more manageable and in line with other professions - and allowing for greater flexibility in relation to part-time opportunities and dedicated study time - is likely to have a positive impact on the hospital workplace.

AMA studies have shown that it is vital that flexibility in training and work practices is supported from 'the top down'.

We need to see greater understanding and support from hospitals, medical colleges and consultants.

Impact on public hospital workplace

The demand for medical services and the intensity of hospital medical practice continues to increase.

New entrants are not replicating the demographics and participation patterns of the senior medical workforce.

The larger number of females entering the medical workforce is instead of, not in addition to, males.

The medical disciplines that traditionally attract females are unlikely to be able to absorb the increase.

The predominantly male medical disciplines such as surgery are facing an ever-decreasing pool of male doctors from which to bolster their ranks.

And the rigidities of the current medical workplace and training models are incompatible with the aspirations and attitudes of the young people now entering the medical workforce.

Workforce Solutions?

But what must we do to cope with this change, this new wave?

Do we increase the numbers of Australian medical graduates?

Do we redefine the roles of doctors, nurses and other hospital staff to focus only on those activities for which they are exclusively trained so as to maximise these resources.

Do we create new clinical jobs - "hospital generalists" - whose focus is on clinical service or training of RMOs?

Are there current activities of doctors and nurses that can be done by other staff?

These are all issues confronting a hospital workplace under greater strain than ever before.

Do we direct greater attention to medical workforce issues in decisions about new hospitals and health facilities?

Are we simply trying to spread our medical, nursing and health workforce too thin across too many hospitals?

These are difficult political issues in a society (and a political system) that has defined health care as a public good.

Training and Work Practices

There is no doubt or lack of agreement about what must be done, however.

We must improve the quality and availability of training with a better mix of training and service. We need more skill centres, and better orientation and clinical handover practices.

Systems have to be put in place that allow hospital staff greater control over their work hours and that strike the correct balance between the training needs of the young doctor and the service requirements of the hospital.

We should look at longer employment contracts to provide greater security of ongoing employment.

We should examine job share registers, leave relief, part time work and training.

Hospital Managers

For hospital managers, a better systems approach is required to audit hospitals and health services for flexibility and opportunities for a better balance between work and family or leisure.

Actual performance of hospitals and workforce should be monitored closely and benchmarked against policy.

Hospitals should champion reform by undertaking pilot initiatives and building alliances with other stakeholders.

All efforts should be made to make every hospital or health service an "employer of choice". Let's get rid of second or third best options by striving for excellence.

And let's all press governments to relax some of the more harsh broader workforce constraints.

Conclusion

Today's hospital workplace is a different beast to that in which many in this room started out their medical careers. So, too, is the profession.

The gender mix of the medical workforce has changed dramatically and will continue to change.

The impacts of this change are only just now being felt in our public hospitals.

The expectations of today's hospital workforce in relation to work, family and life are different from the past.

Medicine is rapidly catching up to the changes that have already occurred in the nursing workforce.

The way hospitals and the professional and training institutions that feed them respond to these changes will be critical.

Therein lies our challenge.

Thank you.