AMA President Dr Mukesh Haikerwal, AMA Vice-president Dr Choong-siew Yong and AMA Doctors in Training Qld Chair, Dr Alex Markwell -- Safe Hours Audit 2006
E & OE - PROOF ONLY
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MUKESH HAIKERWAL: Thank you, and good morning, for attending this launch of our kit, which you have with you. This is a kit which explains the latest survey the AMA's done into doctors' hours of work. It's the first kit that we've put together for five years, and to me the most concerning thing is that in five years not very much has actually changed. Before I go through some more facts, I'd like to introduce the people who are with me.
I've got Dr Choong-Siew Yong, my vice president, who's a child and adolescent psychiatrist from New South Wales, and also works in the public system. And Dr Alex Markwell. She's a trainee in accident and emergency medicine in Queensland, and chairs our Doctors in Training Committee in Queensland as well as being on our federal committee.
The audit today really is a snapshot of the working lives of our doctors in our hospitals. It's really showing that the appropriate amount of time is not being spent, and that people are working significantly longer hours, long hours, unsafe hours, and this adds up to fatigue, adds up to stress and often to burnout. If we have unsafe hours, it's a poor outcome as far as quality and safety of patient care is concerned, and it's also very poor from a hospital point of view, from a health and safety at work perspective.
What we're seeing is that almost two-thirds of our doctors in our public hospitals, all public hospitals across the whole country, are actually working unsafe hours. It's a problem in all states. For instance, in New South Wales, we have a case of an intensive care doctor who works over 100 hours in a week, including 34-hour stints on the trot. In Tasmania, there's a case of a surgical registrar who was rostered for two days off over a three-week period. I'll say that again: two days off in a three week period, despite having worked 113 hours in the week of the survey.
In a Melbourne psychiatry unit, we have an issue of a registrar who was deemed to be at significant risk having worked 35 hours in an unbroken stretch. Also in Victoria, a registrar in obstetrics and gynaecology who did 50 hours of - 58 hours of work, in one week of that survey. A registrar working in surgery also in regional Victoria this time had a 74-hour week reported. And regional areas are a specific area of interest.
In Queensland, in a regional centre, we saw a doctor working two weeks of 83 hours and 72 hours respectively; this included a 30-hour shift non-stop. In the ACT, 102 hours in one week was one report, and 22 hours on the trot. In WA, a registered medical officer at the Perth hospital worked 78 hours in one week and 16 hours in one day. And in the Northern Territory, a hospital registrar worked 78 hours in one week, and 16 hours in one day.
As you can see, unsafe hours are across the board, across the country. Some of the figures are difficult to break down in the smaller states because the sample size is not adequate. But from the larger states we've seen significant figures, and that trend is very much the trend that we hear from our committee of doctors in training, which is made up of doctors in training from each of the states.
It's time to put safer working hours into place. There is a role for government to put pressure on the bad working practices of hospital administrators who've got away with this for far too long. The AMA calls on governments to have a look at these facts, and create a better, safer environment. A better and safer environment for the doctors means a better and safer environment for the patients for whom they care.
When I called home this morning after doing a radio interview, I called my wife and she said, what's all the fuss about? They're down to 37 hours. And then she stopped and thought, well, actually, you know, that's a normal working week for a person. Things have got better in 20 years, from 104 hours on the trot, but we've seen very little change in the last five years, and that's where we need to concentrate on what's happening now and change practice now. I'd like to pass on to Alex Markwell who'll tell you a little bit about the situation for junior doctors, and then I'll pass on to Dr Yong from the public sector.
ALEX MARKWELL: Thank you, Mukesh. The AMA Council of Doctors in Training is particularly interested in this, really because junior doctors are the doctors that are suffering with these work practices.
At the moment we are hearing stories from every state around the country. Junior doctors are working incredible hours. They're still doing the on-call type scenarios that have been in practice 20 years ago, and I know at my hospital it's very common to see a doctor come to work on Friday and still be there on Monday, having been there the whole weekend, on-call, 24-hours, having not actually left the hospital.
Also, in Queensland for example, the country doctors are on call 24-hours a day for up to three to four weeks at a time. There's no restriction on what hours they do; they're on-call 24-hours a day, they have to go to work if there's someone sick. These hours just aren't safe. We're very concerned about the safety of our patients, and it's really important that this survey really highlights the issue of safety, safe for doctors, safe for patients.
CHOONG-SIEW YONG: I'll just speak from the more senior doctors' point of view and I think senior doctors realise that they don't work generally the long, uninterrupted shifts that the junior doctors do. Being the senior doctors, they're on call much more and often are called in at all hours of the night. In regional areas, we still have often our country GPs manning the emergency departments at night in the small hospitals.
So they might be doing a full day's work in the surgery and then having to attend to road trauma, all sorts of conditions, in the emergency departments in the evenings. So I think it's the intensity of work for some of our specialist doctors, and for our GPs particularly in regional areas, is very heavy, and the fact that they're on call, they may be called out at any time day or night, they are called by the junior doctors often to help and to provide some advice, at all sorts of hours.
For instance, when I'm on call for the hospital, I'm on call for a whole week at a stretch. And although I don't have to be in the hospital for all that time, certainly I do get called at all sorts of times for advice by the junior doctor as part of the system of being on call.
So I think for all our doctors, these are real issues of - that are important for us to look at, how we can improve the safety and the working hours for both junior doctors and the senior doctors in the hospitals.
MUKESH HAIKERWAL: The repercussions out of all of this of course are much more about safety and quality of the work that we are doing, but also in terms of retention. We have a significant problem with numbers of doctors in the system. We're recruiting more through the increased medical school training positions, but all of that is work that's wasted if we can't retain people in the system. We have examples of people that actually have left or have changed career paths because they can't stick it, and that's the sort of experience that Alex brings with her.
ALEX MARKWELL: We know that surgical training has especially struggled. Their hours that they're required to do as part of their training, although the college is trying to correct that, are still quite arduous, and people have actually changed career paths; they've given up on surgery or medicine completely. I think we need to really recognise that there needs to be a change in how we roster our junior doctors, and our senior doctors for that matter, and how we look after our trainees, how we look after our doctors in the system and how we can look after our patients.
REPORTER: Is this some kind of weird ancient rite of practice, rite of passage, that's part of your profession? Or is it just, I don't know, cheapo hospital administrations, not being prepared to employ enough doctors?
MUKESH HAIKERWAL: Look I think it's certainly a bit of both. The folklore, the myth, the traditions have been around horrendous long hours of work, being there every hour that God sends, because it's good for learning. But actually you don't learn very much when you're deadbeat on your feet. And you've actually got to have a good learning experience and a good teaching experience from those that are doing the teaching whilst you're alert and sharp.
And of course that then flows through to the sorts of quality of care that you are then able to provide. And I think that that's really very important, that you've actually got to have people who are sharp doing this sort of work. There is an el cheapo culture; hospitals are much more screwed down financially. They've got to meet a budget bottom line.
They've stopped doing things like teaching, training, times available for recuperation aren't there, facilities for doctors to relax if they are on call or in the hospital have disappeared. There used to be lots of cushions, I call them, around making that long and arduous stint in hospital more comfortable. The stint remains the same; the cushions have gone.
REPORTER: But we've seen it historically, this is what you did when you were a young bloke, but that doesn't make it acceptable.
MUKESH HAIKERWAL: Exactly, it does not make it acceptable; 37, 39 hours is half of what I would have done or did when I was working in my training years. It doesn't make it acceptable then, and it doesn't make it acceptable now. That's a normal working week for an individual.
REPORTER: Dr Haikerwal, a lot of the state governments have asked for more surgical trainees, and the College of Surgeons has not given them as many as they want. Isn't this partly because we don't have enough doctors, and sometimes the doctors are actually preventing new doctors coming through?
MUKESH HAIKERWAL: We certainly have a shortage in the number of doctors in the system; that's being increased and addressed through the increasing numbers of medical students going through the training program, increasing from about 1,500 to around 3,200 by 2010. The surgeons will provide as many training positions as are required, but in order for those positions to be fulfilled, the state governments have got to commit to beds in hospitals that are open; they're not treating patients. They have operating rooms, operating rooms open and operating.
So there are lots of bits to that equation that have to be fulfilled to actually get the training positions in place and working. There's no point blaming the surgeons saying, you're not training enough, when the hospitals aren't open or, as in large hospitals in Queensland, they cancel significant numbers of lists every single day. So you don't get any training, which is what you need to be a surgical trainee, if the beds are shut, the operating rooms are closed and lists are cancelled.
REPORTER: Do you see this as a government responsibility to break this culture that's existed, or is it up to hospitals or doctors to stand up and say, that's enough, where is that doable?
ALEX MARKWELL: I think you've highlighted a really critical point. This really needs to come from the whole medical profession; it needs to come from government; there needs to be a united effort. There's a certain amount of culture, both from senior colleagues and colleges, but also from hospital administration. We really need to make this a priority, both in our hospitals and also for our colleges in training our junior doctors. It has to be a united approach.
REPORTER: Just on surgeons' training positions doctor, the ACCC doesn't agree with you. They say that the surgeons' college won't provide enough training positions in that states are providing enough resources to support it. What do you say to that?
MUKESH HAIKERWAL: They're wrong. There are not enough open beds attached to patients going through those beds because what they do is they run out of money, so they stop seeing patients. They run out of money and they shut down theatres. Alex can give you the exact figures of the Royal Brisbane Hospital, but they're pretty horrendous, the number of lists that are cancelled there every day and every week, and therefore you don't get any training when your operating list is cancelled. Therefore you can't have it as an approved training position.
REPORTER: Is there a realistic hope within the next five years of reversing the situation without seeing more gaps in hospital services because of the scarcity in doctors?
MUKESH HAIKERWAL: Look, the working practices first of all need to be safe with the workforce that we currently have. We've got to make sure that we're using people in the system effectively, and keeping them there, because what we're doing by continuing with this tradition or this way of rostering and this cheapskate way of making do with who you've got and pushing them harder and making conditions unsafe, is making them leave the system.
So, we're at a position now that can only improve if we retain the people that are in the system within the system, and then recruit the new people that have been trained through and keep them there as well. But if we actually have a boat that's leaky, because people are leaving it, and you're trying to put more people in the top end, that boat's still going to sink.
REPORTER: On that safety issue, what do you make of these reports that thousands of overseas doctors are coming in and they're not even being tested before they start practising?
MUKESH HAIKERWAL: Well, again, the evidence from around the country is that is unfortunately the case. The Australian Medical Council has a process, and each of the state medical boards has a process, have a process, for making sure people are fit for task. We believe as an AMA that that should be done by the medical boards, but also by the college that looks after that specialty group to make sure people are fit for task.
There's a governmental responsibility to make sure the people that are recruited are fit for task, and if they're not, they need orientation into the system, the culture, make sure the language is up to speed, and also that their skills are assessed. If those things are not happening, you're going to get the situation, which we saw in Bundaberg and unfortunately we'll see again. Where people are sidestepping the checks and balances that have been put in for very good reasons, and therefore you get what you'd call rogues in the wrong places.
REPORTER: So how many people could be slipping through the cracks in that manner?
MUKESH HAIKERWAL: We have within the Australian workforce 30 to 40 per cent of doctors who have trained overseas. Absolutely the vast majority are doing a remarkably good job. They are working well and they're actually doing teaching and training. The concern is that the few that might have got through state by state will bring the whole lot tumbling down with them - not just themselves, but the people around them and the system around them.
And it's very important that anybody working the system is recognised and therefore people who go to the hospitals seeking treatment can have utter absolute confidence in who's treating them.
REPORTER: But certainly another Bundaberg is a real possibility that we can see again?
MUKESH HAIKERWAL: If we do not get nationally consistent pathways for recognition, and this is what COAG has asked for by the end of the year, then we're going to get more problems like that. And that's not acceptable. We would like to see some pressure applied to the states by Commonwealth Government. The Commonwealth Government is the only government department that provides visas.
We believe visas should be a lever to say, if you don't meet a high level, not the lowest level of commonality between the states, but the high level that we set, then you can't get the visa for that person you're trying to get in.
REPORTER: Should patients have any confidence knowing that they can walk into a public hospital and be treated by a zombie who's been awake for 39 hours?
MUKESH HAIKERWAL: Zombie?
ALEX MARKWELL: It's a difficult one and that's really why we're here. We're really worried about our patients and their safety. We know that there's evidence that after you've worked for a certain number of hours people do make errors and that's been demonstrated time and time again. And recently in Queensland with the Caloundra incident, we know a doctor who was 20 hours into his 24-hour shift and unfortunately was implicated in an outcome that was tragic.
Really we need to highlight to the public as well as governments and the hospitals that we're concerned about their safety and that we really need to ensure that these hours - the rostering has changed and we're working safer hours for their benefit.
REPORTER: What's the longest period that you've worked for in a shift without any sleep?
ALEX MARKWELL: I did a country relieving stint in Queensland and I was on call for 24 days and that was my 24 hours a day, seven days a week, no break. Probably 18 hours, I think, at that point before I had a break and then just catching sleep whenever you can. You don't have a choice unfortunately. Babies come when they want to come. Traffic accidents happen when they happen, you just have to meet the demand.
REPORTER: Surely you'd doubt your own capacity? You've got someone in front of you sick and you wanted to go and lie down?
ALEX MARKWELL: Yep, I guess the attitude has been up until this time a tired doctor is better than no doctor. And certainly in extreme cases, when you're talking about life threatening conditions, that's probably true. But what we're trying to do is eliminate these commonplace practices in the hospitals that are occurring on a regular basis. We really want to make sure that it really is only extreme circumstances where doctors are doing these crazy hours, not routine basis, which is what is happening currently.
MUKESH HAIKERWAL: What's scary is that when you look at the research, that once you've done 18 hours your abilities are similar to being .05 or over. So when you get beyond that, you can just see how that deteriorates things. The other thing is that the safety is at risk, but because of the professionalism of people, because of the team around them and because of the, I suppose the adrenalin drive, people do well, they are continuing to be looked after.
But there's a limit to which that can be allowed to be the driver; it should be safe working practices, not a bit of a whistle and a prayer.
REPORTER: What plan.
MUKESH HAIKERWAL: Yeah, absolutely.
REPORTER: Have there been other cases similar to Caloundra? I mean are people dying in Australian hospitals because of these long working hours?
ALEX MARKWELL: I think undoubtedly, it's just that we don't hear about it unfortunately.
REPORTER: If you were to hold the survey again in another five years time, what ultimately do you think would be the desired outcome and what do you think the realistic results would be?
MUKESH HAIKERWAL: The desired outcome is that nobody's working in the at risk range and the definitions are around 14 hours as a shift and 50 hours as a weekly average.
REPORTER: But realistically what do you think?
MUKESH HAIKERWAL: Well realistically in five years, we'll just be getting our new graduates through. And hopefully we will preserve the number of people in the workforce. So we should be better, significantly better than we are today. To me the biggest disappointment is a very small change overall in averages. But in individual cases, we've actually got worse in some areas.
REPORTER: Doctor, you say that Australian governments must urgently put in place measures to dramatically improve work conditions. What exactly do you see as those steps that they need to take? Are they simply putting back those cushions, as you call them, or is there more to be done?
MUKESH HAIKERWAL: Cushions are part of that, that makes things more bearable. But what you've got to do is, there are enterprise bargaining agreements which actually have significant penalty rates for people that are working over a certain length of time. So over 38 hours there's a penalty and then a bigger penalty after that, but that doesn't work. Because that's sidestepped, they will not allow you to claim for the times that you worked beyond the times that you were rostered to work.
And your working hours are not therefore fully compensated for with payments. So, you know, the theory that you can put in a wage bargain that says that it's going to cost the hospital too much to keep people longer, doesn't work. And you know people that kick up about that often find they can't get another job within the hospital system. So they're using a lot of the dependency for your next job and your career training prospects as the lever on younger doctors, to keep them almost as bound labour.
REPORTER: So what you're essentially saying is there's a form of cultural blackmail almost?
MUKESH HAIKERWAL: It's a real cultural blackmail.
CHOONG-SIEW YONG: There's also the issue I think of just governments and training institutions like the colleges. The surgeons was an example before. Really stopping this sort of rhetoric and actually getting together to look at how we can solve the problem, and rather than blaming each other. The state governments really need to commit to significant resources to assist the training. It's one thing to have lots of places available, but you actually need to have everything else in place as Dr Haikerwal said.
Not just the beds and so on, but also support for the senior doctors to provide the training to the junior doctors and the -
REPORTER: Just -
CHOONG-SIEW YONG: Yes, sorry?
REPORTER: Oh sorry I was just going to ask Dr Haikerwal, you were saying at the moment that you are working to keep people from working these horrendous long hours. How hopeful are you this will change for the better under new IR laws, which won't even afford that kind of protection?
MUKESH HAIKERWAL: Well I think the new IR laws, people are most vulnerable where this federal legislation is the only legislation or where the employer has a smaller number of people within in. Having said all of that, the culture has got to be one of health and safety at work. And if you're bypassing that to help your bottom line or to make the hospital have some other service, that's wrong.
You know, your key service, your key personnel that are doing the work that actually keeps the hospital working and keeps people getting treatment. And if you scrimp and save from that, you're actually putting in jeopardy the rest of the machines that go bing and all the rest of it.
REPORTER: Dr Haikerwal do you have any estimate of the number of young doctors who would have been lost in the profession because they just can't take the hours? Is there any national estimate?
MUKESH HAIKERWAL: I'm not aware of any figures, but you know, you certainly hear of people who, having completed their medical degree or certain parts of their training, either walk away completely or take a different direction into an area of non-practising medicine or use their medical degree like any other degree. And that in a situation of overall skill shortages and certainly we hear that, you know, with the new generation coming through, that they are not going to take it. And government just doesn't seem to get it. They don't get the fact that people have a choice.
REPORTER: Have you got any estimate - I mean to get to these safe working hours, surely you need more doctors in hospitals? Have you got an approximate estimate, a percentage estimate of how many more doctors Australian hospitals need overall?
MUKESH HAIKERWAL: The exact numbers we don't have a number on. But if we use the people that we actually have more effectively, if we actually use them and roster them appropriately, what you'll find is that you can actually do much of the work in most of the hospitals with the staff that are there and perhaps a few more. What we're going to see as hours drop down in the community, because of these community norms, the new numbers coming through will actually all be needed.
The problem we're having is how we're going to train them, because you haven't got people, you haven't got facilities, you haven't got availability of time within the hospital system currently. Because teaching and training and research are not seen as cool. And this is the big fundamental flaw in our state health system at the moment. Hospitals have become businesses that are out there to reach a bottom line and come into budget.
And in doing that, because the budgets are so inadequate, the important things for the future, the teaching of our next generation of health professionals, the ongoing training of our registrars and training and the research, that brings the groundbreaking things to medicine are lost.
REPORTER: Do we need more private management in hospitals?
MUKESH HAIKERWAL: I think that what we need is for more hospitals to actually have appropriate levels of funding to make sure that they can provide the core services they're supposed to provide. And those core services include teaching, training and research. Whether it's a private manager or a public funded manager, if they've not got enough money, they're not going to make the system turn properly.
REPORTER: You said before that in the country there was nothing much you could do about having to work those long hours because babies will be born, car accidents will happen, you can't just not go. But you're also saying that part of the problem is we don't have enough doctors. So are you saying that some surgery and things like that is not going to be done? How are you actually going to stop doctors working long hours without leaving some tasks undone? Or are you saying we should cancel more surgery, that's okay?
ALEX MARKWELL: I think it really comes down to balancing the system. There are some situations for example, remote areas, where there may only be one doctor for 100 or 200 kilometres. And in those situations, you make do with you can. Although we recognise that that's highly risky and we would advocate any arrangements whereby these doctors could be relieved. What we are really talking about are doctors in the hospitals where as a routine basis, they're being rostered for a whole weekend - so three days continuous with no breaks.
Now what we're saying is that if there is more sensible rostering, rather than putting someone on call for days on end, limit their on-call period, or have them working a certain number of hours before they're being relieved.
REPORTER: But are there actually the doctors there to allow the hospitals to do that?
CHOONG-SIEW YONG: There are some simple things that can be done. Firstly in many rural areas, we've got doctors leaving the public system because of the red tape burden, because of the fact that things are not done very well. And we should try and attract some of those doctors back into the system. We could certainly, if we had more funding to provide things like more surgery in our public hospital system, some more surgeons would come back from the private system and be available to do the training and do the supervision and share the burden a bit better.
REPORTER: But if you're just adding more surgery, isn't that just adding to the problem that the trainees have with safety? There's more surgery to be done and -
CHOONG-SIEW YONG: There will be more surgery, but there'll be more capacity to actually employ more doctors in the system. So one of the problems is the intensity of work for the junior doctors in the system right now. It's much more intense than it used to be even 20 years ago. The patients are sicker and they leave hospital sooner, so there's less down time if you like in the hospitals. But the other thing is, we're driving our senior doctors away from the system because of the red tape burden, because of the sort of demands of management.
So if we actually looked at doing some of those things, we could relieve some of the problem - not all of it, but some of it in the short term. And as Dr Haikerwal mentioned, we've seen increasing numbers of medical students coming through. So in a few years time, they will be coming through and in fact, it will be a better place to provide the training they need as well, rather than trying to make do with a short change system.
REPORTER: How significant is the issue of the growth in private hospital volumes in terms of drawing doctors, surgeons, specialists away from the public sector?
MUKESH HAIKERWAL: There is considerable work being done in the private sector, both surgical and non-surgical work. Up to 60 per cent of procedures will be done in the private sector. Therefore, it is very important that the private sector is part of any teaching environment for the future. The people who work the private sector will very happily work in the public sector, but they find it too much of a hassle.
Because they will put aside a day, go in to do their operating list and find it's been cancelled. And that happens remarkably regularly and therefore they decide to walk away from that. People would actually like to do that work. They like to do that public work and they like to do that teaching work in the hospitals. But if you take away the teaching, you take away the ability to do some research and you take away the lists that they're going in to do. There's not much left to attract them to stay in the system.
CHOONG-SIEW YONG: Particularly in regional areas, just assisting a couple of doctors to stay in the system, rather than leave it, makes a huge difference. You don't see it so much in the big city, but in a small town or regional centre, one or two specialists or senior doctors leaving can make all the difference to having a trainee doctor there because without the senior doctor you're not going to be able to train the trainee.
And then you see a huge change in the service that the hospital can provide for the community. So it's just - even little changes like that can make a big difference in country areas.
MUKESH HAIKERWAL: One of the key goals is to attract more people into regional and rural centres. In order for that to happen you need to have a critical mass of doctors working there. And you need to make sure the conditions under which they're working are sufficiently pleasant, if you like, for them to then want to return and stay longer term. So that's why it's important to get this right.
CHOONG-SIEW YONG: The other thing is we'd like to see I guess more work done in the hospitals on seeing what they can do in changing the work practices to make the work of doctors more effective. And so far there's not been that much work done on that basis. It's been more about looking around to see how we can get more people to do the same and efficient kind of work, rather than saying, well can we actually make the work of each doctor more effective for more of the time.
MUKESH HAIKERWAL: Thank you very much for that.