St Anywhere is a teaching hospital. Does anyone actually care? What is the difference between a teaching hospital and a non-teaching hospital? The answer to these questions depends on who you ask.
The “bean counters” see only expense from the teaching hospital. They employ extra junior doctors, physiotherapists, nurses and social workers. These individuals take time to supervise, create problems from their inexperience and move on at the end of the year with the arrival of a new crop of inexperienced workers to train. In the case of medical staff, the necessary overtime creates considerable additional expense for the system. The College of Surgeons and other specialist colleges have strict rules about exposure to patients required, library facilities and adequate support for junior staff. Add onto this the need to train undergraduate medical students (unpaid admittedly) but occupying already overburdened staffs’ time and the challenge becomes substantial.
The Federal Government has recently approved and almost doubling of medical student numbers without much planning how they would gain the necessary clinical experience. The so-called tsunami of students is now washing over the system. These students’ demands have been largely absorbed by public hospital staff as part of repaying their “teachers” from before. In the case of medical teachers, until 30 years ago nearly all teaching was done by “honorary” hospital medical staff, unpaid for their contribution to both public hospital patients and students. The new generation of staff and students, however, have grown up in a different system. Students and trainers are more demanding, and staff are less altruistic.
Last week I was contacted by a trainee surgeon who expected to be paid 150% loading to watch an operation they had not seen before but was to be performed in the early evening. I encouraged the attendance but denied the payment. Without strong, enthusiastic teaching hospitals we will not have a new generation of doctors, nurses and other staff to care for us when ill. However, Government must understand teaching is rarely efficient. I can probably do 50% more surgery without a junior doctor to supervise during a theatre list. Trainees also need to understand that what patients and staff give freely to them should also be valued and a teaching environment does not quite function like a strict clock on-clock off work site.
Departments of Health seem to care only about waiting lists, costs and budgets. They do not seem to understand the huge costs of importing and integrating overseas doctors, the value of a community generating its own “home-grown” workforce and fail to measure the excellence in training provided by a teaching hospital.
Ask any bureaucrat within a health department how the KPIs (Key Performance Indicators) for teaching are measured and reported, and watch the glazed look appear. We need to ensure teaching is valued and measured as much as budget over-runs and surgical waiting lists are revered.
Guy Maddern is professor of surgery at the University of Adelaide
Professor Madden has a great point. I think you could also ask how KPI’s for any public servant within the Health Departments around OZ are measured and you get a similar blank look.
All very good points. Teaching of students and trainees is essential and is extremely undervalued, not just by hospital admins but also by the universities (who expect something for nothing), the specialist colleges (who charge thousands but give virtually nothing in return) and often also by specialists themselves (as one said to me last week “do you know how much I could be earning in my rooms rather than teaching students?”). It’s not just the administrators and politicians who need to look at where the value is, nor is it just the trainees who need to respect what is given freely.
In my experience most trainees do understand that medical work is not a simple clock on/clock off job and numerous studies show that most junior doctors do at least as much unpaid work as their senior colleagues (an average of 10-15 hours per week in one survey I undertook).
To play devil’s advocate, why is it not reasonable to be paid the overtime for staying back for a late operation? In your example you see it as an “opportunity”. The trainee may see it differently – they may feel that they are being expected to stay back (at “work”) and therefore should be compensated as per their contract. This is not evidence of a lack of desire to learn or of greed, but simply of being paid fairly. Why should doctors not ask the question “if lawyers, accountants, builders etc charge by the hour, why should I not”. Also, trainees tend to follow the examples of their role models. Most of my (senior) colleagues are extremely unenthusiastic about doing work after hours unless they get paid for it. To argue that trainees should think any differently applies a different standard of behviour without any real justification.
Vocational medical training is a difficult balance between service and education. Trainees are subject to constant pressure from specialists and admin to do things for free, with a smile on their face and at all hours of the day. I think there is a clear inconsistency with arguing that administrators need to value teaching, but then refusing to pay the overtime to allow it to occur. In this setting you have become the administrator and it is you who are undervaluing learning.
I’m glad that there are still people like you out there, and I absolutely agree that teaching is critical and that there are some extremely unrealistic expectations out there but it’s important to remember that the “good old days” were completely different to now in terms of how the entire health system operates, and also that the “good old days” weren’t actually that good…
A similar thing has happened in nursing. The Federal Government is increasing the number of funded places in universities for registered nurses but there is already a shortage of places for their clinical placement and clinical facilitators. If student nurses are to get value out of their clinical time, they need places where the staff have time to teach and the facilitator is readily available, not travelling around wards or hospitals trying to keep track of their students.
Learning in the clinical setting has never been valued by the bureacracy for the health professions and maybe Guy Maddern has explained why, because learning does not fit easily into looking at clinical work in terms of KPIs, but you cannot improve productivity and efficiency in the health system without some time away from the coal face being taught and learning. If that learning is done in work time it should be paid time.
Well said everyone.
I think the main issue here is the complete lack if understanding by non medical administrators as to how medicine and nursing actually work. The inability to understand even the most basic issues and to simply designate a number to complicated services is mind boggling.
Some days working at St Somewhere Else I feel like I am the passenger of a sophisticated jet being flown by a preschooler!! I wait for the inevitable crash and can only stand back and watch the “Well how the hell did that happen?” comments.
Educating staff is a valuable resource, that is time consuming and expensive. Personally I would see it as a priority to keep your staff once they are trained, to train the next generation.
I agree the good ole days weren’t actually that good, we worked long and hard. We spent hours together with our colleagues, and I do actually recall being paid for that.
You encourage the clock on clock off mentality if people stay back unpaid. “Don’t talk to me I am not here”. Most people who are present in an operating theatre actually do assist with the case. Those not actively scrubbed assist the anaesthetist in moving and positioning, and in a crisis run errands.
Pay them Professor Maddern, the goodwill generated I am sure will be worth many times the loading.