As a public hospital surgeon, university academic and Head of the Division of Surgery of a 400 bed public hospital for the past 14 years, the change in work, expectations and satisfaction have been substantial.

Generally the patients are now older with more co-morbidities. Within my area of practice, the demand for cancer surgery has increased at the same time as unacceptable pressures within the Emergency Department, increased demand through the Outpatient Clinics and a greater range of treatments and interventions are now available, all of which contribute to limit the availability of acute beds.

With the explosion of the internet and the appetite of the media for the next “cancer cure”, patients and, in particular, their families often have completely unrealistic expectations of what is possible or even reasonable for their elderly relatives with multiple medical problems, frequently with a background of smoking, obesity and alcohol excess.

Huge changes in surgical care occurred in the early 1990s with an explosion of day surgery and minimally invasive surgery. This led to dramatic reductions in bed numbers required to perform surgery. Now over 50% of all surgical procedures are day cases. Hospital managers and health authorities thought this trend would continue unabated.

Few factored in the wave of ageing patients and the costs that would be expended on their care. Public hospital budgets have always been tight, now they are ludicrous. Each year we begin with a deficit budget and now even have to carry over our losses with absolutely no likelihood of ever paying it off.

Public hospitals have little control over the volume of patients needing to be admitted, a shortage of low acuity beds to discharge them into and families less inclined or unable to assume responsibility for patients after discharge.

Complaint letters, once an occasional event, are now actively sought by patient complaint departments, gleefully passed on to clinicians who have neither the time, the resources nor energy to deal with most of the issues. Complaints about dirty hospitals, long waiting lists, poor English or cultural problems with medical staff cannot be usefully addressed by surgeons trying to stay afloat of the rising patient tide.

Hospital managers are usually accountants with no idea of the practical difficulties associated with emergency surgery or elective surgery. They fail to understand that an elective operation for a nearly obstructed bowel cancer is more urgent than a fractured nose in the Emergency Department.

Dollars rule, and in an environment of already overspent budgets, pump priming of innovative change is almost impossible. They often draw on deprived and dysfunctional systems such as New Zealand or the UK NHS to show what our benchmark should be without understanding the inevitable impact on patients as we lower our standards. I am probably seen by the “administration” as non-compliant, shroud-waving, and an arrogant surgeon but when one’s actions and decisions can kill or cure patients who trust us to care for them, change must be carefully evaluated.

Managers often try to marginalise the clinician by ignoring difficult ones, scheduling meetings (usually at short notice) in the middle of operating lists or consulting clinics. Suggestions of 7am starts or 6pm conferences are apparently unacceptable with the inevitable result of decisions being made with token clinical input.

So why do surgeons stay in the system? Many don’t. Some are choosing never to participate in the public hospital system after qualification. Others are reducing their commitment to almost token involvement, such is their frustration with the environment in which they find themselves. Those that do are becoming part of the Y generation who want humane hours of work, having working spouses, and want to see their families.

We need better systems of handover, continuing of care and team management. With less overtime tolerated, more staff are required, however all have less tolerance for night and weekend rosters. New systems of training, new staffing structures such as “physician assistants”, and new models of care need to be rapidly developed in a system that is barely coping.

With these escalating demands, my family see me less, with the inevitable domestic pressures. My tolerance for ideologically-driven, poorly-informed non-clinician managers is declining. What remains, however, is the absolute pleasure and privilege of treating seriously ill patients and providing the best outcomes possible and teaching our successors how patients must be treated.

The majority of doctors and nurses in our public hospitals commit most of their professional life to making the system work within their institution. They continue to manage the chaos left by the last restructure of the hospital, network or health department. It is a privilege to work with these clinicians and I would not wish to leave them, even if life in private practice offers less frustration and greater income.