Avoiding Burnout

An interesting week this week, with several stories coming together for me.

First up, a discussion on doctors.net.uk / ausdoctors.net (the members only service for UK and Australian doctors) on ‘tips for new consultants’. Covered the sort of things that don;t get taught at medical school or in postgraduate training. Also tips on setting up a private practice and avoiding burnout. A common theme was to ‘say no’ to unmanageable workload and to try to take control of the work environment, not let it control you.

Of course all of this is relevant to rural doctors, which leads to the second theme – that of managing workload in the bush. Scott Lewis (procedural GP in Wudinna and newly appointed President of RDASA) rightly points out the constant stream of negativity regarding rural medicine. Despite this, I think Scott and I agree that rural practice really does offer the ‘best bits’ of medicine – a varied and interesting mix, with opportunities to be challenged every day.

Concurrently this week the doctor in Penola, SA has left – citing an unmanageable workload & bureaucratic bungling by Country Health SA. As well as managing a day time clinic, poor chap was on call 24:7 every day of the year and reportedly chastised for having the temerity to be more than 20 mins from the hospital on one occasion (CountryHealth SA contract allows a 40 minute response time). Ironically this doctor was brought in a year or so ago, to replace the previous doctor, who lasted only 4 months.

Of course there’s the local issue on Kangaroo Island, with the sustainable model of Island docs doing 21 out of 28 days per month on call for emergencies, as well as 365 day a year cover for each of obstetric and anaesthetic rosters. This workload was sustainable and allowed respite from the onerous emergency roster, as well as to balance the demands of running a private general practice.

Common themes?

(i) Financial Incentives

Historically money has been thrown to entice doctors to the bush. Whilst this helps, it is ironic that the same incentives are offered to fly-in, fly-out locums who live in the city and cherry pick high-paying locum work. Indeed some rural communities are wising up to this and realising that paying locums $2500 per day is a disincentive to establishment of permanent resident doctors who have to bear practice costs. KI docs got into a stoush with the Health Department (and the ACCC) a few years ago, when asking for more money to provide on call services. The money doesn’t compensate for working day & night – but it does allow one to purchase much-needed locum relief.

(ii) Control of workload

There are 168 hours per week, which I think of rather like a Mars Bar – it should be divided into equal thirds of work, rest & play. An 8 hr working day is sufficient, and allows time for rest (sleep) as well as play (hobbies, other interests – but also mundane things like cooking, eating, toileting etc). Of course most of us experience ‘bracket creep’ with work intruding into time off and eventually life can become 2/3rds work, 1/3rd rest. Not a good idea. Having strict boundaries between work and home life, as well as declining extra duties means that workload is sustainable.

Much better though to share the workload – a roster of several doctors working part-time is a better model than the traditional solo small town GP. Which leads into the third theme..,

(iii) Learning to ‘say no’

Which is the unenviable position the KI docs find themselves in currently. A model hashed out with the Health Department a few years ago allows KI docs to work 21 out of 28 days per month for emergency on call, with the Health Department providing a locum for their hospital on just one week per month. Meanwhile KI docs provided 365 day cover for separate anaesthetic and obstetric rosters. Not a bad effort for six part time doctors, and allows us time off for a break as well as mandatory upskilling.

A proposal that KI docs take full responsibility for the emergency roster and fund any locum relief themselves was met with disappointment, It sets a dangerous precedent – for if the number of doctors on KI were to fall in the future (as is likely), the remaining doctors would be forced into paying for a locum to staff the hospital. A sum of $10,300+GST per week has been suggested as typical locum costs.

Taken to a logical extreme, if the Island doctors were unable to provide the service (through ill health, absence, whatever) they could be liable for a bill of $10,300+GST x 52 weeks … all for the privilege of doing EXTRA work to their usual 9-to-5 private general practice.

This really is the crux of the tension and difficulty in rural practice. Not only are their insufficient doctors and problems with throwing money at all-and-sundry, ultimately we are independent contractors. We already have a job that consumes a standard working week – that of running our own private practice. With that come attendant costs of staffing, utilities, rent etc which must be met.

To ask us to either take time out of practice to work at the State-owned public hospital (for considerably less money) and yet still pay pay own practice expenses seems unfair. And the demands of working extra hours on call takes it’s toll.

In the city, public hospitals are staffed by doctors and nurses working shifts. They are salaried and also get benefits like annual leave, long-service leave and superannuation. In the bush? Doctors work running their own private practices and traditionally have worked ‘on call’. Sadly workloads have increased (particularly in tourism destinations like Kangaroo Island) making on call a significant burden and at the expense not just of doctor’s health, but also ability to service own clinic patients. There is no Super, no annual leave. The Health Dept just wants to staff the roster, but doesn’t really care how this is fulfilled so long as the cost is shifted elsewhere.

Add to this the demands of a Medicare Locals policy that seems to be more about ‘wants’ than ‘needs’ … and the abhorrent policy in South Australia of charging public patients a fee for non-admitted A&E services (contrary to section 19(2) or National healthcare Agreement). It all seems that costs and services are being shifted from State responsibility to private practice.

Hence it is sometimes better to ‘say no’ and do only what you can do.

Any other thoughts on preventing burn out?

SA Health Budget Waste – Jack Snelling take note!

There has been a change in SA Health his year as outgoing Health Minister John Hill retires and Jack Snelling steps into place. I don’t envy whoever has this portfolio – the cost of health continues to rise, as does demand – and yet available health budgets are shrinking.

This week the ABC reported $1 billion health cuts over the next 4 years in SA health. The Minister was reported as saying “I think we can reduce the number of clinical staff and still maintain a reasonable level of services.” Personally I disagree – hospitals are already at capacity and despite ‘efficiency saving reports’ from the likes of KPMG, ministers need to realise that you cannot run health like a widget-factory; there needs to be surge capacity and slack in the system. However, I am all for saving money when appropriate. Which is why recent spending on unnecessary equipment by Country Health SA puzzles me.

In late 2012 a new anaesthetic monitor was delivered to us on Kangaroo Island. We were told it was part of an across Country Health SA strategy “to meet requirements” in Operating Theatres. Sure enough, the new monitor is a ‘you beaut’ device, with touchscreen technology and allowing us to do fancy things like spirometry and bispectral index sensing – which we never had before.

The problem is, the old monitor worked perfectly well and didn’t need replacing. I’ve checked and double-checked the ANZCA guidelines – and can’t find a requirement to have these extra functions which we’ve been told are ‘mandatory’. I’m not even convinced of the need for BIS, other than in paralysed patients being transported where risk of sedation failure may be present (read more on BIS here).

The disappointing thing is that we really need an EXTRA monitor in our location.

Currently post-op patients are monitored in ‘Recovery’ which is also our small ‘Emergency Room’. We use the MRX defib as a post-op patient monitor. Which is fine, so long as there is no emergency patient who also needs monitoring. As well as the need for two monitors, there have also been occasions when the anaesthetic monitor has malfunctioned – so having a backup immediately available makes good sense (particularly when you are on an Island!)

Using MRX defib as sole monitor in ED/Recovery – no backup!

So my efforts in the past have been directed to getting an additional monitor for our ED/Recovery…as well as to purchase equipment to meet ANZCA standards (equipment to manage a difficult airway being one particular bugbear). We’ve had some success – we’ve sourced and fitted out a difficult airway trolley and some signage. Sadly there has been no committment by CHSA to supply a fibreoptic device or videolaryngoscope (I ended up purchasing my own) to manage a difficult airway…and have been told there are ‘no funds’ to purchase an additional monitor.

The Health Minister Mr Jack Snelling wants to save money. I get that. But this new monitor allegedly cost $17K. There are fifteen sites across CountryHealth SA which provide anaesthesia – so that’s $255K spent on monitors which may not be needed.

There you go Mr Snelling – a $255K saving for you.

I’ve emailed the CHSA lead for anaesthesia, Dr Sara Norton to ask about this. She tells me she was unaware of the decision to purchase these new monitors and did not consider either BIS or spirometry as mandatory requirements for monitoring. Which makes the purchase of these $17K per piece monitors even more puzzling. To date, Sara has not been able to get an explanation from Peter Chapman (Acting CEO of CHSA) re: this decision.

Seriously – that money could have been better spent in rural hospitals on essential additional equipment. We are repeatedly told there is ‘no money’ and purchase of much equipment falls upon efforts by local charities like CWA and Rotary. I think rural Australians deserve the same access to essential equipment as their metro cousins…and wish that decisions on equipment purchase were made in consultation with local clinicians.

Perhaps Jack Snelling should be asking Dr Peter Chapman – who is making these decisions and where is the governance?

Contract Negotiations (again!)

Well it seems that some country doctors in SA remain embroiled in dispute over on call contracts with Country Health SA.

The last contract expired in Nov 2011 and was supposed to be replaced by a contract offering improved terms for rural doctors who offer on call VMO services to public hospitals in addition to running their private practices. You can imagine the disappointment of many doctors when no contract materialised in Dec 2012. Protracted negotiations ensued between Country Health SA and both the Rural Doctors Association of SA and the AMA(SA).

As I understand it, the AMA(SA) advised their members not to sign as there was a failure to reach an acceptable outcome for members.

The RDASA continued to negotiate and reached a compromise of sorts in July 2012 (seven months after the previous contract expired). You can read a press release from them here.

The difficulty in the relationship revolves predominantly the tension between doctors running their own private practice and the need to service a public hospital run by CHSA. As workload in both primary care and hospital-based services increases, the impact of being on call for the hospital becomes increasingly negative on running a private practice.

Contract wins included 

• a payment to recompense the impact of being called out of private practice clinic to attend hospital patients (note life-threatening emergencies excluded from this payment) and,

• a payment to compensate missed clinic sessions the next day after a busy overnight on call (note only applies to admitted in-patients; A&E patients excluded).

Disappointments included

• no increase in on call allowances

• refusal to pay attending doctor through fee-for-service arrangements for WorkCover, motor vehicle accident or other non-Medicare compensable patients (such as overseas visitors). In a location such as Kangaroo Island where motor vehicle crashes involving overseas tourists are not uncommon, chasing bad debts for on call work is a hassle that doctors would rather do without.

• continued situation where patients presenting to the public hospital with non-GP conditions needing A&E care (broken bones, lacerations, acute psychosis out-of-hours, forensic medical exam etc) are charged private fees as CHSA maintains that the doctor will only be paid for admitted patient services. Interestingly this situation does not occur interstate, with State Govt taking responsibility for provision of A&E services and paying doctors who are called to attend

• a move by CHSA to insist that the responsibility for providing A&E services moves from the State Govt to one or more practices in each location, with practices required to continue cover even if doctor numbers decrease or practices withdraw.

As I understand it, existing ‘sweetheart’ deals offering better terms of service continue in rural SA and have been excluded from contract negotiations – these include locations such as Whyalla, Naracoorte, Mt Gambier, Riverland and Gawler. Suffice it to say that terms and conditions are considered more favourable than the contract offered to other doctors through the standard contract, recognising the particular needs of each location.

Several other rural locations are unhappy – the media report dissatisfaction in Victor Harbor, Snowtown-Clare, Quorn and Kangaroo Island. Millicent is rumoured to be in a similar position and there may well be others who have declined to sign the contract or remain unhappy with terms.

Locally on Kangaroo Island?

The doctors who provide A&E services on Kangaroo Island (through a single entity, Island Locums) have been allowed to continue to provide services until 30/1/13 under existing arrangements – basically Island Locums works 3 weeks per month and CHSA provides a locum service for the fourth week, allowing the local doctors a break.

Bear in mind that some of the doctors contracted to Island Locums are also on call for anaesthetic and/or obstetric rosters, as individual contractors. Having the locum relief for one week in four for A&E provides an important ‘safety valve’ for doctors who are otherwise on call for the hospital every day for around two thirds of the year, plus have to work running their own private practice.

CHSA now want to get rid of the locum and make Island Locums responsible for 24 hr cover 365 days of the year. With a limited number of doctors, (some of whom may leave in future) the pressure on those remaining would be untenable – unless the doctors in turn employ locums for around $2000 per day to provide hospital on call services – a cost currently borne by CHSA. This is not affordable.

CHSA have also made the ability of individual doctors who provide anaesthetic or obstetric on call services to be dependent on the ability of Island Locums to provide 365/24/7 A&E on call – despite these rosters being contracted to different entities. Having been hauled before the ACCC a few years ago by CHSA for alleged anticompetitive behaviour over rosters, the lumping together of rosters provided by different entities by CHSA seems truly perverse and in itself appears anti-competitive.

I’ve indicated the CHSA my willingness to sign a contract for anaesthetic on call – but after three months have still not been allowed to sign as CHSA insists that this service is dependent on another group of doctors providing A&E services.

In short, KI docs face loss of admitting rights and clinical privileges under standard contract terms for procedural on call, unless a solution is found.

The preference would be for existing arrangements to continue ie :the responsibility for staffing A&E remaining with CHSA and doctors contracted to Island Locums providing as much cover as possible without the collapse of local primary care services. Meanwhile procedural on call provided by individual doctors to continue so that Islanders and visitors have access to obstetric, anaesthetic and A&E services all year round.

In the last month the CEO of CHSA (Adj Prof Belinda Moyes) indicated that unless Island Locums assumed responsibility for A&E cover 365/24/7, there would be a threat to procedural services on the Island. As I understand it, Ms Moyes has now moved on (this will be the fourth CEO of CHSA in a decade, they seem to last 2-3 years on average) and is succeeded by Dr Peter Chapman as acting CEO. Perhaps NOW we will see some real action ?!?

Personally I am sick of the failure of Country Health SA to engage in meaningful discussion or acknowledge the different needs of different locations.

As a doctor I want to provide services to my community. Currently I am still in dispute with CHSA over fees for attending hospital patients to the tune of several thousand dollars. This and ongoing contractual disputes and threat of loss of procedural services make the tension for a rural doctor between running own business and working for CHSA almost unbearable.

The grass is looking increasingly greener elsewhere. But if doctors leave rural areas, the on call demands on those remaining escalates…in turn making the need for locum relief more acute.

There has to be a decision about whose responsibility it is to staff the hospital – individual doctors doing so in addition to their own business, or the State Government as a responsibility to provide rural services to taxpayers.

You can read more about some of the other SA contract disputes below :

Adelaide Now online http://www.adelaidenow.com.au/news/south-australia/south-coast-district-hospitals-on-call-conditions-may-impel-gps-to-work-30-hours-straight/story-e6frea83-1226514731619

Situation in Victor Harbor (same health cluster as Kangaroo Island, different on call arrangements) http://www.victorharbortimes.com.au/story/741920/hesitation-about-doctor-handouts/

Situation in Quorn-Hawker http://www.abc.net.au/news/2012-11-15/doctor-to-end-on-call-service-for-hawker/4373654

Situation in Clare-Snowtown http://www.abc.net.au/news/2012-11-13/snowtown-health-care-under-cloud/4368530

Rural Doctor Magazine http://www.ruraldr.com.au/news/sa-gps-resisting-after-hours-deal

Australian Doctor magazine http://www.australiandoctor.com.au/news/latest-news/gps-in-dispute-over-on-call-contracts

MP Michael Pengilly speaking on Country Health in Parliament http://www.michaelpengilly.com.au/news/default.asp?action=article&ID=345

DISCLAIMER : The opinions here are my own. The reported situation on circumstances elsewhere in SA is from the media using links above. There has been no discussion of roster arrangements between separate practices or individual entities. I remain committed to the maintenance of current status quo – local doctors providing A&E services to the level appropriate to available workforce, as well as the continuation of individual procedural doctors providing anaesthetic and obstetric services to their island community under standard contract terms.