Operating at breaking point

No one likes a complaining doctor. Doctors are supposed to cure complaints, not make them. But sometimes even doctors need to self-diagnose their problems.

The closure of the emergency department at Caboolture Hospital last week has brought to a head a national problem. Junior doctors are being used around Australia as fodder to staff unsafe district hospitals.

As in southwest Sydney and in Perth ‘s maternity hospital, the system in Queensland has cracked. The confidence and morale of the public hospital system’s frontline troops is at an all-time low.

Over the coming month graduates around Australia will enter into this crisis of confidence as fledgling interns. They will be subjected to unacceptable pressures that have plagued junior doctors for decades.

Despite breakthroughs in miracle medical cures for many diseases, the ailments facing a young doctor remain unsolved.

Like their colleagues in the nursing profession, for years young doctors have trumpeted the cause for safer working hours, better supervision, and improved working conditions.

But it remains commonplace for a young trainee to work 24 hours straight, many young surgeons still find themselves on call for days on end, and doctors with only a few years’ experience are the most senior on-site clinicians in smaller hospitals.

Over the next few years these interns will find themselves stretched to breaking point. Is this the kind of care we want in our public health system?

One of the main problems is the conflict between education and service provision. Young doctors learn their trade while providing an essential service to public hospitals. Any patient will know that it is the junior doctors – the residents and registrars – who take care of them on a daily basis.

During a typical admission the patient will see a consultant doctor only a handful of times.

The most effective training occurs in large central teaching hospitals with access to the best experienced clinical teachers. Better training leads to better skills and better patient care.

Yet state governments continue to push for smaller district hospitals to be staffed around the clock with little capacity for training.

Although consumers expect 24-hour access to the very best health care on their doorstep, quality health care is not like a McDonald’s drive-through.

Lack of supervision leads to mistakes and deaths.

The Macarthur health inquiry highlighted gross gaps in service provision at Sydney ‘s Campbelltown and Camden hospitals, both in the number of junior doctors available to fill positions, but more importantly in the access to quality training and advice from senior staff.

Despite these lessons, a leaked document from Queensland Health still plans to staff Caboolture emergency department with junior residents rather than senior emergency physicians.

New South Wales health’s solution has been to devise a system that directs more juniors into district hospitals.

This has eased staff shortages little and done nothing to tackle the key systemic issue of supervision.

It also has decreased the quality of training available to junior doctors. So, although there may be more junior doctors in a hospital, they are increasingly out of their depth.

So what is the prescription? There can be no doubt that district hospitals are more dangerous places than their larger, central counterparts.

The Healthcare Reform Group has pointed out that providing 24-hour emergency care at district hospitals is no longer sustainable.

This highly experienced group of Sydney doctors and nurses advocates reform to overhaul the role of smaller district hospitals and transfer the bulk of acute and critical care services to central teaching hospitals.

The problems of poor supervision of juniors, workforce shortages and severe lack of resources in rural health care can be tackled using this plan by the Healthcare Reform Group.

Emergency services should be available only at larger hospitals, and the role of district hospitals changed to non-acute centres that transfer critical cases to partner teaching hospitals. This will allow junior doctors to spend more time in larger hospitals where supervision and training are better.

From a rural perspective, country hospitals will then be serviced by larger numbers of well-trained junior doctors who can better respond to the pressures of unsupervised rural service.

The Australian Medical Workforce Advisory Committee suggests that young doctors who complete rural terms are more likely to return to rural areas, which could ease the rural health crisis further.

Of those doctors who start next week, we can expect one in 10 to leave the profession in the early years of practice. Instead we should be encouraging the retention of young doctors in the public system.

Truthfully, it has become impossible for many medical graduates to find balance in the life of a doctor.

Some will look for relief in other health systems overseas, many will return to their previous professions and leave medicine entirely. Whatever they do, in the current climate, it would not be an unreasonable choice.

One of the core skills of a doctor is to draw attention to problems – to diagnose dysfunction in the human system. It is time to start taking notice of that skill in another context – the diagnosis by experienced doctors of dysfunction in the public health system.

There is a crisis of confidence in the very people who are trained to keep the system alive. If we don’t pay attention, we very easily could lose a generation of doctors to apathy, burnout and disillusionment.

• Dr Nick Coatsworth is a medical registrar in the public health system and was previously president of the Australian Medical Students Association. He co-authored Doctors in the Waiting Room published in the Centre For Independent Studies journal Policy.