NSW commits to improving health of doctors-in-training

EARLIER this year, I wrote about the New South Wales Junior Medical Officer (JMO) Wellbeing and Support Forum, convened by the NSW Minister for Health Brad Hazzard on 6 June, 2017, in response to a series of well publicised suicides of doctors-in-training.

This month, the NSW Ministry of Health released the JMO wellbeing and support plan, which commits to delivering 10 initiatives over the next 12–18 months to hopefully improve the health and wellbeing of doctors-in-training in NSW.

Overall, the plan is an impressive commitment to addressing some of the longstanding, modifiable stressors imposed by the public health system.

Importantly, it also calls on other key stakeholders to put some skin in the game, because their policies and behaviour also have a significant impact on the wellbeing of doctors-in-training. Key among these stakeholders are senior doctors, the specialist medical colleges, universities, and peak bodies such as the Council of Presidents of Medical Colleges, Medical Deans Australia and New Zealand and the Australian Medical Council.

The most impressive initiatives in the plan are:

• Changing mandatory reporting legislation to exempt treating practitioners from the legal requirement to report an impaired patient who is also a health practitioner to the regulator (Initiative 1).

Unfortunately, the plan does not specify how NSW will amend their current law, and there is a risk that changes won’t go far enough. I agree with the Australian Medical Association (AMA), Avant and MDA National that the best model is the one in Western Australia, which provides a clear and complete exemption for treating practitioners. Any hybrid model, such as that in operation in Queensland, will continue to confuse and to deter help-seeking.

The plan also fails to recognise the urgency of this initiative. Minister Hazzard has predicted lengthy delays while nationally-consistent reforms are pursued. He has said that he favours a model as close as possible to Western Australia’s – so he should get on with legislating it. Copying Western Australia’s law would not add any complexity to the status quo but it would immediately benefit NSW’s 34 399 doctors.

Another significant omission in the plan is any mention of whether NSW will also repeal its bizarre and unnecessary requirement for immediate reporting of any health practitioner or student upon involuntary admission to a mental health facility. This unfair law makes no sense, as a practitioner’s patients are fully protected while the practitioner is contained within a psychiatric ward. It also risks coercing acceptance of “voluntary” treatment so as to avoid a mandatory report.

• Committing to an investigation into unclaimed, unpaid overtime and unsafe working hours (Initiative 2).

This is a much-needed exercise that, properly conducted, is likely to reveal an enormous number of hours that doctors are currently working for free. Aside from unpaid overtime breaching the Public Hospital Medical Officers Award, it also hides the true service demands within public hospitals, averting process improvements and the hiring of more staff.

• Placing a limit on shift lengths (initially of 14 hours, but with an aim of 12 hours) and imposing a minimum 10-hour break between rostered shifts (Initiative 2).

The key risk to successful implementation of this initiative is unrostered overtime – if that is not also reduced, then actual shift lengths will continue to exceed 14 hours and breaks between actual shifts may be far shorter than 10 hours.

• Introducing an annual training survey (Initiative 3).

The AMA has been calling for a national survey for many years, and while the Medical Board of Australia is apparently working on one, it is pleasing to see NSW get on with it in the meantime. Without a regular survey, we are deprived of valuable data to monitor the impact of initiatives such as those stated in this plan, to help guide new initiatives, and for workforce planning.

• Introducing “length of training” contracts (Initiative 6).

NSW already offers 2-year contracts to medical graduates (the only jurisdiction to offer longer periods is Western Australia, with 3-year contracts), but in the plan they have acknowledged the superiority of also offering multiyear contracts for specialty training. The current practice – also common in other jurisdictions – of offering only 12-month employment contracts during specialty training is stressful and inefficient for both trainees and employers, and causes particular problems when trainees wish to take a break from training, such as to use parental leave.

The plan also acknowledged several other concerns of doctors-in-training, including a lack of cover when staff are on leave (which discourages doctors from taking the leave they are entitled to, especially sick leave when they are unwell), the toll of estrangement from support networks while on “away” rotations, bullying and harassment particularly by senior staff, removal of communal facilities such as the old doctors’ mess, and a culture liable to punish those who seek help for a mental health issue.

The document also describes pre-existing initiatives offered by the Ministry of Health and other bodies such as the specialty medical colleges, most of which remain very underwhelming. Of particular concern is that the Ministry-run “JMO support line” was apparently developed for doctors-in-training “who feel they are being subjected to unacceptable behaviour in the workplace,” yet one of the consequences of calling this number may be for the caller to be referred to a “performing under pressure” course. The appropriate response to unacceptable behaviour is to manage it at its source – not to put the victim through a training course. Both the “JMO support line” and the plan should be revised in this regard.

Sensibly, the plan commits to a review of progress in 18 months’ time.

Overall, Minister Hazzard deserves congratulations for his response to our colleagues’ premature deaths. The plan rightly focuses on dealing with systemic problems within medical training rather than blaming individuals for having the wrong personality traits or lacking basic mental health knowledge, as others have done.

There remains opportunity to do more, including addressing the unhealthy aspects of medical hierarchy; committing to eradicate unrostered, unpaid overtime; limiting runs of shifts to, for example, seven in a row; providing cover to better enable doctors to take their leave; addressing training pipeline bottlenecks; and properly tracking the mental health of doctors over time. However, the plan makes a solid start in NSW.

It is now time for the other states and territories to at least match these commitments, and it is vitally important that the specialty medical colleges heed Minister Hazzard’s call to “join with us in examining their programs and practices, to identify where action can be taken”. Addressing unnecessary training stressors such as exorbitant training costs, excessive barriers-to-entry and once-a-year exams linked to training progression should be key targets, and if the colleges don’t deal with these issues proactively, regulators should step in and force them to do so.

Benjamin Veness is a psychiatry registrar with a Master of Public Health and a background in corporate strategy. He is a Churchill Fellow and a past president of the Australian Medical Students’ Association. Twitter @venessb.

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