THIS week, like so many other doctors, I was appalled and saddened to read Dr Yumiko Kadota’s blog describing her experience as an unaccredited plastic and reconstructive surgery registrar in Sydney. Although it is rare to hear of such a harrowing account expressed so articulately, publicly and bravely, behind closed doors I believe Dr Kadota’s experience to be far more common than we, as doctors, care to admit.

Reading through the many news articles covering the blog, I was gladdened and reassured to see that the majority of messages were supportive ones. Comments ranged from general well wishes to those imploring Dr Kadota to come and join their specialty. However, there were a small number of comments that I found concerning and that I think demonstrate how little is known about the role of unaccredited registrars in today’s hospitals.

For those unfamiliar with the term, an unaccredited registrar (sometimes termed a service registrar) is a doctor who performs all the duties of a registrar but does not have a formal training position. These positions predominate in specialties with highly competitive entry processes and are seen by doctors-in-training (DiTs)as a way to gain further experience in a specialty before applying or reapplying to a training program.

The value of these positions has long been questioned. They do not exist in many comparable health systems and have been criticised as a source of inefficiency in Australian medical training. They have been further slated as being of questionable developmental value due to lack of formal training, appraisal or supervision. Perhaps most concerningly, there is no cap to the number of years that you can work as an unaccredited registrar, and crucially there is no guarantee of career progression. Many DiTs work for years on end hoping to finally get onto a training program.

Which brings me to the first set of concerning comments; the ones along the line of “yes, I remember working hours like that”. To me, some of these comments seemed to verge dangerously close to excusing the hospital. But, regardless of intent, in my opinion, such comments often draw a false equivalency.

According to her blog, Dr Kadota was in her eighth year as a doctor. Not so long ago, surgical training would have taken that same amount of time. In fact, the Royal Australian College of Surgeons-run surgeons.org website still states that “surgical training usually takes 5 to 6 years following completion of a medical degree”. Not “5 to 6 years, following 5 to 6 years working as an unaccredited registrar”.

I have written previously about how elongated training times can increase vulnerability and the effects of bullying. Others have commented on the need for doctors to complete training within a reasonable timeframe for a range of social, family and lifestyle factors. Still, even if Dr Kadota had been successful in gaining a Surgical Education and Training position for 2019, her training would have likely extended beyond 13 years after university – a common reality for the modern aspiring surgeon. Few, if any, of those commenting would have worked for 13-plus years as a resident and registrar before becoming a Fellow. If you add the nearly compulsory fellowship, then 14-15 years might be a more realistic figure.

The second group of comments that I found concerning went along the lines of “where was her College to intervene and help out”. Although well meaning, these comments seem to misunderstand just how vulnerable unaccredited registrars are. As they are not formal trainees, they have no college to support them. Indeed, the RACS President of Council and Board Chair, Dr John Batten, was quoted as saying “we have limited influence over unaccredited registrars, whose protection predominantly falls to hospitals’ human resources department”. In a subsequent statement from the College, Dr Batten stated that:

“While the RACS remit regarding addressing issues that affect surgical trainees is confined to the working places in which they are undertaking their training, we are also concerned about the overall working culture at the prevocational level. It is important to acknowledge that RACS is not the employer in either of these settings. However, RACS strongly supports the same accreditation standards being applied to the prevocational space as the accredited training space. We call on other colleges to support RACS in championing doctors who work in unaccredited registrar positions to have a safe working environment.”

But what is clear to me, anecdotally at least, is that most unaccredited registrars are too afraid of jeopardising their chances at selection to a training program to “kick up a fuss”, even when it is obvious to everyone else that they are being far from “fussy”.

According to her blog, Dr Kadota was trusted to perform highly technical microsurgery by herself, teach other doctors core skills, and be the primary source of plastic and reconstructive surgery advice for the emergency department and GPs within the catchment area for as many as 180 hours straight. Yet, she was not given the dignity or the protection of a formal training position. I struggle to believe that this was because she was not worthy or capable of one.

It is time that we realised that if there is clinical need for an unaccredited registrar (or even two or three) at a hospital, then there is a moral imperative to create a training position to fill that clinical need. Until that occurs, maybe take some time to speak to the unaccredited registrars in your hospital, you might just make their day.

I wish Dr Kadota all the best as she continues to make her recovery and thank her for her bravery in sharing her story.

Dr Tim Lindsay is an Australian doctor and PhD student in the MRC Epidemiology Unit, at University of Cambridge, UK, supported by the Cambridge Commonwealth Trust.

 

If this article has raised issues for you, help is available at:

Doctors’ Health Advisory Service (http://dhas.org.au):

NSW and ACT … 02 9437 6552
NT and SA … 08 8366 0250
Queensland … 07 3833 4352
Tasmania and Victoria … 03 9280 8712  http://www.vdhp.org.au
WA … 08 9321 3098
New Zealand … 0800 471 2654

Medical Benevolent Society (https://www.mbansw.org.au/)

 AMA lists of GPs willing to see junior doctors (https://www.doctorportal.com.au/doctorshealth/)

 Lifeline on 13 11 14

beyondblue on 1300 224 636

beyondblue Doctors’ health website: https://www.beyondblue.org.au/about-us/our-work-in-improving-workplace-mental-health/health-services-program

 

 

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless that is so stated.


Poll

If a hospital has a need that can be filled by an unaccredited registrar, then a training position should be created instead, to fill that need








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27 thoughts on “Time to end unaccredited registrar positions

  1. peter bennett says:

    thanks for the excellent summary of the issues.

  2. Kay Dunkley says:

    The correct phone number for the DHAS service in Victoria and Tasmania is 03 92808712 http://www.vdhp.org.au. The DHAS in Victoria is known as the Victorian Doctors’ Health Program or VDHP.

  3. Cate Swannell says:

    Thanks Kay! Will correct immediately

  4. Anonymous says:

    There is advantage to surgical units having unaccredited registrars. There is no formal commitment to teach them. When their specialty conference is ‘on’, there is no compulsory requirement for them to attend and the unit on-call is covered – now, we couldn’t have the consultant being first on call could we? With safe working hours under scrutiny for accredited trainees, having one or more unaccredited registrars create the perfect fodder to circumvent these issues. An unaccredited registrar is the most vulnerable of the junior doctors – they desperately need a favourable report from their bosses in their interminable quest to become an accredited surgical registrar. Lets be done with unaccredited registrars. If units are not prepared to put the effort into making these positions meet the requirements for accreditation as well as providing a safe working environment, then they should resign and let somebody else take their place. These days, there are plenty of qualified surgeons who do not have a public hospital position and desire one – and do not think for one moment that those young surgeons who have got a public appointment and those who do not are at a different level of capability – for most interviews, there is already a prefered and likely successful candidate.

  5. Madeleine Hetherton-Miau says:

    I just think all the parties to this system are implicated. Perhaps the H&R of different hospitals are primarily responsible – but it’s a total abrogation of responsible behaviour on the part of the RACS to avoid tackling this issue. Absolutely unethical and opportunistic behaviour as far as I can see from all responsible parties and individuals. This has been going on for a long time and needs to be dealt with properly and quickly. The RACS media responses and social feed in response to this issue is not reassuring that they will be doing this any time soon.

  6. Madeleine Hetherton-Miau says:

    Excellent article by the way!

  7. Dr Shirley Prager says:

    I suggest that all Australian public hospitals be listed on a link to MJA as being known to have safe hours for all employees. If MJA receives a report that this is not correct, then the particular public hospital is removed from the website while the matter is being investigated eg inquiry by MJA to CEO of the particular Public Hospital.

  8. Michael says:

    I agree with your concerns, but I think your post propagates some misconceptions about these roles. They by definition are not training posts so should have a different structure – when surgical boards assess training positions they actively look to accredit as many posts as possible and if an unaccredited position fulfils the requirements for training it gets accredited. They are generally designed for very junior or inexperienced staff to get a skill base before training but more importantly ensure this is really the career for them. Once in a training program it is extraordinarily difficult for doctors who have invested heavily in to change course so it is vital people make good choices for themselves early. These roles also allows trainers to give some career guidance and feedback at an early career stage – there should be no unaccredited registrar toiling for years like this with no realistic expectation of being accepted onto a training program. RACS is not the employer, but all Fellows follow a code of conduct that says “in accordance with their teaching role, take responsibility for the teaching and training of future surgeons, junior doctors, medical students and other health care professionals”. A Blog post we must remember is one side of a story, but this has opened a really important discussion about Surgeons and their responsibilities – if we think these roles are beneficial and important for training then we have to make sure they are not abused and Fellows are looking for a response from our College. We should thank Dr Kadota for her bravery in shining some light on this issue.

  9. Michael Nightingale says:

    I agree with your concerns, but your post propagates some misconceptions about these roles. They by definition are not training posts so should have a different structure – when surgical boards assess training positions they actively look to accredit as many posts as possible and if an unaccredited position fulfils the requirements for training it gets accredited. They are generally designed for very junior or inexperienced staff to get a skill base before training but more importantly ensure this is really the career for them. Once in a training program it is extraordinarily difficult for doctors who have invested heavily in to change course so it is vital people make good choices for themselves early. These roles also allows trainers to give some career guidance and feedback at an early career stage – there should be no unaccredited registrar toiling for years like this with no realistic expectation of being accepted onto a training program. RACS is not the employer, but all Fellows follow a code of conduct that says “in accordance with their teaching role, take responsibility for the teaching and training of future surgeons, junior doctors, medical students and other health care professionals”. A Blog post we must remember is one side of a story, but this has opened a really important discussion about Surgeons and their responsibilities – if we think these roles are beneficial and important for training then we have to make sure they are not abused.

  10. Anonymous says:

    Surgery isn’t the only place this happens. I spent nearly five years doing service Registrar work in Obstetrics and Gynaecology during which time I consistently failed to gain a place in the training program (which takes six years)

    It was the final straw and I called it quits when I realised that a medical student I had taught in the women’s assessment five years before had successfully gained a place and I hadn’t. Something was not right, but I could not work out what. I was never short of multiple job offers and encouraged to stay and keep applying. Yet never quite good enough for the training program.

    If we have Service Registrar jobs they need to be tied to a back up career plan, giving the trainee general experience. I could have done ED, paeds, neonates and learned more than just picking up knowledge by osmosis. These unaccredited regs also deserve to know why they are being passed over, and do look out for their mental health. I nearly missed the application for training in that fifth year, I felt lost, I was burned out, I didn’t know who to put as my referees on the application. I stared at the screen five minutes til it was due because I felt nobody had my back at work. Nobody deserves to feel so unsupported.

  11. Anonymous says:

    Two separate issues are being conflated:
    1. Safe working hours are mandated under law and there is no excuse for such egregious abuses of junior staff
    2. Unaccredited registrars are not trainees: it is unreasonable to expect the Colleges to oversee jobs that have nothing to do with them.
    Colleges inspect all the posts they are asked to inspect (and approve as many as they can, particularly after the caning that RACS received from the ACCC a decade ago), but the request for accreditation is only initiated at the behest of the employer; if they don’t ask, the College has no role.
    It is the task of the unit involved to lobby the hospital if they believe the unaccredited registrar is doing a job substantively the same as an/the accredited trainee. But whilst there is cudos attached for a unit to have more accredited trainees, there are also disincentives in the mounting re-tape and compliance that supervision of accredited training involves.

  12. Anonymous says:

    Unaccredited positions no doubt contribute to physician burnout and fatigue. They are devoid of any requirement for supervision or training. Furthermore, the positions are no doubt contributed to by colleges and/or fellowed doctors trying to restrict their future competition.

  13. Andrew Watkins says:

    Unaccredited posts have been a scam for years – as noted, they proliferated in the disciplines with highly competitive closed shops, providing some protection for Colleges against ACCC enquiries about “closed shop” practices to minimise competition.

    It provides the units with terrified, highly motivated and compliant doctors, who can be guaranteed to do as they are told and not complain about any abuse, lest they not get selected one day. Administrators get their grunt work done for them without having to put many resources into training or supervision and if they are really lucky the candidate is an OTD so they can be paid less than the award rate as well ( and will often be even more desperate, respectful and compliant, as a bonus ). What’s not to like?

    Ban them – make hospitals and consultants put the effort into providing accreditable training for all juniors. It is a basic duty to any of our employees, to say nothing of our patients

  14. Sarah says:

    It is pretty unfair to have these high responsibility jobs unaccredited- perhaps the hospitals need to accept more HMO posts and time, and be sure senior HMOs have actual time doing surgery rather than paperwork.

  15. GEOFFREY Toogood says:

    I am from the medical side

    But medical training faces the same issues

    The training is getting more prolonged often with no carrot at the end of it

    Its very tough road for the modern trainee

  16. Anonymous says:

    I’m fairly certain there is no longer any such thing as an unaccredited registrar position in anaesthesia (and has not been for quite a few years). ANZCA only accredit a department – they do not specify the number of training positions within that department, that is up to the head of department (and hospital HR – obviously, as they have to pay the trainees). I understand that ANZCA’s position is that they accredit the department, and any trainee doing the job within the department can register with ANZCA’s training program. Clearly that comes with an obligation to provide access to teaching and training to allow that trainee to progress through the training program.
    While the ANZCA training program does have ‘volume of practice’ requirements that stipulate a minimum number of cases/procedures/etc for different components of the training, an increased number of ‘accredited’ trainees has obvious implications for workforce numbers in the future. This has been a significant issue in recent years with an oversupply of new specialists in anaesthesia, but I understand it has also been an issue within other specialties (ICU and Emergency Medicine).
    Ultimately, in my opinion, the continuation of unaccredited positions will work against any moves to improve safe working hours and working conditions for junior doctors because there will be one set of rules for one group and a different set of rules for another group who ultimately do the same work.

  17. Lynette Foster says:

    Surely this issue can be solved by mandating safe working hours and enforcing that.
    Let’s be careful also that we ensure Senior Medical Officers and Career Medical Officers (who usually have extensive experience and have chosen not to pursue Fellowship) are not adversely affected b any changes and are still able to continue in their careers. These senior doctors work in every state and are a valuable resource

  18. Anonymous says:

    Unaccredited training exaccerbates bullying. With the tantalising carrot of an accredited training position wave in front of your eyes, you will be willing to endure almost anything.
    Let’s look at the college cartels which make no effort to match public demand to doctor supply.

  19. Greg the Physician says:

    I agree with Anonymous (Post #11). The days of registrars working unrostered overtime and not claiming it for fear of retribution by their employers or supervisors should be long gone. If all junior staff claimed all the hours they work, hospitals would find it more cost-effective to employ more staff and minimise overtime.
    However there is a significant cost to accreditation of a training position. There must be adequate numbers of consultants or VMOs for supervision and teaching. There must be the capacity for trainees to attend courses and conferences, and qualified specialists must do likewise to meet CPD requirements. Principal house officers can provide cover for training registrars at such times, and can also substitute for training registrars in the event of unexpected absences from work, such as illness or maternity leave.
    It can be difficult to meet College accreditation requirements. I have been a long-term supervisor of advanced training in a physician subspecialty, but the position has lost its accreditation because the large (700+ beds) private hospital at which I work no longer provides outpatient clinics. Our previous advanced training position has been converted into a PHO one which now provides valuable, well supervised experience with large numbers of inpatients to enhance the occupant’s chances of being selected for an accredited advanced training position next year.

  20. Dr Shirley Prager says:

    Anonymous stated 1. Safe working hours are mandated under law and there is no excuse for such egregious abuses of junior staff.

    What is the legal penalty to the CEO and members of the Public Hospital Board if a Public Hospital is found guilty of employing one or more employees for unsafe working hours ?

    Is it a civil or criminal crime or both ?

    Have there been any cases prosecuted in Australia ? If so were any CEOs or Public Hospital Board members found guilty, fined, or gaoled ?

  21. Sarah says:

    Replying to commenter ‘Michael’:
    Sure, unaccredited reg positions are designed for junior staff to gain skills, but in practicality the unaccredited surgical reg is an unprotected trainee with as much responsibility as a registrar on the program but none of the support. Candidates can gain experience in theatres as a resident to ‘test the waters’, no need to create unaccredited reg positions that are in danger of being exploited.

  22. Marcus says:

    Instead of calling them “unaccredited registrars” (which already sets expectations) call theses doctors PGY3(+), which is what they are.
    There is a workforce need in some hospital specialty settings for doctors.
    This may not be matched by a similar need for consultants in those specialties in the outside community in later years, as indicated by Anonymous #16.
    Getting rid of unaccredited posts doesn’t get rid of the hospital work that needs to be done.
    How much more cruel would it be to put all these doctors into training programs only to find that there is no work for them afterwards (even if we could find accredited training for them all) in their chosen specialty?
    And no, this is not about closed shops, but about adequate training opportunities, workforce needs and avoiding the make-work over-servicing that is already rampant in the cities.

  23. Dr Tom says:

    reading the blog was heartbreaking and those involved in the department at hospital X should be sanctioned and ashamed
    many unaccredited posts are rewarding stepping-stones to SET training for those (many) who have been unsuccessful in applying or are commencing the process. They allow surgeons a good look at prospective candidates and keep future surgeons within the specialty.
    the problem is not the system but the individuals and departments who abuse their junior doctors

  24. Anonymous says:

    If we get rid of unaccredited positions then they will be filled by senior residents on the resident medical officer pay schemes without 5 paid training hours per week. It will also mean that when these same residents get on they enter at registrar pay year 1.

    I say this as someone who has trained through both ANZCA (anaesthesia) and CICM (intensive care).

  25. Anonymous says:

    I am writing as a recently retired HOD of OandG at a large public hospital. It’s a very busy unit, but some efforts to improve life for the junior doctors have been successful. At the beginning of last academic year, I changed the night roster to 7 X 12 hour shifts followed by a week off. This caused some issues with HealthRoster, but eventually they were overcome. I switched one registrar shift a day from 8:00-4:30 to 13:00-21:30. The goal was to provide more support at the witching hour of 16:30, when all the people covering consults, ED, EPAS, and OT handed over to the on call team. This proved to be somewhat helpful, but we were 5 doctors short due to multiple maternity leaves and unfilled positions. This left registrars doing “long shifts” from 8:00to 21:30. The plan to backfill the morning antenatal clinics with antenatal shared care GPs under the supervision of a consultant was supported by everyone involve except for the CE,
    The point is that the public hospital system could be reoriented to be more efficient, but you have a lot of moving parts to deal with.
    The hard limit on O&G training positions is the number of gynae operations available to the trainees. You simply can’t train more people than you have the clinical material to teach. In the future this might mean splitting the specialty into just OB or just a Gyn. I hope that doesn’t happen. At present, a large number of people in SRMO and unaccredited spots are trained overseas, these positions provide a means of getting Australian experience, as well as support in applying for training positions or SIMG interviews. Some of these people will not prove to be suitable RANZCOG trainees, however their skills and experience are valuable as in unaccredited/CMO role.

  26. Anonymous says:

    The system is a disgrace, with clear inequities and bias. Clearly, some are still defending this.

  27. Anonymous says:

    It’s important not over generalize and conflate the many issues this case has raised. Clearly, Dr Kadota’s experience was terrible and unnacceptable. I feel it would be more sensible to address the failings of the systems already in place which should have prevented Dr Kadota’s experience, rather than push for another layer of oversight. Workplace law should have protected her. Hospital management, and senior staff on the plastics unit, also failed.

    Accreditation is not a panacea for all workplace issues. The college remains in the position of not being the employer of trainees. They can stipulate conditions they expect of accredited training positions, but in my experience these are rarely all met. When issues such as excessive on call exist in a training post, the college’s only course of action is to insist on less on call or remove accreditation for a post. This is not usually rectified within term of the trainee raising the issue; hence accreditation will not resolve all the issues with over-rostered jobs.

    It is also important to recognize that many unaccredited positions are enjoyable posts, which registrars use to learn and decide on their future careers. In an ideal setting, unnaccrediteds learn from more senior accredited colleagues, get a taste of the realities of life in a specialty, and are usually shielded from the more demanding aspects of the job. In my experience it is more often the accredited registrars doing the lions share of the on call and the unrostered overtime. Clearly this was not the case however for Dr Kadota.

    The issues raised need more consideration than the knee-jerk response of “ban the unnaccrediteds.” More useful steps to take might be all junior doctors, from interns through to accredited registrars, always claiming all unrostered overtime. This adds transparency and highlights issues for hospital management. It also goes without saying that all hours worked deserve remuneration. Perhaps a significant punitive outcome for those seniors and management types who allowed this to happen on their watch (and worse, ignored Dr Kadota when she sought help) would serve to discourage others from mistreating their unnaccrediteds registrars (or interns, residents or accrediteds) in the future.

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