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OVER 2.5 years after writing her internationally viral blog post “The ugly side of becoming a surgeon”, Dr Yumiko Kadota has seen no improvement in the situation for unaccredited registrars working while they try to find a place on a specialist training program.
“No one seems to be answering the question of who looks after unaccredited registrars,” Dr Kadota told InSight+ in an exclusive podcast.
“It’s an in-between position in that the Postgraduate Medical Councils look after [postgraduate year] 1 and 2, the accredited trainees are looked after by the Colleges.
“But no one knows who’s looking after the unaccredited registrars in the middle. That’s going to be an ongoing issue until we have one body – even if it’s a new one – that looks after that very vulnerable group of doctors.
“Because when you’re not yet selected onto a training program, you’re very vulnerable to exploitation.”
Dr Yumiko Kadota
Dr Kadota resigned from her post as an unaccredited registrar at Bankstown Hospital in Sydney’s west on 1 June 2018, after working 24 straight days, including 19 on 24-hour on-call duty, with no prospect of her situation improving despite six senior doctors speaking up for her.
“I had been trying so hard not to complain because I knew what was at stake. I needed to get onto the advanced training program. It was like I had put my whole life on hold and I was not a valid human until I got accepted onto this program. I needed my bosses to support my application, which meant I would have to keep working tirelessly and produce perfect surgical results. I couldn’t keep my eyes open, but I could keep my mouth shut. During the day, if I had a spare moment, I would go to the registrars’ office, cover my face with my jacket and sleep on a chair. “Who’s that?” I would hear a voice say. “Oh, that’s the Plastics Reg, she’s always here,” would reply another. I stopped caring that I was looked upon with so much pity … I didn’t even know who or what I was anymore. [Bankstown] was a small hospital. The Head of all of the surgical departments had gotten involved by this point. ‘You can’t make her do all of this on-call. The roster must be changed’. Those were his orders, but ultimately it was up to my department. I had already expressed a concern that my ability to care for patients had become compromised because of my extreme exhaustion. It was beyond burnout. On the 1st of June I resigned. It wasn’t okay anymore. I was physically alive, but spiritually broken. At lunch time, I begged the Head of Department if I could go home. The answer, as always, was no. ‘Just hang in there.’ I felt like I had already ‘hung in there’ for 3 months. The 1st of June was my 24th consecutive day of work, 19 of which were 24-hour on call days. I knew what it would mean to resign – I would be black-listed and I would never get a job in plastic surgery again in Sydney. But I couldn’t keep going. I crashed my car on my way home. At the news of my resignation, the Head of Department rang me. ‘Can’t you just finish your term? It’s only a few more months’, said the voice down the line. ‘I don’t think I can’, I said. ‘It’s a shame. You have good hands. You’re good at what you do … but if you can’t handle the hours, maybe this isn’t for you.’ And that was that. The chilling final words from my Head of Department.”
Dr Kadota now works teaching medical students anatomy at the University of New South Wales and works part-time as a surgical assistant in the private sector. And she still hasn’t heard from the Royal Australasian College of Surgeons (RACS).
“I am aware that they did send around an email after my blog post, because friends of mine who are trainees showed it to me,” says Dr Kadota.
“There were members of the College who offered to pay for counselling. [But by then] I’d gone through psychiatric treatment. I’ve gone through a lot more than a little counselling is going to figure out.
“So I heard from individuals but not directly from the RACS itself. But I have been approached by the other Colleges to share my experiences and talk at various meetings. I think it is something that the Colleges do care about. They do want to make it better for their trainees.”
None of which helps unaccredited registrars. A search for “unaccredited registrars” on the website of the Confederation of Postgraduate Medical Education Councils comes up with no results. Similar dives into the RACS, the Royal Australian College of General Practitioners and the Royal Australasian College of Physicians websites also come up empty.
Dr Kadota draws hope from the medical students she teaches.
“I have had students ask me about it, and I’ve always been open about talking to them about it,” she says.
“I don’t want to discourage any students from going for their dreams, if they want to do it. I fully support them doing it. I don’t see my job as protecting students and telling them not to do it, I see my role as just increasing awareness that there will be challenges and to know that it can happen and potential ways to deal with it, rather than saying don’t do it.
Students are far more aware now of what they’re getting themselves into, she says.
“I feel encouraged that students are very proactive about these issues. We’re seeing a real movement now, in all areas, not just medicine, where we are trying to stop these unacceptable behaviours from happening.”
Dr Kadota believes the younger generation can not do it alone, however. Senior doctors who went through abusive training practices need to break the cycle.
“We talk a lot about the younger generation, and I see so much hope when I look at [them] but we do need the people who have suffered in the past to say, I suffered, but I can stop it.
“They’re the ones in the positions of power at the moment. It is the consultants who can really drive that change because they’re at the top. People say the fish rots from the head – we need better institutional leadership, and not just rely on the people at the bottom to make change. It goes both ways.”
And perhaps now is the time to introduce quotas into the medical workforce, Dr Kadota suggests.
“When we think about the lack of visibility of surgeons in Australia, perhaps we do need to start thinking about quotas,” she says.
“I know that a lot of people say targets are better than quotas, but it’s taken such a long time, with not much of an increase – at the moment, only 11% of surgeons are women, and it’s even smaller in areas like orthopaedics, which I believe is 4%.
“Part of the problem with misogyny is lack of visibility. If there aren’t enough women around to say, ‘hey, that’s not cool, what you just said’, or ‘no’, or role modeling and seeing other women, or other people who look like you in surgery, it does affect the experience of women.
“Culturally, we need to change to make [surgery] more welcoming for women.
“But cultural shift takes so long, and I don’t know whether things are changing fast enough. I feel like we’re still 10, 20 years away from seeing a real big shift.
“The young medical students becoming consultants will take another 10–20 years. When they become consultants, maybe things will be better. But that’s still a long time away, and still a long time for things to happen badly.
“I am not going to pretend that I know all the answers, but I feel like one way to improve things would be to increase the diversity, not just with gender, but also ethnically as well.”
Dr Kadota has just released her memoir, Emotional female (Penguin Random House).
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It is very concerning how young bright eyed , bushy tailed doctors can be blacklisted, not- selected, felt continually diminished in what appears to be entrenched patterns of psychopathological behaviour by high stakes players who are thickly armored by the anonymous protection of notions such as a “college”, “health service”, provider. Doctors are gagged by fear of losing their job, their training- everything they had for the last 10 years of work and high expectations. To compare the current generation of doctors to cannon fodder would be an understatement. Were they not so busy working , studying, trying to impress a clique of obsolete , often self- proclaimed Royal Besties in surgery to “get selected”, “to get on” , these doctors would probably be walking out on the streets and lobbying for their rights just like anyone else can. May be for the older generation of older RoYal surgeon, it was ok to have a gruelling roster when there were 10 people living in Sydney, but now this is a thriving full on multi million metropolis of interracial violence, new high level trauma which cant fit in the old cookie cutter model designed to tintillate the ego of a few monomaniacal power grabs Can one person cover a tough million people subburb in West Sydney. I’ d imagine, he/ she couldn’t. We would like to ask some of the “untouchables” to leave the heavy leather armchair and caccooned , “too- good to share” private practice sinecures and swing from the chandelier across hospital floors and wards, but in this day and age, not in the golden days of half a century ago. Lets see if the elites still can or are they too rusty coz the reges have to do all the dirty work otherwise they wont “get on”. To withhold training because you fear competition and drop in your yearly private practice revenues is a criminal matter which needs to be addressed urgently as the system is bleeding out. For reges to have to apply for years yearly for a job , to move from a different state for work while the bosses sip Cab/Sav and enjoy the unparalleled views of Double Bay appears to have become archaic , mundane and definitely not Fair Dinkum. Talking to my friends and colleagues in Europe and America, availability of training cannot be sparse- they immediately enter training programs with permanent 5 year attachment to the hospital . Why is Australia so backward and cant train doctors? To the Fellows, do savor your apperatif , while another doctor commits suicide in acute distress , in the doctors room consisting of worn out leather couches no doubt from St Vincent de Paul. Cheers to the Boy Club- its a long fall to the very bottom from the top
Sounds like pure abuse of doctors and utter danger in Australia! I agree unaccredited registrars should not exist, not properly trained and can endanger patients. Wait till a lawsuit comes along when mistakes or death occurs and they would stop this abuse
These practices are not just reserved for surgeons or unaccredited trainees – as a procedural physician advanced trainee in a tertiary city hospital I spent two years in a 1:2 on call roster ie. Every second week myself and the other trainee would take turns doing on call 24/7 for 7 days in a row. What added insult to injury was that if one of us were on leave, the other would be expected to be on call the entire time. My head of department even suggested that if I were to take maternity leave, the other trainee would have to cover for the duration of my leave (as had supposedly happened before many years prior). To be kind to each other we never took more than 2 weeks off at a time, leaving the other to be on call for 21 days in a row. It wasn’t the busiest hospital so we all survived it (barely) but it would have been nice if the consultants did a couple of days of first on call or even a weekend ward round when the other trainee was away. Apparently this was just too much.
RANZCOG The college of obstetrics and gynaecology also are similar with respect to the disparity between unaccredited, and accredited trainees. I spent five years trying to get into a six year training program working in tertiary hospitals. Much of that time I worked unsupervised on nights and weekends. I left and I thought “I should write a book!” I got talked out of it but I’m glad Yumiko did. I experienced different issues to Dr Kadota who suffered more than I did, due to disparities with her overwork and on-call. I received minimal feedback, had an imbalanced roster compared with the accredited trainers, I never got a choice about when I took my holidays, the accredited trainees would feel entitled to muscle in on my exciting cases (triplets etc). There was so much going on and I wanted to learn more, do more, but I was always on the outer, a I felt like a second-class citizen. When I started there appeared to be a clear path into training but it soon became obvious after not being selected to training that things were changing. More and more service registrars employed year after year, I was leapfrogged by younger better doctors. I tried to get some kind of qualifications before I left but I have no letters to show for all those years, the thousands of deliveries. I have a stack of surgical operation report printouts. Otherwise you’d just have to believe me.
So, surgeons who are both in private practice and members of RACS/AMA/their society are restricting training because of their business interests… this is a conflict of interest. Is this even legal? It certainly isn’t ethical. Why are you just reading this and not doing something about it? There should be a royal commission or corruption and misconduct enquiry into this.
I would suggest the title “unaccredited registrar” is abusive. It is appalling we are treating human beings and fellow doctors in this way.
A while ago, the UK colleges ruled that non trainee registrars were entitled to the same work provisions as trainees (including fair balanced rotas, study leave, attendance at courses and training days, yearly feedback and other basics). This should happen in Australia. There needs to be a certain numbers of doctors on the ground to cover the out of hours work, but not the unfair distribution. Equally, having a pool of unaccredited doctors doing six months of only nights, not belonging to a team, so not having a recognised mentor, is just service provision and is outdated. Nobody should be on call 19 days in a row…..!
The other part to these “Unaccredited Registrar” Positions, particularly in smaller surgical services where there is only 1 or 2 registrars, is that they provide 24-hour cover as well as doing their rostered shifts – either 5-days or 7-days depending on what the service requires. This combined with the Dept of Health 4-hr rule means that through the night when they are woken with every patient that needs a treating decision (discharge or admission) regardless of the acuity of the patient. For serious issues, sick patients or anyone that needs an urgent operation/ICU admission the middle of the night phone call is appropriate. However the stable patient or the dischargeable patient that needs to be linked in with an outpatient process middle of the night phone calls are not appropriate, when the registrars will be backing up the next day for a “normal” shift, which is often 10-12+ hrs including operating (who wants to have an operation if the surgeon has not had a good night sleep!).
It only takes 1 or 2 phone calls to totally disrupt your sleep/rest. If this is happening day after day it is not only inappropriate it is UNSAFE for the patients and the employee (doctor)!
Once you’re in training RACS can protect Trainees by expecting a 1 in 4 roster for all training registrars (minimum number of surgeons required by RACS to provide a 24hr/7d surgical service to provide SAFE Surgical Practice & is standard for both Fellows & Trainee Positions) however this is NOT translated in to smaller departments or units that have non-training registrars only. These departments can roster their non-training registrars as they wish to provide a 24-hr service and often use historical registrar requirements or patient numbers to justify a department with only 1, 2 or 3 registrars and do not use minimum safe number ratios to staff their Registrar Services and have no safe sick and annual leave cover either!
All doctors outside the the Prevocational Years (PGY1/PGY2 +/-3 & training registrar years) are incredibly vulnerable, have no medical college support and limited industrial support. They are also SO SCARED to speak up when they are being industrially abused because if does destroy their career.
These doctors need 2 big changes: 1) the development of a “Training” Body to oversee these position, provide some credentialling and oversight as well as advocacy for safe work practices and training/education opportunities & 2) Review by relevant state Department’s of Health to ensure ALL Junior Doctors at every level are being provided a SAFE work place – which includes SAFE WORK HOURS of both ROSTERED & ON-CALL shifts (it’s the on-call rosters where the SAFE-WORK hours are totally abused and unsupported)
I think we need to address the ethics, and dangers, of (medical) labour workforce restriction. It is the same group of VMOs/SMOs/Consultant within the Health Departments/RACS/Colleges who simultaneously wear multiple hats and use subterfuge to escape culpability while stuffing their (and their relatives or mates) pockets with cash. The implications of this ‘disavowed approach to training’ lead to geographical narcissism, the collapse of regional hospitals departments, and further disparity of accreditation versus service provision. Ballooning of the unaccredited registrar pool also seriously threatens the value of the entire medical community. This could lead to doctors working for a relative pittance. Ultimately, access to ‘accredited’ health care is also restricted, a fundamental health care right of all Australians. RACS and associated colleges need to be disembowelled of this sort of power and the grubby hands of the power players need to be shackled. Here is another thought, where is RACS Whistleblower Policy? What about the Colleges? What about the government health services?
When I was an Intern many years ago, all Registrars with Part 1 FRACS exam were trainees.
We would study in our Junior or Senior RMO year, pass the exam, then apply for a Surgical Registrar position with the Hospital and simply register with the College that you were training. 3-4 years later one would sit the Fellowship and finish training. Many would then go overseas for a year or so of “cutting” experience and return to start Practice.
In 1981, the College invented the Trainee Registrar and the Service Registrar. The transition was that those Registrars currently employed but who did not have Part 1 were stuck as Service post registrars and those already with Part 1 were “safe”. Following this, the number of new Trainees in my State plummeted from 20 annually, down to around 3.
The purpose of this new approach was to restrict the training of Surgeons because there were deemed “too many Surgeons” and this was restricting the viability of those already in practice.
The purpose of restricting training today remains the same.
This abuse of junior staff is condoned by health service management. Management abrogating their responsibility down the management food chain would not be found to be just by workplace investigators. It is abhorrent that such rostering continues to exist after all the research done on safe work practices. It is unsafe for patients. Employers are not providing a safe work environment for their employees. It needs to be stopped immediately.
There is no mention in the article of the economics involved in both the costing of both recognised and unrecognised registrar posts or indeed all junior medical officer posts.
Dictum: ‘Those who control the Treasury, control the Government’.
The Department Heads of hospitals are given fixed annual budgets by management that is often subject to opaque managerial variability. They have virtually no ability to easily or even rationally expand their budgets so as to employ more doctors for the open ended tasks required of them.
Constant Health Dept directives demanding so called ‘efficiency dividends’ are the norm. These constant weasel worded coded demands for cuts to their Recurrent Budgets by the financial bureaucracy of the organisation completely ties the hands of department heads and removes any likelihood of ever obtaining rational staffing levels for the work load within their departments.
Until the non-medical senior hospital managers are made fully and personally accountable for the Workplace Health and Welfare aspects of ALL junior medical staff, then this blatant exercise in ‘slave labour,’ that has persisted for ever in medical training will continue to be sold and exploited as just some sort of ‘right of passage’.
Cui Bono: Hospital Administrators.
Follow the money.
The RACS is the only College (I think) that doesn’t allow ANY doctor who works as a registrar to sit the exams. Unaccredited registrars should not even exist. The system and the people stuck in it have been abused for decades.