THE BULLYING CULTURE OF RESIDENT DOCTORS
Recently, an article called “Let’s stop the bullying of trainee doctors – for patients’ sake” summarised an Australian’s ABC television expose “At Their Mercy: The bullying and bastardisation of young doctors in our hospitals” which aired in Australia on the 25th of May.
The controversial comments made earlier this year by Dr Gabrielle McMullin from the Royal Australasian College of Surgeons in response to neurosurgeon Dr Caroline Tan’s allegations of sexual harassment provided the expose’s starting point. “At Their Mercy” referred to the “entrenched practice” of bullying in the medical profession and discussed breaking the “silence around the destruction of careers and health that doctors cause among their own”.
The expose highlighted that bullying in hospitals start early on in a doctor’s career. Resident doctors are often subjected to ‘teaching by humiliation’ methods and abusive type behaviours from senior doctors. As a result, many young doctors have their self-confidence worn down over time which in turn is likely to affect their focus and ability to perform. When a doctor’s performance is impaired this can have a negative impact on patient safety.
One doctor that was interviewed commented that resident doctors are given the impression by staff throughout medical school that the hospital environment is one which is built on team work and collegiality – but, resident doctors soon realise that this is often not the case as they start to experience senior doctors taking advantage of the trainee apprentice model and using the hierarchy of disparity in authority amongst doctors to abuse their power.
Doctors in training are confronted with a situation where those who are doing the bullying are often their direct supervisors – such supervisors are required to sign off on various procedures and make recommendations about these resident doctors. The understanding amongst doctors and in the hospital workplace is that it is dangerous to complain about a medical professional higher up in the hierarchy than you – this is because they essentially hold your career in their hands and when you make a complaint you are faced with “losing it all”. Bullying behaviour is difficult to police because it is can be subtle and is underreported.
Resident doctors often look to their most recent role model – often a more advanced doctor. If a senior doctor demonstrates bullying behaviour then this can increase the likelihood of those that he or she teaches repeating similar training techniques and attitudes towards others. Doctors need to be able to say “I do not want to be like that bullying doctor” and use the trainee apprenticeship model as a positive tool to inspire and productively teach others.
The expose referred to statistics gathered from research undertaken in 2013 by the Australian organisation ‘Beyond Blue’. Around 14,000 doctors and medical students participated in the survey. Some of the survey findings included: 1 in 20 Australian doctors were left feeling stressed due to bullying in the workplace over the last 12 months, 1 in 5 medical students and 1 in 10 doctors had had thoughts of suicide – in comparison, 1 out of 45 of the general population had these thoughts. Statistics like these speak volumes in regards to the stress and pressure that we face every day. Bullying (and other destructive) behaviour negatively impacts a doctors’ mental health and adds to this stress and pressure.
In terms of making progress on these issues, instances of bullying, sexual harassment and inappropriate behaviour must be reported. In order for this to occur, doctors need to be confident that there is not going to be any retribution if they speak up and make a complaint. Employers need to determine how they will address these serious issues – this includes how to deal with complaints made by doctors against doctors in an impartial way.
The expose concluded with the following statement “the medical profession now accepts that it has an entrenched problem in its culture… but does it have the will to fix it and the courage to support those who speak out?” If you want to watch the expose online see the following web address: http://www.abc.net.au/4corners/stories/2015/05/25/4239823.htm
The discussion in “At Their Mercy” largely resonated with many of the comments and findings produced from the recent research the NZRDA has undertaken in regards to these issues affecting RMOs in our hospitals. The NZRDA has arranged a meeting at the end of July with leaders from throughout the profession and DHB’s to discuss what needs to be done to address these issues. We will give you an update on this matter following this July meeting.
THE VULNERABLE CHILDREN ACT 2014 AND SAFETY CHECKING REGULATIONS
The Regulations under the Vulnerable Children’s Act 2014 apply to government employees who work with children. DHBs are legally required to ensure core children’s workers starting with them as employees are safety checked before commencing work in order to help achieve safer recruitment. The purpose of this vetting is to assess whether staff might pose a risk to children and to prevent known abusers from entering the children’s workforce.
The Act creates two categories of children’s workers: core children workers (who have primary responsibility or authority over children) and non-core children workers (who have regular but limited child contact). In most circumstances, RMOs will meet the core children worker definition but there may be some exceptions. If in doubt, err on the side of caution and assume that you do. The required children’s worker safety check is the same for each type of worker but the requirements come into force earlier for core children’s workers.
On 1 July 2015 the first phase of the new requirements commences (on 1 July 2016 the second phase commences). All new state funded core children workers are to be safety checked before starting a new role. So this applies to all of you who start work at a new DHB at the next change over and includes moving between the three Auckland area DHBs and between Capital and Coast DHB and Hutt Valley DHB. But don’t worry – vetting is likely to be portable so if you are safety checked, given the all clear and then change jobs, you will not need to be checked again for three years as long as you still meet the legal requirements.
The employment and pre-employment screening regulations include confirmation of an employee’s identity, collecting and assessing information about the employee such as their work history, a referee check, an interview of the worker and third party checks with their professional registration body or licensing authority and police vetting. (Note that if you are from overseas it may be very time consuming to obtain the relevant information – you need to take this into account). All the information will be evaluated and an assessment made of the risk that the employee poses to the safety of children if engaged to work with them.
These regulations will affect thousands of employees across the country: around 376 000 people working for central government agencies in the children’s workforce, 217 000 people working in the core work force and around 159 000 people working in the wider workforce.
All government agencies including DHBs are accountable to the government and are supposed to take an educative approach to supporting compliance, not a punitive one. NZRDA will be keeping an eye on the various DHBs policies regarding implementation of these regulations. Only the DHB and the potential employee should be able to view the safety check information – if you have any privacy or other concerns about this vetting process (specifically or generally) then please do not hesitate to contact the NZRDA office.
UPDATE: THE PUBLIC RELEASE OF (YOUR) MEDICAL PERFORMANCE DATA
NZRDA recently attended a meeting held by the MCNZ in Wellington about the publication of data on doctors. Various interested parties attended this meeting including representatives from the Office of the Health and Disability Commissioner, the Ministry of Health, the Office of the Ombudsman, ASMS, RANZCOG, RNZCGP, RACP, RANZCR and Pathways. In addition, a number of representatives from hospitals all over New Zealand attended.
In March of this year the Medical Council of New Zealand (MCNZ) released a discussion paper which is currently generating interest and debate from across the country from both the medical profession and wider stakeholders including the public. The paper raises the issues of the value of performance and outcome data including how such data can promote the competence of doctors and benefit the New Zealand public and healthcare system.
Recently, the Ombudsman ruled that a DHB should release surgeon specific case volume data and raised the public interest argument to support his claim. But the DHB declined to release the information. The MCNZ has received further similar requests from the media. As the Ministry of Health and MCNZ actively consider these issues it is clear that publication of data on the profession is not a matter of “if” but rather one of when and how and why.
Those with vested interests include doctors because it is their medical performance which makes up ‘the data’ whether this refers to data in the collective sense or at an individual clinician level. The release of performance data will also affect the public in terms of potentially allowing access to more detailed information and as a result having greater decision-making power based on that information. DHBs, as employers, have an interest as they are responsible for ensuring the quality of the medical service provided to consumers.
Both the United States and United Kingdom jurisdictions already make available some medical performance data about individual doctors. By contrast, in New Zealand, there is no publicly available way to check a doctor’s record (apart from those who have been struck off). For instance, DHBs that do heart surgery cannot produce reliable comparisons of individual heart surgeon’s patient complication and death rates. Even if they could provide such data it would be unlikely that it would be made available to the wider public.
There are a variety of reasons contributing to the fact that we have such limited information available including the challenges around determining what performance data should consist of and how obtaining, articulating and disseminating such data would operate in practice. These questions must be thoroughly considered because performance data that is deficient is a risk. For example, data without proper context could destroy the team based approach if one doctor is perceived to be responsible for performance outcomes. Doctors in DHB employment are also rarely ‘in control’ of their entire environment and therefore holding these doctors accountable for others performance would not be realistic.
The MCNZ have made clear that the necessary first step is to ensure that there is clarity around the purpose of the data collection. We need to specifically identify for whom the data is meant and in what form it should take. There is a difference between what members of the public might want to know versus what a regulator might perceive is important – as a result this is likely to alter how the data is presented. For instance, it might be more relevant to a patient to know whether the surgeon cares, rather than his or her complication rates.
As mentioned above, context is critical. It is necessary to question how data will be moderated in a way which is meaningful but also avoids unintended consequences. A patient’s co-morbidity for instance can affect outcomes and risks. It is essential that data collection and publication processes do not put surgeons off treating sicker patients or carry out more complication procedures on the basis that doing so would “make for worse data” in situations where “clinicians may avoid doing the ‘right thing’ if the right thing might appear to worsen that doctors ‘statistics.’” ‘Context’ also takes into account a number of locality factors to consider – for example, in the far South the population is older and during the winter months “more patients may tend to be having chest infections at the time they need operations” and this would result in increased surgical complications. This example illustrates the difficulties that can arise when comparing performance data.
Another factor to consider, should the data focus on doctors alone or the whole team or the institution? Interventionists may prefer one type of system as opposed to separate systems pertaining to for example, psychiatrists or GPs. How are we able to ensure that the regulator can manage the system(s) in a way which ensures that standards are being met?
Publication of performance data is important to the public because patients have the right to be informed when seeking medical care and making decisions in respect of that care. It is imperative that society has confidence in the profession and our healthcare system. Data could benefit doctors too – how do you know without data if and where CPD is needed?
Not only do we need to ask who will benefit from the publication of data but also we need to ask practical questions such as where does the money and resources to make this all happen (once we define what ‘this’ is) come from? The evidence to date indicates that this is an expensive process if we are to get it right. Trustworthy data may operate to help carry out a number of health related initiatives but who will be the one(s) to bear this cost?
So… what is the way forward from here? Firstly we must clearly define what the patient wants. As simple as this may sound, different patients and patient populations will have particular needs and want different things. It is also important to keep in mind the distinction between what the patient ‘wants’ as opposed to what the patient ‘needs’? In addition, preliminary research needs to target what clinicians both want and need to know.
We need to stock take the available data we already have and define how we should go about extracting additional information keeping in mind that context is crucial. We already have some things underway in the cardiac field and clinical support data such as lab results, radiology and pharmacy, so it makes sense to start with what we have and work from there.
This is a process which must be lead by leaders within the profession, colleges in particular but also institutions, in both the public and private arena. The process should be nationally based, starting small and in a meaningful way with the purpose and aims clearly defined. We need to ignore ‘white noise’ such as from the media whilst we work on getting this right. We need to be mindful of what our purpose is and check back with consumers about what they want whilst remembering that different parties in the system want different things.
So what is the point of it all? Essentially it is to improve the quality, safety, transparency, trust and confidence in our health care system as a whole and in the medical profession. This process will not be a quick one to resolve, but having started it will slowly progress.
CONSULTATION ON PROPOSED MEDICAL COUNCIL FEES FOR DOCTORS
The Medical Council is proposing a re-costing of its fees. The MCNZ is requesting feedback from you and other interested parties such as the NZRDA prior to making any decisions in regards to the implementation of the new fee schedule. At the end of May we emailed all members a copy of the consultation document and requested feedback. The NZRDA will be compiling the comments received and making a submission to the MCNZ at the end of June. Thank you to those who have already provided feedback – we are still collecting responses so please send these through to email@example.com no later than Friday 26th of June.
UNDERSTANDING CHANGES TO THE MECA
Clause 5.3 Temporary employment agreements should only be used to cover specific situations of a temporary nature (page 8 of the MECA under clause 5.0 Appointment Term).
Specific situations of a temporary nature include but are not limited to: where a position needs to be filled where the incumbent is on study or parental leave; where there is a task of finite duration to be performed (this is a rare occurrence but could include for example where a particular research project is required to be carried out); and where GPEP trainees are employed whilst on an Alternative Vocational Scope placement (AVS is a GPEP run which takes place in the hospital workplace and is aimed at topics in the general practice curriculum which helps to allow the registrar to develop an area of special interest).
It is important to note that the MECA remains the overriding contract even when you enter into a temporary employment (or fixed term) agreement – the terms of the MECA cannot be extinguished. Rather, a temporary contract simply calls clause 5.3 of the MECA into effect.
If you are presented with a temporary contract and have any queries regarding its terms and conditions do not hesitate to contact us prior to accepting it. If you accept the contract and it does not meet one of the grounds set out in clause 5.3 there may be a basis for an invalid contract. This doesn’t mean you will lose your job but to the contrary, that your job may change from fixed term to permanent. Temporary employment agreements must not be used to deny staff security of employment in traditional career fields. So the DHBs must not engage staff as either casual or fixed term employees other than for bona fide purposes as contemplated by the contract. This constraint is intended to encourage DHBs to engage permanent employees whilst still allowing for appropriate use of casual and temporary staff.
GET IN TOUCH WITH US SOONER RATHER THAN LATER
One of the roles of the NZRDA advocates is to provide support and advisory services to our members when you need it. NZRDA staff are highly experienced in advocacy services and are particularly skilled in dealing with employment issues both generally and those pertaining to you, your employers and your contract. Here at the NZRDA office, we help a number of individuals with a variety of situations on a daily basis such as: disciplinary matters, personal grievances and breaches of the terms and conditions of your contract. In a nutshell, we are here to assist and to guide you when (as does happen) things “go wrong”.
However, we stress that when things do “go wrong” you need to get in touch with us sooner rather than later! This might sound relatively straight forward and common sense but you would be surprised at how many members contact us well after the fact – say for example, after they have been to an initial (or a number of) meeting(s) with their employer without any support person or worse still, with their “mother” as a support person (assuming your mother is not a medico-industrial practitioner). In this situation, there is a risk that important points will not be conveyed to the employer. You may jeopardise your position by acknowledging or agreeing to something without understanding all the various implications.
It is important to be aware that any talk with an employer is rarely ‘just a chat’. You always have the right to representation and we can advise you on how to best communicate. So… we suggest that when an issue arises, you contact your delegate directly in the first instance. We can also advise you on how to go about dealing with your situation whatever that may involve: attending a meeting, writing a letter or generally how to handle things!
Often issues are a lot easier to rectify when members are prompt in involving us in matters rather than delaying and bringing them to our attention further down the track. When you do get in touch, do not forget to provide us with all the necessary information. In the majority of cases all information comes to light eventually so it is best to be transparent with us and share all the details right from the outset so we can in turn give you the best advice. In case you are worried or feel embarrassed – trust us, there isn’t much we haven’t heard! We are always here to help you with what might be a difficult or troubling subject.
FLEXIBLE WORKING ARRANGEMENTS
Flexible working arrangements when properly implemented and with the appropriate protection in place, can have benefits both for you and your employer – they are becoming an important part of workplaces across New Zealand. All employees have a right to request flexible work. Flexible work can relate to a change in your hours or days (or place) of work.
1. All employees (not just caregivers) may request a variation to their working arrangements.
2. The employer must deal with the request as soon as possible but no later than 1 month. If an employer is non-communicative and unresponsive then this is a breach of good faith.
3. Employees may make the request at any time – starting from their first day of employment.
4. There is no limit on how many requests an employee can make per year. However, there must be a genuine reason for the request. Genuine reasons are not defined but could include for example; taking care of children or other family members, accommodating travel time and transport needs with respect to getting to and from your workplace.
5. The employer may refuse a request but only if it cannot be accommodated on certain and limited grounds. If an employer refuses a request then they must tell you why – it is not enough for the employer to simply cite the legislative ground pertaining to the refusal.
6. The request must be consistent with the MECA otherwise the employer must refuse it.
Note that there are particular requirements that your request must adhere to in order to be valid – it must be in writing and must state: (1) that it is being made pursuant to Part 6AA of the ERA; (2) the variation of the working arrangements requested including if the variation is permanent or for a period of time and what the intended start and finish dates are; and
(3) what changes the employer may need to make in order to accommodate such a request.
Before making a request it is advised to consult with the College in regards to your training requirements and to consider the impact that your request may have on your training. Get in touch with us if you need help drafting a request, if you believe that your employer has not dealt with your request properly or if you have any other questions about flexible work.
DHB FUNDING AND THE PBFF FORMULA
The gap between ‘rich’ and ‘poor’ district health boards is an ongoing issue in New Zealand. At the end of the 2013/2014 financial year nearly half of all DHBs were ‘in the red’. Southern DHB had the largest deficit (-$11.8 m) and Capital and Coast DHB and Waitemata DHB were ‘in the black’ with the largest surplus (both at $6.8 m). The 20 DHBs provide health and disability services to their defined populations.
Despite some DHBs making progress with respect to meeting national health targets, a large disparity in DHB financial positions continues to remain. So, why does it matter if there is a gap between ‘rich’ DHBs and ‘poor’ DHBs? There are several important ramifications stemming from the divergence in ‘wealth’ across the DHBs – a divergence which is due to a number of factors.
One important consequence of such a gap relates to the different levels of negotiating power held by the DHBs. DHBs in a strong fiscal position have ‘more to offer’ or hold a ‘better hand’ when it comes to negotiating compared to those DHBs ‘in the red’ – who will not be as willing and able to contribute the same (financially) in a number of scenarios for example, towards an increase in pay for employees.
The reality of this situation continues to place pressure on the functionality of MECAs and overtime this pressure (especially if it drives a lowest common denominator approach) is likely to cause MECAs to break up. To achieve a more “level playing field” for DHBs, this gap needs to lessen!
DHBs are non-profit providers and receive public funding from the Ministry of Health on behalf of the Crown. The overall level of funding is agreed to by the Ministry of Health, Treasury and Cabinet. Last year DHBs received a total of more than $11 billion (more than three quarters of the entire health budget).
The planning and funding divisions of each DHB are responsible for deciding which health and disability services should be purchased in order to meet local, regional and national health priorities.
The PBFF (population based funding formula) was introduced in 2003 and determines the share of funding to be allocated to each DHB. The PBFF takes into account the total number, age, socioeconomic status and ethnic mix of the DHBs population. The aim of PBFF is to fairly distribute available funding between DHBs according to the relative needs of their populations and cost of providing health and disability support services to meet those needs.
Rules are applied so that each DHB receives a minimum increase in funding (for 2014/2015 it is set at 1.5%). Where DHB inter-district services occurs there will be a transfer of funds from the funder arm of one DHB to the provider arm of another DHB.
The PBFF is currently under review which is supposed to be completed by June 2015. An advisory group is analysing the structure of the current formula to ensure that it allocates “funding according to relative health needs, including shifting the system towards wellness, and explore opportunities for improving the allocation of funding between districts”.
The University of Otago published research in 2012 which raised concerns about the transparency and fairness of the formula and found that the money allocated per person varied by almost 25% across the DHBs. The research also highlighted the fact that compared with New Zealand many other countries have “greater accessibility of detailed data on the development and construction of their funding formulae”.
Any recommendations arising from the review will need the approval of the Health and Finance Ministers, with any changes resulting from the review to be introduced in the 2016-2017 financial year.
DELEGATES TRAINING 2016
The NZRDA Delegates Training and AGM for 2016 is taking place on the 16th, 17th, 18th and 19th of March in Tauranga! We will provide further information about this closer to the time. In the meanwhile, if you have any questions in regards to Delegates Training or you would like to know how to become an NZRDA Delegate then please do not hesitate to contact us.