Category Archives: Career

Avoiding Burnout

An interesting week this week, with several stories coming together for me.

First up, a discussion on doctors.net.uk / ausdoctors.net (the members only service for UK and Australian doctors) on ‘tips for new consultants’. Covered the sort of things that don;t get taught at medical school or in postgraduate training. Also tips on setting up a private practice and avoiding burnout. A common theme was to ‘say no’ to unmanageable workload and to try to take control of the work environment, not let it control you.

Of course all of this is relevant to rural doctors, which leads to the second theme – that of managing workload in the bush. Scott Lewis (procedural GP in Wudinna and newly appointed President of RDASA) rightly points out the constant stream of negativity regarding rural medicine. Despite this, I think Scott and I agree that rural practice really does offer the ‘best bits’ of medicine – a varied and interesting mix, with opportunities to be challenged every day.

Concurrently this week the doctor in Penola, SA has left – citing an unmanageable workload & bureaucratic bungling by Country Health SA. As well as managing a day time clinic, poor chap was on call 24:7 every day of the year and reportedly chastised for having the temerity to be more than 20 mins from the hospital on one occasion (CountryHealth SA contract allows a 40 minute response time). Ironically this doctor was brought in a year or so ago, to replace the previous doctor, who lasted only 4 months.

Of course there’s the local issue on Kangaroo Island, with the sustainable model of Island docs doing 21 out of 28 days per month on call for emergencies, as well as 365 day a year cover for each of obstetric and anaesthetic rosters. This workload was sustainable and allowed respite from the onerous emergency roster, as well as to balance the demands of running a private general practice.

Common themes?

(i) Financial Incentives

Historically money has been thrown to entice doctors to the bush. Whilst this helps, it is ironic that the same incentives are offered to fly-in, fly-out locums who live in the city and cherry pick high-paying locum work. Indeed some rural communities are wising up to this and realising that paying locums $2500 per day is a disincentive to establishment of permanent resident doctors who have to bear practice costs. KI docs got into a stoush with the Health Department (and the ACCC) a few years ago, when asking for more money to provide on call services. The money doesn’t compensate for working day & night – but it does allow one to purchase much-needed locum relief.

(ii) Control of workload

There are 168 hours per week, which I think of rather like a Mars Bar – it should be divided into equal thirds of work, rest & play. An 8 hr working day is sufficient, and allows time for rest (sleep) as well as play (hobbies, other interests – but also mundane things like cooking, eating, toileting etc). Of course most of us experience ‘bracket creep’ with work intruding into time off and eventually life can become 2/3rds work, 1/3rd rest. Not a good idea. Having strict boundaries between work and home life, as well as declining extra duties means that workload is sustainable.

Much better though to share the workload – a roster of several doctors working part-time is a better model than the traditional solo small town GP. Which leads into the third theme..,

(iii) Learning to ‘say no’

Which is the unenviable position the KI docs find themselves in currently. A model hashed out with the Health Department a few years ago allows KI docs to work 21 out of 28 days per month for emergency on call, with the Health Department providing a locum for their hospital on just one week per month. Meanwhile KI docs provided 365 day cover for separate anaesthetic and obstetric rosters. Not a bad effort for six part time doctors, and allows us time off for a break as well as mandatory upskilling.

A proposal that KI docs take full responsibility for the emergency roster and fund any locum relief themselves was met with disappointment, It sets a dangerous precedent – for if the number of doctors on KI were to fall in the future (as is likely), the remaining doctors would be forced into paying for a locum to staff the hospital. A sum of $10,300+GST per week has been suggested as typical locum costs.

Taken to a logical extreme, if the Island doctors were unable to provide the service (through ill health, absence, whatever) they could be liable for a bill of $10,300+GST x 52 weeks … all for the privilege of doing EXTRA work to their usual 9-to-5 private general practice.

This really is the crux of the tension and difficulty in rural practice. Not only are their insufficient doctors and problems with throwing money at all-and-sundry, ultimately we are independent contractors. We already have a job that consumes a standard working week – that of running our own private practice. With that come attendant costs of staffing, utilities, rent etc which must be met.

To ask us to either take time out of practice to work at the State-owned public hospital (for considerably less money) and yet still pay pay own practice expenses seems unfair. And the demands of working extra hours on call takes it’s toll.

In the city, public hospitals are staffed by doctors and nurses working shifts. They are salaried and also get benefits like annual leave, long-service leave and superannuation. In the bush? Doctors work running their own private practices and traditionally have worked ‘on call’. Sadly workloads have increased (particularly in tourism destinations like Kangaroo Island) making on call a significant burden and at the expense not just of doctor’s health, but also ability to service own clinic patients. There is no Super, no annual leave. The Health Dept just wants to staff the roster, but doesn’t really care how this is fulfilled so long as the cost is shifted elsewhere.

Add to this the demands of a Medicare Locals policy that seems to be more about ‘wants’ than ‘needs’ … and the abhorrent policy in South Australia of charging public patients a fee for non-admitted A&E services (contrary to section 19(2) or National healthcare Agreement). It all seems that costs and services are being shifted from State responsibility to private practice.

Hence it is sometimes better to ‘say no’ and do only what you can do.

Any other thoughts on preventing burn out?

How I Met My Specialty

I’m a big fan of rural practice. To me it offers all of the ‘best bits’ of medicine and has been a rewarding career. But it is not everyone’s cup of tea…many junior doctors make their career decisions based on what they don;t like…and many will not be exposed to the over 70 different career options within medicine. Sadly many will be put off rural medicine through lack of exposure and the misapprehension that the work is unrewarding.

I have just been sent this piece by a colleague, spoofing the manner in which choice of specialty in medicine is made. I seem to recall a similar collection of comments posted on ‘Doctors Net UK’ – regardless, it is deserving of a wider audience.

I particularly like the concept of specialists ‘stuck in a loveless marriage of convenience’. I’m lucky to be a rural doctor, flirting with many different interests…

How I Met My Specialty

I was an impressionable yet cock-sure intern when I started a relationship with a girl called Surgery. She was really sexy and I’d had my eye on her most of my time through medical school. I finally wooed her after a lot of hard work and for a little while things went well. My friends thought she was hot and my family thought she would be good for me long term. But behind closed doors, she was either aloof or extremely demanding and I seemed to be spending all my time trying to please her. In the end she was just too high-maintenance for me and we went our separate ways. I think we both knew from the beginning it wasn’t going to work out. On the quiet, behind closed doors, she was far too much into sadomasochistic control and humiliation. She liked to inflict pain on all her new boys, for a very long time and whether they want it or not, and I’ve never been one to put up with that kind of abuse. Plus she was obsessed with how people are put together rather than going any deeper. Never the girl for me, although I spent a lot of time thinking I wanted her, until I got to know her.

I soon started a relationship with a lovely girl called Anaesthetics. I have to admit I had been kind of seeing her behind Surgery’s back. She was a wonderful girl. We spent ages just sitting there watching the world go by, talking about nothing. We had some really exciting times too. Well at the beginning. But those times became fewer and farther apart as I got to know her better. I was comfortable with her and she was very supportive but there was a side of me that was never going to be happy. Added to which I kept on flirting with Surgery over the green curtain. In the end, as much as I cared for her very much, I just couldn’t see myself with her for life. Besides that, a friend told me that she went to sleep with multiple partners…


Of course, it wasn’t all bad – there was a weird little ménage-a-trois going between Anaesthetics, ITU and General Medicine for a while. They both got along really well – they were quite alike in some ways but really bewitchingly different in others. ITU is like the supermodel version of medicine – a tired, broken shell of what she used to be. General Medicine, or Genny as we call her, has been too kind to too many for too long and spends all of her time overwhelmed, so there’s no love and attention anymore, she’s just dragged from one disaster to another, never really loved and used by so many people. It would be great if she could harden up and say no to some people now and again, but her upbringing won’t allow it and her old fuddy-duddy parents accuse her of laziness, and manipulatively demean her with “in my day” stories when she points out modern problems. She’s got some great new mates really trying to help her out and make some opportunities for her, but I can’t be there whilst she gets sorted out – it may never work, and I’ll give up too much watching her sobbing through every night to spend my life with her.

Anaesthetics was such a calm, sorted out person but sometimes when I just wanted a bit of crazy in my life she was not really up for it.  Fortunately ITU was there and was always ready for a riot – usually at 3am on a Saturday night! She could be pretty aloof sometimes, and picked and chose her moments – Genny Medicine really got upset with the way she sometimes just sauntered off and refused to get involved.

Our happy little ménage-a-trois was suiting everyone really well – Anaesthetics had her devotees who would see no-one else, and ITU had a couple (but not many) regulars – she didn’t like the full commitment, too much pressure.

Unfortunately some of the more judgemental of the new-wave evangelists couldn’t understand our love, and hated us for it. They said we were only dabbling in a relationship and kept trying to split us up. They said I should make a decision now and forever between the two. It was all very confusing.

So I left the girls at it and flirted with EM (she’s changed her name – she was A+E when I met her of course) and I seemed to have found the right girl. It was tricky at the start because my friends and family thought she was a bit of a nightmare and rather unconventional. My mum certainly took time to approve of her. My uncle, an orthopaedic surgeon, thought she was a bit of an easy tart. But they came around because they realised that I loved her. We were made for each other. Sure she often threw complete hissy fits and I was up all night essentially getting abused, but she calmed down eventually. She tolerated my short attention span and my own tantrums. She was always challenging me (she’s rather experimental at times!) and coming up with something new for us to do together. I look back on those times with some fondness – it was dysfunctional, chaotic, passionate, stimulating and somehow it worked.


As a mate said, EM’s always good when you are on the rebound because: 
  1. EM is easy in, easy out. If you don’t want a major commitment you can have an on/ off relationship with EM and it’s OK.
  2. There’s a lot of variety. You want to try something new, pretty much anything and EM will let you get away with it.
  3. You want to have a bit of a dalliance elsewhere for a few months, or bring an old flame like anaesthetics or surgery into what you do at nights with EM and that’s all good…

EM liked a bit of the rough stuff, and didn’t half knock me about but it was all in the heat of passion so it was ok. She certainly knew what got me going. However, I noticed that my juniors seemed to prefer a more stable nurturing relationship – with a girl like, say, Anaesthetics – where they may start off quite unsure of themselves but they can be taken in hand and gently shown all the tricks and the way to do things without fear of embarrassment or feeling neglected and unsupported.

So, although I was very happy with my tempestuous relationship with my wildcat missus EM, I was quite jealous of the number of suitors the somewhat homelier girls seem to attract. I began to think that perhaps EM needed to clean up her act a bit (actually, a lot) otherwise she faced the very real danger of ending up as a bitter lonely old spinster


So what to do? By this time I was several years out of medical school – I’d had dalliances with surgery, with anaesthetics (and a bit of ITU on the side) and a rough n tumble with EM. I needed something different…

I think it was at a party when I met Psychiatry. I’d heard about her before I met her, and to be honest she sounded a bit scary. But as soon as I met her I found her a fascinating character. There was never a dull moment in our relationship, always something wild and crazy going on, and although she’s often misunderstood by others I thought she was just the most amazing girl ever. Until I realised she was a bunny boiler.

I reckon it was then that I sought solace in someone younger. I had a romance with a teenager called Paediatrics. She was a wonderful member of the family; very rewarding, fun, an excuse to have good toys and everything can be made right with a sticker. My parents loved her, although my ex-partners were very jealous of the attention that I gave her. Like EM she tended to have tantrums at night and woke me up at very inconvenient times, even if she was staying with someone else. There was also the massive problem of her birth mother, Midwife. She is an evil witch and tries her best to undermine me at every turn. One minute Midwife is being nice and asking for my help, the next she is a screaming banshee! 

Paediatrics tended to behave like the child in the nursery rhyme; when she was good, she was very very good but when she was bad she was horrid! She inflicted great joy but also great sadness. Her best friend and ally, Parents, were also trying at times. In the end I realised that she was just too young for me… I needed something more mature.


I met someone called aged care. She was profoundly unattractive, obese, smelled terribly and was into all sorts of kinky shit. She knocked me out, kept me in the basement and beat me daily, frequently anally violating me violently and forcing me to eat broken glass and drink my own piss. Gradually I came round to see that this sort of shit life was all I deserved anyway. For a solid six months it seemed normal to dress in a gimp suit daily and if was lucky, she’d occasionally let me out on a leash. I was still getting sodomised everyday though…

Then one night I met a lass called Neurology. She was sexy, and everyone was very impressed that I’d managed to woo her. It was a very cerebral relationship – she loved setting me puzzles and watching me solve them and at first we had lots of fun together. But gradually, I realised that once we’d solved the puzzle together there was nothing afterwards – she didn’t know how to treat anyone well in the long term. As the puzzles kept on coming, I gradually saw that even my clever-seeming girlfriend didn’t really know all the answers.

I started dating GP. She had some of the nice qualities of EM, but was a little less erratic. Plus I found that things were almost tantric, sometimes going on for months rather than the hours that EM had. I eventually married GP but I always remembered EM, though…

Recently EM and I got back together after a chance encounter in Australia. Turned out GP was a bit curious too – and so I have found myself with EM several times a week, and sometimes with GP at the same time! GP is really happy about this as she knows that when I am with her I am actually better than I used to be. EM likes it too, as sometimes GP pops up in the hospital and I’m better there too. 


As if that wasn’t enough, Anaesthetics comes to play a few times a month and we have the most fantastic times together – I’m not as young as I used to be, and there’s a chance that doing all three will kill me…but I’ll keep it up for as long as I can manage.

Who’d have thought that I’d have ended up a polygamist!

Still, I look at some of my specialist colleagues from medical school – trapped in a loveless marriage of convenience.

Splendid News!


Just heard that former Kangaroo Island doctor, Dr James Doube, has been awarded the Antarctica Medal.

Jamie is currently over in NSW doing anaesthetics upskilling. If we are going to talk about skills of rural doctors, then I reckon this chap is up the top – he’s a GP-surgeon, an excellent doctor and will soon have his anaesthetic ticket.

Moreover, he’s comfortable with tackling ropes, steering a boat in frigid Antarctic waters and even penguin or seal anaesthesia.

James came to Kangaroo Island a few years back as a GP-registrar, having already served one tour down on Macquarie Island. Inevitably he was drawn back, especially to be part of the rabbit eradication programme down there.

He is truly one of those Magyver’s of medicine and if I were ever stuck in a lifeboat I would pray that someone with the calibre of Dr Doube was with me.

You can read more at
and I copy this from the press release 21/6/12

“Dr Doube who was the Station Doctor, Search and Rescue Leader, Field Training Officer and Watercraft Operator for more than three years received the award for outstanding service to Antarctic expeditions to Macquarie Island.
“Dr Doube has an exceptional level of skill across a variety disciplines including generalist medicine, expedition medicine, public health and occupational medicine,’’ Mr Burke said.
“He has honed skills in biology and science, communications, media, search and rescue and field support and enabled the success of the various expeditions and programs and is an inspiration to other doctors practicing remote medicine.”

Jamie, bloody well done mate. You are a credit to rural doctors and the AAD.

Just get your good self back to Kangaroo Island next year, because you and I have to set up the faecal transplant clinic next door to the Hospital, as well as the planned penguin anaesthesia theatre suite.

Dr JD, back row, left with fur skin hat