Category Archives: Workforce

Contract Negotiations (again!)

Well it seems that some country doctors in SA remain embroiled in dispute over on call contracts with Country Health SA.

The last contract expired in Nov 2011 and was supposed to be replaced by a contract offering improved terms for rural doctors who offer on call VMO services to public hospitals in addition to running their private practices. You can imagine the disappointment of many doctors when no contract materialised in Dec 2012. Protracted negotiations ensued between Country Health SA and both the Rural Doctors Association of SA and the AMA(SA).

As I understand it, the AMA(SA) advised their members not to sign as there was a failure to reach an acceptable outcome for members.

The RDASA continued to negotiate and reached a compromise of sorts in July 2012 (seven months after the previous contract expired). You can read a press release from them here.

The difficulty in the relationship revolves predominantly the tension between doctors running their own private practice and the need to service a public hospital run by CHSA. As workload in both primary care and hospital-based services increases, the impact of being on call for the hospital becomes increasingly negative on running a private practice.

Contract wins included 

  • a payment to recompense the impact of being called out of private practice clinic to attend hospital patients (note life-threatening emergencies excluded from this payment) and,
  • a payment to compensate missed clinic sessions the next day after a busy overnight on call (note only applies to admitted in-patients; A&E patients excluded).

Disappointments included

  • no increase in on call allowances
  • refusal to pay attending doctor through fee-for-service arrangements for WorkCover, motor vehicle accident or other non-Medicare compensable patients (such as overseas visitors). In a location such as Kangaroo Island where motor vehicle crashes involving overseas tourists are not uncommon, chasing bad debts for on call work is a hassle that doctors would rather do without.
  • continued situation where patients presenting to the public hospital with non-GP conditions needing A&E care (broken bones, lacerations, acute psychosis out-of-hours, forensic medical exam etc) are charged private fees as CHSA maintains that the doctor will only be paid for admitted patient services. Interestingly this situation does not occur interstate, with State Govt taking responsibility for provision of A&E services and paying doctors who are called to attend
  • a move by CHSA to insist that the responsibility for providing A&E services moves from the State Govt to one or more practices in each location, with practices required to continue cover even if doctor numbers decrease or practices withdraw.

As I understand it, existing ‘sweetheart’ deals offering better terms of service continue in rural SA and have been excluded from contract negotiations – these include locations such as Whyalla, Naracoorte, Mt Gambier, Riverland and Gawler. Suffice it to say that terms and conditions are considered more favourable than the contract offered to other doctors through the standard contract, recognising the particular needs of each location.

Several other rural locations are unhappy – the media report dissatisfaction in Victor Harbor, Snowtown-Clare, Quorn and Kangaroo Island. Millicent is rumoured to be in a similar position and there may well be others who have declined to sign the contract or remain unhappy with terms.

Locally on Kangaroo Island?

The doctors who provide A&E services on Kangaroo Island (through a single entity, Island Locums) have been allowed to continue to provide services until 30/1/13 under existing arrangements – basically Island Locums works 3 weeks per month and CHSA provides a locum service for the fourth week, allowing the local doctors a break.

Bear in mind that some of the doctors contracted to Island Locums are also on call for anaesthetic and/or obstetric rosters, as individual contractors. Having the locum relief for one week in four for A&E provides an important ‘safety valve’ for doctors who are otherwise on call for the hospital every day for around two thirds of the year, plus have to work running their own private practice.

CHSA now want to get rid of the locum and make Island Locums responsible for 24 hr cover 365 days of the year. With a limited number of doctors, (some of whom may leave in future) the pressure on those remaining would be untenable – unless the doctors in turn employ locums for around $2000 per day to provide hospital on call services – a cost currently borne by CHSA. This is not affordable.

CHSA have also made the ability of individual doctors who provide anaesthetic or obstetric on call services to be dependent on the ability of Island Locums to provide 365/24/7 A&E on call – despite these rosters being contracted to different entities. Having been hauled before the ACCC a few years ago by CHSA for alleged anticompetitive behaviour over rosters, the lumping together of rosters provided by different entities by CHSA seems truly perverse and in itself appears anti-competitive.

I’ve indicated the CHSA my willingness to sign a contract for anaesthetic on call – but after three months have still not been allowed to sign as CHSA insists that this service is dependent on another group of doctors providing A&E services.

In short, KI docs face loss of admitting rights and clinical privileges under standard contract terms for procedural on call, unless a solution is found.

The preference would be for existing arrangements to continue ie :the responsibility for staffing A&E remaining with CHSA and doctors contracted to Island Locums providing as much cover as possible without the collapse of local primary care services. Meanwhile procedural on call provided by individual doctors to continue so that Islanders and visitors have access to obstetric, anaesthetic and A&E services all year round.

In the last month the CEO of CHSA (Adj Prof Belinda Moyes) indicated that unless Island Locums assumed responsibility for A&E cover 365/24/7, there would be a threat to procedural services on the Island. As I understand it, Ms Moyes has now moved on (this will be the fourth CEO of CHSA in a decade, they seem to last 2-3 years on average) and is succeeded by Dr Peter Chapman as acting CEO. Perhaps NOW we will see some real action ?!?

Personally I am sick of the failure of Country Health SA to engage in meaningful discussion or acknowledge the different needs of different locations.

As a doctor I want to provide services to my community. Currently I am still in dispute with CHSA over fees for attending hospital patients to the tune of several thousand dollars. This and ongoing contractual disputes and threat of loss of procedural services make the tension for a rural doctor between running own business and working for CHSA almost unbearable.

The grass is looking increasingly greener elsewhere. But if doctors leave rural areas, the on call demands on those remaining escalates…in turn making the need for locum relief more acute.

There has to be a decision about whose responsibility it is to staff the hospital – individual doctors doing so in addition to their own business, or the State Government as a responsibility to provide rural services to taxpayers.

You can read more about some of the other SA contract disputes below :

Adelaide Now online http://www.adelaidenow.com.au/news/south-australia/south-coast-district-hospitals-on-call-conditions-may-impel-gps-to-work-30-hours-straight/story-e6frea83-1226514731619

Situation in Victor Harbor (same health cluster as Kangaroo Island, different on call arrangements) http://www.victorharbortimes.com.au/story/741920/hesitation-about-doctor-handouts/

Situation in Quorn-Hawker http://www.abc.net.au/news/2012-11-15/doctor-to-end-on-call-service-for-hawker/4373654

Situation in Clare-Snowtown http://www.abc.net.au/news/2012-11-13/snowtown-health-care-under-cloud/4368530

Rural Doctor Magazine http://www.ruraldr.com.au/news/sa-gps-resisting-after-hours-deal

Australian Doctor magazine http://www.australiandoctor.com.au/news/latest-news/gps-in-dispute-over-on-call-contracts

MP Michael Pengilly speaking on Country Health in Parliament http://www.michaelpengilly.com.au/news/default.asp?action=article&ID=345

DISCLAIMER : The opinions here are my own. The reported situation on circumstances elsewhere in SA is from the media using links above. There has been no discussion of roster arrangements between separate practices or individual entities. I remain committed to the maintenance of current status quo – local doctors providing A&E services to the level appropriate to available workforce, as well as the continuation of individual procedural doctors providing anaesthetic and obstetric services to their island community under standard contract terms.

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.

Catching up with colleagues

Interesting weekend, spent with Dr Pete Gilchrist and family who were visiting Kangaroo Island…Pete is a fellow SA GP who, like me, had to move interstate to NSW in order to upskill in anaesthetics due to the dearth of training positions locally. Six months down the track we were able to catch up and compare notes on experiences both whilst training and also now in independent anaesthetic practice without the immediate backup of a FANZCA.
At the same time, I read an interesting comment from Dr Minh le Cong (aka the internet’s “most promiscuous medical blogger”) of RFDS Queensland who commented on his own anaesthetic training and relevance to prehospital medicine…particularly the need to learn key skills early and focus on the basics – securing the airway, maintaining ventilation over-and-above fancy or advanced techniques….but also to be well versed in crisis management and dealing with the unexpected’ – as there is noone to back you up in the bush. Minh comments:

“During anaesthetic rotation I got taught RSI a certain way and was told get good at this and you will be fine. Only occasionally I would get an anaesthetic supervisor who would really put you through your paces and test what you thought were adequate routines. Doing a whole anaesthetic using mask ventilation alone, or giving only half the usual dose of propofol for intubation..or tubing from the side position. In prehospital and retrieval medicine, nothing is standard and trying to make anaesthetic skills fit into that environment is challenging when you have learnt them in a controlled setting. The only way to manage this is deliberate practice of non routine. Practice your routine but throw in an uncommon problem and troubleshoot. Practice the permutations. Airway management in the critically ill and injured , in the prehospital setting , is like a street fight. If all you ever learnt in unarmed combat was how to deal with punches and kicks and then you get into a situation where someone pulls a knife on you, what good is your training? Its generally true that most of the time, you dont need RSA , DSI or bougie via SGA. But the challenge is when you do need those skills, are you prepared?”

I’m grateful for the 12 months experience I had in NSW…and the Joint Consultative Committee on Anaesthesia seem to have a fairly robust curriculum laid out. Of course, one of the difficulties for both budding anaesthetic trainees and their supervisors is the need to impart key knowledge that is relevant.
A common criticism is the mismatch between anaesthesia as practiced in the elective, fasted non-urgent theatre case vs management of the emergency airway in a critically-unwell patient…Cliff Reid’s excellent rant ‘the propofol assassins’  makes this distinction very well indeed. So, what then are the key components for the rural GP anaesthetist (or indeed the rural GP on the A&E roster who is a de facto ‘occasional intubator’?).
  • competence in airway assessment, use of adjuncts and effective bag-mask ventilation
  • ability to safely deliver an anaesthetic via laryngeal mask or endotracheal tube
  • critical decision-making in airway management
  • ability to manage the emergency airway (typically unfasted, soiled with blood/vomitus and hypotensive)
  • anaesthetic crisis management
  • a smattering of ICU and prehospital care
In the past year I have been fanatically looking at difficult airway management – not because I particularly want to manage anticipated difficult airways (these are the cases I will be referring to my specialist colleagues)…but more because I recognise that occasionally an unanticipated difficult airway arises and needs to be managed – so I want to have both the tools and the training to safely manage on my own. Thankfully this is a shared passion, and the past year has seen a wealth of information coming through the blog-o-sphere, much of it not taught by old school anaesthetists. Paul Baker of ANZCA has given me some great advice, as has Minh and a few other medicos ‘out there’.  So added to my thereapeutic armanentarium are tips and techniques such as:
Hopefully some of these will be alluded to as my paper on ‘difficult airway equipment for rural GP procedralists’ draws closer to publication – reviewers comments gratefully received last week and corrections duly made, so hopefully it will get final approval shortly…

On the whole I was fortunate enough to be exposed to supportive anaesthetists who ‘got’ what Pete and I needed to learn in our limited period of anaesthetic training. Recognising that we had particular needs and a strong practical focus to deliver safe anaesthesia for both elective and emergency cases, they taught us the basics in a reliable manner to ensure our safety and that of our patients. But of course, there’s always the odd one out. Some specialists struggle with the concept of rural doctors delivering non-primary care services such as emergency medicine, obstetrics and anaesthetics. They feel, and I can understand this, that the criteria to safely practice in a specialty are the appropriate period of specialty College training and demonstrated competence by primary and exit examinations. The problem of course is that there are no specialist emergency physicians, obstetricians or anaesthetists in much of rural Australia. By necessity, rural doctors undertake training beyond that of an office-based general practitioner in order to safely deliver these services in the absence of specialist care.
So there is a potential tension between some specialists and the concept of “Macygvers-of-medicine” rural doctors. At a personal level, this manifested last year in one specialist behaving as a bully to the GP-anaesthetic trainees under his care. There was a report about bullying in medicine in the media last week, and it reminded me just how awful it was to be a forty-something doctor, going ‘back to school’ in the tertiary hospital and occasionally treated as something that the cat dragged in by one specialist who clearly held GPs in low esteem. Thankfully I have insight enough to see that this says more about that individual than myself..indeed, it has reinforced my belief to ‘act like a professional, even when others around you are not’. I won’t name this individual…complaints were made last year, but AFAIK nothing came of them. Ultimately neither Pete or I will have to work with this individual again…however specialist colleagues will and they may wish to not rock the boat to make working life tolerable.
Whilst this bullying behaviour casted a blight upon an otherwise enjoyable year, by golly it made it good to get back to private practice and get away from the hierarchy of a teaching hospital. I have reaffirmed to treat my registrars and students as I would expect to be treated myself…
The 2011 GP Anaesthetist Trainees from NSW
The identical T shirts are an unlikely coincidence – no reference
is implied to any specialist anaesthetist alive or dead


Dismissal of the value of rural doctors is not just confined to a few individuals. On a system level, there is an increasing move towards centralisation of services. In SA many health-decisions are metrocentric, with opinions from city specialists often driving such changes. My fear is such an approach leads to ongoing deskilling of rural doctors, of downsizing of rural hospitals in terms of capabilities and staffing, and increased movement towards centralisation of services…
And so the house of cards collapses – a rural hospital loses obstetric services due to a metro-based health edict…and within a year or two theatre services are also lost…nursing staff begin to look to the city to do lucrative agency shifts rather than work locally…rural doctors with procedural skills have no opportunity to use them…and so move elsewhere (often interstate)…and within a very short period the local community is bereft of both doctors and nurses, and their local hospital is further downgraded to a first aid station…and any patient with a problem more urgent than needing a band aid is sipped off to the city, usually by the hardworking RFDS and put more strain on the already-stretched metro public hospitals.
One other thing struck me talking to Pete – the similarities with the hassles he has faced with his regional training provider (my training finished in 2005, but seems not much has changed) and the fact that the issues he faces in his rural practice are much the same as mine – yet there is no common method of talking about things like practice management, dealing with health bureaucracy. We are all operating in silos, rather than in unison. Now clearly there may be ACCC issues if rural doctors collude on price fixing etc…but one wonders if there is scope for sharing of knowledge on practical problems – ensuring adequate numbers and skills of future doctors, equipment & training for emergencies etc etc – surely such collaboration is for the betterment of patient care, not to detract from it? The internet is a powerful medium…the UK’s www.doctors.net.uk has been effective in coordinating over 180,000 UK doctors…shame we don’t have a similar network for rural docs in Australia to problem-solve and advocate for our communities.