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?

Whose Hospital Is It Anyway?

Sometimes I wish I could just get on with the business of being a doctor. Like other rural clinicians I am trying my best to bring ‘quality care, out there’.

In a model sanctioned by the CEO of CountryHealthSA, for the past 2-3 years KI doctors have been providing 24/7 on call services all year for both obstetrics and anaesthetics. For the more onerous emergency on call roster, a deal was reached whereby KI doctors were contracted to provide 3 weeks in every month, with the remaining week covered by a locum provided by Country Health SA. Of course our private clinic practice continued as usual Mon-Fri all year, public holidays excepted.

Put simply, the Island doctors did as much of the emergency on call work as they were able with the number of doctors available, with the Health Department filling in the remainder. After all, it’s the Health Department’s hospital….

Govt to pay for a locum one week per month … or 52 weeks per year?

With the new contract for SA rural doctors, Country Health SA has insisted that, rather than work a manageable 3 weeks in 4, instead KI docs take on 365 day emergency medicine cover despite the fact that we have insufficient doctors and the fact that the current model works well.

Their rationale? Paying for a locum costs the Health Department. So they would like to pass full responsibility for the A&E roster to the single practice on Kangaroo Island…even if it means that the KI doctors pay for the locum relief themselves. They suggested we pay $10,300 per week (plus GST) for a locum to service the A&E roster 1 week in 4 – a locum they currently provide.

It all comes down to a question of just whose responsibility it is to provide an on call roster at the hospital.

We met the Health Department this week and explained that this model would not work for us. Whilst we have enough doctors to manage our private practice clinic, we do not have enough of us to provide 24/7/365 A&E cover. We can do 3 weeks per month – but certainly won’t pay for a locum to man A&E when the responsibility lies with the Health Dept.

Loss of procedural services?

Their response? To threaten to disband the on call rosters for A&E, anaesthetics and obstetrics and replace the entire A&E service with locums. Anaesthetic and obstetric rosters would not be replaced. Their logic being that if KI docs could not do ‘the entire A&E roster for 365 days per year’ then it would have to be outsourced to another party.

Given that it costs $10,300 per week for a locum, that means an expenditure of $535,600 per annum to replace us with locums for A&E. Either that or set up a rival general practice using Government funds … to solve the unrelated but pertinent problem of staffing the hospital A&E.

This also feeds into recruitment and retention of doctors. Doctors with procedural skills are unlikely to move to a location where they cannot provide their services or will not be paid to be on call. Current doctors are unlikely to remain if they cannot do the same.

Dark days ahead for our community unless some commonsense prevails.

Trainwreck

CountryHealthSA spokesman announces “a smooth conclusion to contract negotiations”

My Bloody Valentine

It’s 14 Feb and have just uploaded a new video on IV access to ’50 Shades of Brown’ section of KI-docs – the collation of resources to help rural docs ‘when the shit hits the fan’

This video showcases the Rapid Infuser Catheter or RIC kit. Yes, fellow FOAMites, I know that nowadays we are supposed to practice minimal volume resuscitation (rather than the old EMST/ATLS mantra of ‘two litres crystalloid, stat). But sometimes one needs to bang in fluids fast…and the RIC is such an easy piece of kit to use.

Have a look at the video. Of course fluids should be warmed – on KI we use the EnFlow fluid warmer, again simple to set up and use. There is a video for that too.

Any suggestions for short videos welcome. Will be working on a short video on packaging the rural retrieval patient shortly, but any other suggestions are most welcome. Email me at KI-docs.com or leave a comment below.

IV access and RIC kit