Tag Archives: Rural Doctors

Loving the Job

I reckon the work as a rural doctor is the best that medicine offers. Just heard from a colleague with whom I did anaesthetics last year in NSW.

“Mate I love this job! In the past 7 days I’ve thrombolysed a 44 year old with a STEMI, resuscitated a 5 year old who had a fit in the local pool, drained a 2L pleural effusion off an ol’ fellas chest, gassed 5 people on a gen surg list, managed a snake bite, released two carpal tunnels, resuscitated a floppy neonate after a ventouse and seen a whole load of people in general practise. I LOVE MY JOB! Hope you’re having fun mate. This job just keeps getting better!”

No, he hasn’t been at the drugs cupboard. He is expressing the simple joy of being a rural doctor with the skills to do your work. As I’ve stated before, I reckon that being a rural doc is one of the best jobs around – especially for those with procedural skills.

Sadly skills aren’t all you need – you need the equipment to do your work well and you need structures behind you to ensure that your work is sustainable in what is, ultimately, a high-pressure job. For most of us, that means adequate locum relief or being paid for the work you do.

With regard to equipment, I’ve just submitted my paper on the availability of difficult airway equipment for rural doctors. Of the estimated 448 rural GP-anaesthetists out there, I’ve got responses from 293 – a 65% response rate, which is apparently quite good for an internet-based survey. So paper has gone in for submission…

I won’t give the game away (wait for the paper, if it survives the review process) – suffice it to say that there are common themes amongst the rural GP-anaesthetist cohort – lack of funding for basic and advanced airway equipment predominating amongst respondents. 

I’ve tried to outline in my paper some suggestions for affordable equipment to help advance the cause – for under $4K a small hospital can purchase some of the intubating LMA AirQ-II blockers, plus a fibreoptic device to allow intubation through the iLMA (something like the flexible AmbuAscope 2 or the Levitan malleable intubating stylet). There’ll still be change leftover to buy a KingVision videolaryngoscope – all of this gives a fairly robust kit for the ‘occasional intubator’ or GP-anaesthetist.

A&E Services & Contract Negotiations

Meanwhile, the State opposition Minister for Health has finally twigged to the inequity of country patients being charged for non-admitted A&E services that their metropolitan counterparts receive for free through Emergency Departments. Minister Hill is now on record saying that the ‘only solution’ would involve putting in salaried medical officers which would ‘send GPs in rural towns broke’ (The Advertiser, p15 9/3/12). He neglects to consider the alternative option – pay the oncall rural GP for A&E under existing fee-for-service arrangements, regardless of whether patient is admitted or not.

This solution would ensure patients attending the A&E with problems deemed inappropriate for routine GP would not face fees. It would mean the doctor is paid by the Health Dept without having to chase fees. Everyone is happy…

And it would be fairer to rural patients who already face significant health inequalities due to rurality.

This issue is all the more relevant as the existing contract between rural doctors and CHSA expired on 30/11/11 and has been postponed not once, but twice. I dunno about other rural docs, but I’m a little fed up of CHSA failing to come to the negotiating table and sending missives advising of a 90 day ‘contract extension’ on the last day of the existing contract.

It’s not a good way to do business and seems symptomatic of a relationship whereby CHSA treats rural docs and patients as a hinderance to their bureaucracy, rather than a vital component of the health service.

Back in the saddle

Well, have been a bit hectic the past few weeks since getting back to Kangaroo Island after my year away doing anaesthetics in NSW. Thankfully it’s relatively easy to slip back into the groove of rural medicine – and in fact it’s been a welcome relief after being back in the tertiary hospital system. But still had to get used to running on time, all the paperwork that seems to swamp us as well as catch up with friends and family back home.

Hence no blog posts since early January.

However today I am on call, sitting on the deck with a 12 month old kangaroo that Trish has taken on board in my absence, watching the rains over the north coast of KI.

Being on call again is actually quite refreshing – the Kangaroo Island doctors as a whole are now doing three weeks out of every four on the EM roster…the remaining (4th) week covered by a Country Health SA locum. I believe similar arrangements have been in place elsewhere in the State, where local doctors are struggling to fill the EM roster. Meanwhile between four of us we are providing full cover for anaesthetics and obstetrics, with two doctors doing each discipline.

I’ve also been getting to grips with delivering anaesthetics on KI – two lists so far which have been uneventful, although I’m still trying to work out how to make the anaesthetic machine display a minimal alveolar concentration of anaesthetic agent, and struggling with an end-tidal CO2 monitor that reads in unknown units (3.5-4.5 seems the average, not the 35-40mmHg I’m used to). One for the hospital to work out…

When not at work, I have been analysing the results from the GP-anaesthetist survey – over 370 responses so far, and a fair proportion are dedicated GP-anaesthetists as well as ‘occasional intubators’ (rural docs who are on an EM roster and may be called upon to intubate seldomly). Results have been interesting, with no surprises that rural docs don’t have access to a lot of the airway kit that would be taken fro granted in the city. More worryingly, a session at the local (mostly volunteer) ambulance station last week showed me that they’ve got some kit on the ambulance that we don’t have in our hospital! Had some helpful insights from airway giants like Paul Baker (NZ) and Minh le Cong (RFDS Qld), as well as lots of comments from the wider GP-anaesthetist cohort who seem to share similar frustrations as we do locally. But more on that later, as I polish my manuscript and hope to get published later this year. Meanwhile, will try and give a few talks during the year to interested parties.

But back to on-call….I’ve realised that it’s been almost two years since I’ve done an EM shift on Kangaroo Island – away for all of 2011 doing anaesthetics and for 2010 the docs on KI were reeling from all the nastiness over contract negotiations with Country Health SA and the ACCC. Now I am on-call for anaesthetics for half the year and doing one emergency shift a week….and wondering where we are at with contract negotiations – the last contract was due to end Nov 2011, rather than the usual three years…as rural docs were generally unhappy with the contract terms but were prepared to accept an interim contract hoping things would improve.

Back on 30/11/11 the head of Country Health, Belinda Moyes, wrote asking for a three month extension to contract negotiations. That extension is due to expire on 28/2/12 and I’ve not heard peep from Country Health over contracts. One has to wonder if they are serious about negotiating a new contract, or will just keep ‘extending’ the current contract rather than negotiate.

A big issue for me (and many other doctors) has been the sheer unfairness of Country Health insisting that people presenting to the emergency department are billed privately by the on call doctor, unless they are admitted to a hospital bed. This seems plainly unfair – whilst patients in metro areas are treated for free in the Emergency Dept of public hospitals, their country cousins are charged. 

Many of these services are for things that are not routine ‘general practice’ ie: X-raying a fracture and setting a limb in plaster, suturing an extensive laceration, pulling a dislocated shoulder back into shape, dealing with an alleged rape or victims of a motor vehicle accident. Country Health has managed to formalise this in the most recent (well, in fact the first) contract from 2010 with a clause stating that:

non admitted emergency services are provided under the Medicare system (ie the patient is charged by the medical practitioner and seeks reimbursement from Medicare). For the avoidance of doubt, CHSA shall not be liable to pay any fee for such services”

Their rationale is that such patients are an extension of the doctors private practice. Indeed, CHSA states that:

“This funding model with MBS being paid for public patients attending state hospitals, is acceptable to the Commonwealth due to an exemption in the National Healthcare Agreement that ‘in those hospitals that rely on GPs for the provision of medical services (normally small rural hospitals), eligible patients may obtain non-admitted patient services as private patients where they request treatment by their own GP, either as part of continuing care or by prior arrangement with the doctor.’ 

As far as I know, South Australia doesn’t have an exemption under the National Healthcare Agreement but continues to obfuscate this issue. What really twists my melon, and that of the patients who I see who are charged for their attendance, is that they have neither requested treatment by their own GP, nor is there treatment part of continuing care or a prior arrangement with the doctor. Basically, it’s not a private service…it’s just Coutnry Health SA cost-shifting dollars from State to Federal expenses.

In fact, the on call doctor is called to attend patients in the ED as part of his/her role as the doctor on-call for emergencies in a contract with CHSA. There is no prior arrangement, they are not private patients and usually this is not part of continuing care.

Quite how the Health Department continues to get away with this blatant cost shift from State to Federal (Medicare) coffers amazes me. And it is cold comfort to our patients – the rural ones are already disadvantaged enough, and the metro or interstate ones are flabbergasted to be charged fees for services in ED that they would receive for free at home. And of course the overseas tourists (and we see a fair share on Kangaroo Island) are less than impressed to receive a bill and aren’t covered by Medicare.

Bottomline, the doctor on call for emergency medicine for CHSA doesn’t get paid to come and see emergency patients, unless they are admitted to hospital for over four hours…

Let’s hope this issue will be resolved in contract negotiations – although with two days to go until contracts expire, I am not optimistic.

Contract Negotiations

Well, it’s just over three weeks until the expiry of the current contract between rural doctors and Country Health SA.

Call me a cynic, but I won’t be holding my breath. It’s no secret that many rural doctors are less than enthralled with their working relationship with CHSA in the past. Up until 2009 we didn’t even have a contract describing working rights and responsibilities between doctors and their hospitals. Moreover the existence of ‘local deals’ saw a huge disparity in oncall payments between doctors in different health units.

Astute readers on the web or those dialled into medical politics may be aware of the Kangaroo island doctors being caught up in a brouha in 2009 when they expressed dissatisfaction with their terms of service and threatened a boycott. Indeed, at a recent NSW rural proceduralists meeting, when I mentioned that I was from Kangaroo Island, many doctors stated they’d been following the matter from afar (news to us, as we felt isolated in more ways than one!). I guess that I am tired of explaining the issue, so here is the short story.

Back in 2009 the KI Docs were fed up with the lack of a contract and the fact that their colleagues over at Victor Harbor were paid on a totally different (and more generous) package, despite us sharing the same CEO for both hospitals. Seeing patients at the hospital is at the expense of running a practice (put simply, every hour that a doctor is called away from his/her clinic means more patients that aren’t being treated…and the doctor remains responsible for his her practice costs whilst subcontracting to CHSA as the oncall doctor). Oncall work is an essential part of being a rural doctor, but in a tourist destination, the work of running A&E for the Health Department comes at the expense of doctor’s private practice…with none of the benefits of long-service leave, Workcover, superannuation or adequate remuneration. The disparity between our pay and that of our ‘sister’ hospital was making it hard to recruit and retain doctors locally, threatening the viability of medical services on Kangaroo Island.

In frustration, we spoke to the ACCC and our hospital CEO; the former advised us that as a group practice we were allowed to collectively negotiate our terms …and the latter suggested that if we didn’t like it, we escalate our issue. With ongoing stonewalling by CHSA, we wrote to the Hospital CEO and proposed a withdrawal of our services unless a contract of our liking was instituted. Within a week the (then) CEO of CHSA had flown in to meet us, agreed a handshake promise that a new contract would be forthcoming, and we agreed to continue working and thought no more of it…until the week after, when the ACCC invited us to Adelaide to explain our actions (noone is sure who reported us to the ACCC, but I can say with some certainty that it wasn’t the KI doctors!).  

The ACCC required all five of the doctors to fly up to Adelaide to be interviewed – the irony that in so doing the island would be without sufficient doctors to provide oncall services seemed lost on them. Over 2-3 days of interviews and a tense wait, we finally received a slap on the wrist over our actions and a promise not to do it again (apparently we were allowed to collectively negotiate…but not to threaten a boycott – a fact that we were unaware of). 

“Medical Observer” magazine summed it all up

All in all this was a harrowing experience that lead to the loss of one doctor from the Island and was both professionally and personally exhausting. Needless to say, this affair did little to bolster confidence in our relationship. Indeed, the following year saw the virtual collapse of our ability to deliver A&E services (doctors left, two went on maternity and paternity leave, one declined to rejoin the roster after a sabbatical etc) and CHSA flew in locums at great expense, not all of whom were up to scratch.

The current contract was negotiated in 2010 by the RDASA (the AMA rejected it) and signed by many rural docs in SA for a limited period of 12 months only, in the expectation that a better contract would be negotiated for the future. Of course, those on existing ‘sweetheart’ deals continued on them and will do so until their expiry…

So – the new contract is due on Dec 1st. You can see the proposal by the RDASA here. I am unaware of any response to this offer at the time of writing…and it fills me with alarm that only three weeks remain for a contract to be agreed, signed and implemented – especially one that ties rural doctors in for three years.

Not a good way to do business, I fear. To my mind, several issues remain to be answered satisfactorily by CHSA in any new contract:

– remuneration for being oncall and attending meetings etc, reflecting the cost of so doing to the doctor’s private practice (we have to pay staff/utility bills/rent etc even when we are working at the hospital),

– clarification of ‘who pays’ for non-admitted A&E attendances (in rural SA, patients are billed by the doctor for services which they would receive for free in a metropolitan ED).  CHSA refuses to accept liability for the doctor’s fees unless the patient is admitted to hospital for over four hours (so things like reducing a shoulder dislocation, rehydrating a migraine, suturing a wound, forensic medical exam etc are cost shifted from State to Medicare by CHSA, despite these services provided as the oncall doctor’s duty when working for CHSA)

– safe working hours and locum relief. We are all getting older, and the idea of working a 72 hour shift for A&E is increasingly untenable. Obstetric and anaesthetic doctors may be rostered oncall for several months at a time, with scant opportunity for a locum to relieve them,

– clarification of whether admitting rights are to be tied to signing the oncall roster. Many doctors provide a valuable service to inpatients (palliative care, frail elderly etc) but, for various reasons, may not wish or be able to participate in the oncall roster. Better to keep these doctors on side, rather than ‘conscript’ them…as towns then risk losing valuable doctors who can participate in clinic and routine ward work, but aren’t prepared to be up all night,

– status of existing ‘sweetheart’ deals in rural SA (eg: Victor Harbor, Naracoorte, the Riverland, Whyalla and who knows how many others). Simply, will there be a uniform contract for all rural doctors, or will their continue to be different deals according to geography/local circumstances etc? If so, how are these determined?

There are probably lots of other things that will need clarification…but in the absence of a draft contract to read and a real time pressure before the current contract expires, I am less than sanguine about CHSA’s sincerity. 

To my mind, a partner who was willing to engage meaningfully would have sorted all this stuff out weeks or months ago. But I have been burned in the past…

I’ll update if there’s any news.

A CHSA negotiator prepares to ‘negotiate’ with a rural doctor
“Watch where you’re putting that fist!”