The plight of unaccredited registrars has recently been in the news here with the shocking story of a young female registrar who finally left her unaccredited surgical position after months of overwork and what would be considered abuse in any other profession, and should be considered abuse in medicine.
Dr Yumiko Kadota (1) gave up her dreams of becoming a plastic surgeon after becoming burnt out on a roster of 10 days every 14, including 180 continuous hours every second week. The worst thing about reading this story for me, as a senior surgeon, was my initial reaction of: “What’s so unusual about that? That’s what we had to do.” Which just goes to show how much we have learned to tolerate abuse in medical training.
In Australia, there is fierce competition for specialist training positions, with many more people applying for them than there are positions available. Once a doctor has completed their basic training, if they want to be a specialist they often find jobs as an unaccredited registrar in that specialty, hoping to impress the relevant specialists enough to gain an officially accredited post that will count towards their specialist training. There are many such positions in Australia, and our hospitals depend on them to function adequately.
Unaccredited registrars are in a very vulnerable position. They are not required to be supervised, taught, or assessed in the same way that officially accredited registrars are, nor are they under the protection of that particular specialist college. This poses danger not only to the doctors but to their patients, as their treating doctor may be not only exhausted or burned out, but is also a junior doctor working with inadequate supervision.
They are totally reliant on the goodwill of their superiors to progress in the queue towards the holy grail of accreditation, which makes it very difficult for them to speak out about any problems in their working conditions, or to say no to extra work, knowing that their “attitude” will cost them the precious accredited job.
Why we need unaccredited registrars is unclear to me … if there is enough work to employ them as trainees, surely there will be enough work to keep them busy when they finish their training and so all the training jobs can be accredited and count towards their training requirements … but I am no economist and perhaps the economics of supply and demand dictate that we need to train too few specialists so that those of us who practise are in high demand … which may be great for our incomes but also means that we remain overworked and in danger of burnout. This is especially so in rural and regional Australia where the numbers of specialists are lower.
The touted reasons for not accrediting more training posts include the fact that we cannot supervise them adequately, but in major teaching hospitals, senior trainees supervise juniors and spread the teaching load. Does this lack of supervision not also suggest that we actually need more specialists, which means we need more accredited training positions?
In smaller hospitals such as the one I work in, we have worked with one specialist eye registrar for many years, each of whom is here for three months, which means that we as the supervising consultants need to take their on call to given them a break. We have recently gained a second trainee position and having two registrars has taken so much stress off all of us, and made the workload more manageable and more enjoyable for all.
Emergency physician Dr Rob Mitchell, past chair of the AMA Council of Doctors in Training, says many unaccredited registrars are languishing for years in the role without any guarantee of a formal training place.
“There is real potential for exploitation — as has been highlighted through Dr Kadota’s experiences,” he says. (2)
Dr Mitchell said the solution was obvious and overdue: these posts should be phased out and accredited for specialty training.
“The major barrier is the extent to which posts can meet current college training standards, particularly with respect to caseload and supervision requirements,” he said.
Trainee doctors are expected to work in conditions that are untenable and unsafe, for them and for their patients. Dr Kadota was on call from early Monday morning one week to late Monday afternoon the next – about 180 continuous hours of rostered work with added phone calls, interrupted sleep, and emergency consultations and operations. She would then have one night off and be on call again for another 80 hours straight until Friday afternoon. And the next Monday morning, the cycle would begin again.
This is absolutely unsafe, for doctors and their patients. Studies have shown that being awake for 18 continuous hours is the performance equivalent of having a blood alcohol level of 0.05% (the legal driving limit) and that being awake for 24 hours is like having a blood alcohol level of 0.10%. (3,4)
We need to employ enough doctors to do the work in a way that allows them not just to exist, but to live as human beings, to rest and recover and enjoy life as well as medicine, for their sake, for our sake as their supervisors and colleagues, and for the sake of our patients.
Unaccredited registrars are accountable to the administration of their employing hospital, and I have heard stories of people being told not to claim the overtime they have worked, which gives a false idea of how much work they are doing. If these doctors were paid overtime rates for every hour of their worked overtime, hospitals would soon realise that it would be more economical to pay more people to do fewer rostered work hours each, but if they are not paying for overtime, then those economics are hidden.
We cannot have a system which insists on fair working conditions for one group in order to protect both doctors and their patients, and then completely ignores these rules for another group, making both doctors and patients vulnerable. We as senior doctors need to support our juniors, and rather than expecting them to work in the appalling conditions we were trained under, advocate for them and support them to enjoy basic human rights of fair pay, decent working conditions and rostered time away from work.
We know to our cost that doctors are not superhuman, and if the current epidemic of burnout, exhaustion, depression and suicide is to be dealt with, we all need to be treated as people in order to be able to care for ourselves and do our jobs and and provide the deep care that we all feel for people.