THE MAGAZINE OF THE ASSOCIATION OF SALARIED MEDICAL SPECIALISTS ISSUE 116 | OCTOBER 2018

CELEBRATING THE WORK OF OUR WOMEN MEMBERS | P3 THE CHALLENGES OF MEDICAL LEADERSHIP | P13

ASMS BRANCH OFFICERS’ MEET | P19 TOI MATA HAUORA INSIDE THIS WOMEN IN ASMS ANGELA BELICH | ASMS DEPUTY EXECUTIVE DIRECTOR

ISSUE hen I came to work for ASMS – 3 out of 11. We know that women form and, since 2007, criteria for the starting ISSUE 116 | OCTOBER 2018 Win 2001, women were 22% of a larger proportion of members at the salary has been carefully defined in a way the ASMS membership. Now women bigger DHBs but the smaller DHBs tend to that should minimise unconscious bias. constitute 37% of ASMS members. Given be male-dominated. that ASMS’ membership density in the Factors such as years of relevant permanently employed DHB workforce is We know anecdotally from our industrial experience and qualifications can be around 90%, this is likely to be consistent officers that we have a steady stream of taken into account but reference to women appointed at lower steps, with lesser for all senior medical and dental officers. recruitment and retention as a factor in MORE WAYS TO GET FTE and without the extra allowances of Given the proportion of women in medical their male colleagues. We have even joked setting starting salary was knowingly and YOUR ASMS NEWS school and the proportion of women that a woman joining the roster seems to consciously removed by the parties (both You can find news and views registrars, it seems inevitable that the be a signal that recruitment and retention DHBs and the Association). The ASMS- relevant to your work as a specialist senior salaried medical workforce will is no longer a problem and that any extra DHB MECA is, however, a minimum rate at www.asms.nz. The website is become a majority female workforce in the payments are no longer necessary. When document so there is nothing to prevent updated daily so please add it to near to medium term. It will not necessarily the ASMS industrial staff know about this, an employer paying above the MECA in a your favourites or online bookmarks follow in a straight line. In New Zealand, a we can almost always get the obvious variety of ways. Given the overseas data, to remain up to date. very large proportion of our doctors are inequities corrected. DHBs have no there is reason to suspect that this will international medical graduates (IMGs) ideological commitment to treating women play out in a way that favours men over We’re also on Facebook, Twitter and it’s possible that in New Zealand we unfairly. It is just something that ‘happens’. WOMEN IN ASMS women and male-dominated specialities and LinkedIn, and links to those 03 train more women locally and then recruit Why is explained in the book Why so slow? over the female-dominated. If this is pages are at the top of the ASMS more men than women from overseas. the advancement of women by Virginia happening, it is a breach of the Equal Pay Valian (Valian 1998) which was referred website homepage. Act which has been in force since 1972. 04 CELEBRATING THE WORK OF OUR WOMEN MEMBERS Since 2002 the Association has been to extensively by Caprice Greenberg in collecting data on where senior doctors her presidential address to the American and dentists are on the salary scale by It is a sociological truism that professions USING QR CODES DOES INCREASED USE OF PRIMARY CARE REDUCE PRESSURE ON Association Academic Surgeons (https:// that become female-dominated lose gender. There are important caveats to academicsurgicalcongress.org/aas-2017- You’ll notice QR codes are 11 HOSPITAL SERVICES? this data. It reflects steps on the salary status, power and relative wealth (Pringle president-address-caprice-greenberg-md- 1998). The Association and our members used throughout this issue of scale but not hours of work or any mph/ and also see Greenberg 2017 for full will need to find a way to make sure that The Specialist. They will take you MEDICAL LEADERSHIP – WHY SO HARD TO DO THE ‘RIGHT’ THING? allowances. So, it doesn’t reflect FTE or text of address). to the websites or online articles 13 call or availability or any other after-hours becoming a female dominated profession mentioned in the magazine without payments or recruitment and retention The ASMS DHB MECA (and the salary does not diminish our members’ leadership manually having to type in a REVIEW OF THE STATE SECTOR ACT payments or clinical leadership allowances. scales we have in our other collective role in the public health system but leads website address. 15 agreements) should be very effective at to an era of sustainable work patterns and Over the years, the survey has shown a mitigating against the unconscious bias REMOVAL OF PATHOLOGY FROM THE LONG-TERM SKILL patient-centred care. If you don’t already have a QR steady gap between the salary of men we are all subject to (an online gender SHORTAGE LIST and women members (see Figure 1). reader/scanner on your smart phone, 17 bias test can be found at the following: REFERENCES you can download one for free from We hypothesised that this reflected the https://implicit.harvard.edu/implicit/ relative seniority of the age cohorts that Greenberg, C. C. (2017). “Association for Academic your phone’s app store (eg, Google 2018 ASMS BRANCH OFFICERS’ WORKSHOP takeatest.html). were male dominant and therefore at the Surgery presidential address: sticky floors and Play on Android or the App Store on 19 top of the scale. After 16 years it may be Contrary to the clichés of human glass ceilings.” J Surg Res 219: ix-xviii. Apple phones). It’s simply a matter time to revisit this hypothesis. Pringle, R. (1998). Sex and medicine: gender, power, THE CURSE OF DEFERENCE resources and business management, then of pointing the QR reader at 23 flexibility and deregulation is most likely and authority in the medical profession/Rosemary the QR code on the page of the What else do we know about women in to allow these unconscious biases or Pringle. Cambridge, New York, Cambridge magazine and then clicking through ASMS? We know we have never had a University Press. VITAL STATISTICS schemas to unfold without restriction. to the website link that appears. 25 female President and that we presently Valian, V. (1998). Why so slow? : the advancement of have the largest number of women we ASMS salary scales require movement women/Virginia Valian. Cambridge, Mass., have ever had on our National Executive up the scale on satisfactory performance MIT Press. The Specialist is produced with the generous ASMS 30TH ANNUAL CONFERENCE support of MAS. 25 100% 85% 90% Work through illness COLLECTIVE BARGAINING IN THE NON-DHB SECTOR 84.6% 92% ISSN (Print) 1174-9261 26 80% 75% Work through 73% ISSN (Online) 2324-2787 70% infectious illness 78% FIVE MINUTES WITH NEIL STEPHEN 60% Report witnessing bullying 65% 28 to some degree 70% 50% The Specialist is printed on Forestry Score with 44% 40% personal burnout Stewardship Council approved paper DID YOU KNOW? 59% 30 30% Score with 39%

PERCENTAGE SPECIALISTS PERCENTAGE work-related burnout 47% 20% 25% Self-report as bullied 32% ASMS FREE SERVICE 10% 15.4% 31 to some degree 40% 0% 1 2 3 4 5 6 7 8 9 10 11 12 13 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% HISTORIC MOMENTS SALARY STEP 32 Men Women % Female SMOS 2017 % Female SMOS 2007 % Male SMOS 2017 % Male SMOS 2007 THE PROBLEMS OF TREATING THOSE CLOSE TO YOU FIGURE 1: PROPORTION OF SENIOR DOCTORS AND FIGURE 2: KEY DATA FROM RECENT ASMS RESEARCH 33 DENTISTS ON THE ASMS SALARY SCALE BY GENDER AS IT PRESENTS ACCORDING TO GENDER ALL DIFFERENCES BETWEEN MALE AND FEMALE RESPONDENTS FOR EACH VARIABLE ARE STATISTICALLY SIGNIFICANT (P<0.05)

2 THE SPECIALIST | OCTOBER 2018 WWW.ASMS.NZ | THE SPECIALIST 3 I always thought that if the boys could do it, then I could too.

TANYA WILTON

Tanya Wilton has worked as an emergency physician for the past 10 years, and is employed by Hutt Valley District Health Board. I have had an interesting journey want to play as well as having time for through medicine. I was a graduate my own non-work pursuits. student entering medical school When I started emergency medicine after completing a degree in physical training, there were few specialists in education. It was at the start of my New Zealand and even fewer women. medical degree that higher fees and Those I came across were encouraging student loans were introduced. I had Tanya Wilton (left) with friend Kate CELEBRATING THE WORK and interested in getting trainees on the Neas, who is also an ASMS member managed to pay my own way through path to emergency medicine but it was my first degree without any debt. a pretty tough run for them being only However, the fees and loan scheme refused to accept the historical limits OF OUR WOMEN MEMBERS one of one or two consultants supporting meant that I graduated from medicine that were part of the social mores of a whole department. I completed with a large student debt, in spite of their times. There are many who have most of my training in Australia, continuing to work part time throughout made it easier for women to have a where emergency medicine was more my medical degree. Incongruously one career in medicine. I think the current developed and had greater numbers of of my jobs was at a bottle store and I challenge for medicine as well as ew Zealand led the way 125 years ago which we established at the request of Our next steps include conducting a pilot specialists from whom to learn. had the signs of chronic liver disease emergency medicine in Aotearoa is to when it became the first self-governing our members. survey of members to identify whether a N frequently in front of me! I trained with a generous and increase the diversity of our workforce country to grant women the vote. As part gender pay gap exists for our members. collaborative group of women who We have also been conducting research In hindsight, I think that the increased so that we better represent the of the commemorations of that event, In a further piece of work which will be were combining career and early into issues which affect many of our fees and student loan scheme communities we serve and can improve ASMS is celebrating the work of our reported on later this year, ASMS Principal parenthood. We had study sessions members but seem to have a particularly disadvantaged and continues to the barriers to health that often trouble women members, whose own practice of Analyst (Policy & Research) Dr Charlotte adverse impact on women senior doctors disadvantage those students who end at odd times of the day, often with our communities. medicine builds on the foundations laid by Chambers is analysing qualitative and dentists, such as the high rates of up earning less - often women, who take babes at the breast and toddlers I feel strongly that we need to hold on this country’s early suffragists. roaring around as we shared our burnout reported (https://www.asms. research into why younger women time out of the paid workforce to have to the taonga that is our public health study knowledge, kid knowledge, our ASMS is responding to the issues raised org.nz/news/asms-news/2016/08/12/ members may be more prone to burnout children. I have non-medical friends who system. It seems there is an increasing successes and failures. It was this crazy by our women members by providing burnout-rife-among-senior-doctors- than their male counterparts. still have a sizable student debt more creep of private medicine in New and accepting support group that got opportunities to network at each ASMS dentists-working-public-hospitals/). We than 20 years after graduating. Zealand. It is argued that this ‘takes the me through the training programme. Annual Conference and to connect have also been taking up issues such as In this article, we hear from six women I recall a lovely GP talking to a group strain off the public system - freeing it up for those that need it’. However, in my with other women doctors at all stages breastfeeding policies and facilities when specialists at various stages of their own of us (I guess all female) when we were The department I worked in was experience this does not always alleviate of their medical careers through the we meet with district health board chief careers about their journey into and medical students in Dunedin, saying flexible. They didn’t get upset when my the pressure on the public system but Facebook group Women in Medicine, executives and senior managers. through medicine. that you couldn’t do it all. That to husband turned up with a hungry baby reduces the availability of clinicians combine having a career and having and we had a meal break together. I committed to the public system as children was hard. I thought to myself was determined; it never seemed like it more move to the often less frustrating that this was slightly ridiculous - I couldn’t be done. However, there were conditions in private medicine. always thought that if the boys could some exhausting and difficult times. do it, then I could too. However, I think I’m not surprised that the recent ASMS In my dream health system there would there is a partial truth to her caution. survey found that it was the 30-39 age be equity of access to medical, nursing It doesn’t seem to be my husband group of women that had the highest and allied health training, as well as EARLY NEW ZEALAND who notices that the kids have grown levels of burnout. As all parents know, equity of access to receiving health out of their clothes or need to take a those early years of parenthood are care regardless of gender, economic present to their friend’s party or even demanding and often severely sleep- status or cultural background. This is WOMEN DOCTORS remembers the friend’s party, and there deprived, especially when combined the future that I wish my children to live are a lot of little things that end up with work and study. in. In this way we can all flourish and make the best of our various talents. Some of New Zealand’s early women doctors included: being on my plate. Maybe other families Overall, I am hugely grateful to those manage this better? Na-ku te rourou, na-u te rourou, ka ora • Emily Hancock Siedeberg: https://teara.govt.nz/en/biographies/3s16/siedeberg-emily-hancock women who have come before me The challenging thing for me has been and forged a path into medicine and ai te iwi • Margaret Cruickshank: https://nzhistory.govt.nz/nzs-first-registered-woman-doctor-margaret-cruickshank figuring out how much of myself to opened doors for women like me. With your basket and my basket, the • Sylvia Gytha de Lancey Chapman: https://teara.govt.nz/en/biographies/4c17/chapman-sylvia-gytha-de-lancey devote to the different roles I need and Gratitude also to those women who people will live • Theodora Clemens Easterfield:https://teara.govt.nz/en/biographies/4h6/hall-theodora-clemens • Eleanor Southey Baker: https://teara.govt.nz/en/biographies/3b5/baker-mclaglan-eleanor-southey • Jean Mary Sandel: https://teara.govt.nz/en/biographies/5s1/sandel-jean-mary • Cecily Mary Wise Clarkson: https://teara.govt.nz/en/biographies/4p12/pickerill-cecily-mary-wise I am hugely grateful to those women who have come before me and forged a path into • Doris Clifton Jolly: https://teara.govt.nz/en/biographies/4g14/gordon-doris-clifton medicine and opened doors for women like me. • Eily Elaine Gurr: https://teara.govt.nz/en/biographies/5g23/gurr-eily-elaine

4 THE SPECIALIST | OCTOBER 2018 WWW.ASMS.NZ | THE SPECIALIST 5 I am encouraged by the increasing number of female surgical trainees and registrars working on the wards and theatres in New Zealand.

JESSICA BUCHANAN

Jessica Buchanan is an oral and maxillofacial surgeon at Greenlane Clinical Centre with the Auckland District Health Board. GUIN HOOPER I am the first woman to graduate as an theatres in New Zealand. More recently, oral and maxillofacial surgeon from the Oxford University has introduced University of Otago, and therefore a me to a global network of women in Guin Hooper works in the emergency department for Wairarapa DHB. majority of my mentors were men, great surgery. All doctors have unique work I work in the Emergency Department as I think that in general, medicine is a pretty surgeons who care about their patients challenges, and being able to share, an SMO, and have done so for about two good fit for women, if you are willing to and work. network and gain solutions on similar to three years, although I received my make significant personal sacrifices. My training involved both medicine issues is important. MBChB around 20 years ago. It took me I have felt very conflicted in the past a while to decide on a specialty, and by and dentistry, and I have been Most clinicians work in high pressure when you have, for example, a sick child, that stage I had started a family, so the lucky to work alongside incredible roles which can affect their performance. and a shift that needs covering. It has logistics of full time study and full-time anaesthetists, intensive care specialists, Creating a healthy, safe, sustainable generated a lot of stress for me, knowing parenting were incompatible. neurosurgeons, general surgeons, ORL workplace culture is important. Health that I am letting my colleagues down, but specialists and dental specialists. I have care systems that are patient-centred Jessica Buchanan In general, I find that medicine as a knowing that I cannot leave my child alone especially been inspired by the work of and value-based have been shown to profession is a lot more accepting of and unwell at home, and I suspect that Dr Heather Keall, who has dedicated improve patient outcomes but also women than it was 20 years ago, though a situations like these are one of the reasons large proportion of my class were women her career to treating children with cleft promote a good workplace culture. in Aotearoa New Zealand. Gaylene that burnout is highest in younger women back then too. I remember that a number lip and palate at Middlemore Hospital. I am encouraged by the work ASMS Preston has produced a short-film in medicine. I have been an SMO for five years now undertakes to support this, and also from the memoirs of suffragists, of older professors were inclined to make Generally my colleagues have been very and I am currently reading for a MSc the research undertaken at Ko Awatea, revealing that these were women incredibly sexist and patronising comments, supportive in situations like these, but of Surgical Science and Practice at Counties Manukau. who challenged the world view, were and I’m pretty sure that sort of thing would management has occasionally been less Oxford University. determined to do the job well and be unacceptable nowadays. The exhibition ‘Are We There Yet?’ at so. That makes it really tough, sometimes. I am encouraged by the increasing the Auckland War Memorial Museum make a difference to society. In general, I find that very few of my colleagues treat me any differently than I’d like to see a future where those kinds of number of female surgical trainees and Tamaki Paenga Hira celebrates the This is also the story of many women in they do men in the profession, and I commitments are acknowledged registrars working on the wards and 125th anniversary of women’s suffrage medicine and surgery. appreciate that. and supported. Guin Hooper

Oxford University has introduced me to a global network of women in surgery. Medicine is a pretty good fit for women, if you are willing to make significant personal sacrifices.

6 THE SPECIALIST | OCTOBER 2018 WWW.ASMS.NZ | THE SPECIALIST 7 When I spoke to the deputy medical superintendent in chief about needing to take leave, he said “If you plan to have any more children, Dr Marks, please talk to your colleagues first”.

ROSEMARY MARKS

Rosemary Marks is a paediatrician at Starship Hospital, Auckland DHB. I came to New Zealand from the UK in adults. I was relatively isolated from other 1977 for a year, having done my medical medical colleagues because of its location. Hardly any of the consultants were female. You could literally count them on the fingers training at Bristol University and worked for However, I was very well supported by a couple of years as a house surgeon in the John Newman, who was also a relatively of one hand. south-west of England. I had always been new paediatrician at that time who went interested in New Zealand. on to manage Starship. In my first year in the old Princess Mary I had thought it was too difficult to Hospital I was asked to take on a registrar practise medicine and have children but role because someone hadn’t turned up. my husband persuaded me otherwise. I was a very green paediatric registrar, There were other women consultants on not having done any paediatrics since LIZ ALMOND the same path as me, and in fact my son Rosemary Marks qualifying; the support I received from my was at the tail end of a string of paediatric seniors was quite variable. I was asked pregnancies. When I spoke to the deputy young people coming through the medical Liz Almond is a general adult psychiatrist with a special interest in perinatal mental to do consultant clinics when there was medical superintendent in chief about training now have different expectations health at Masterton Hospital and is employed by Wairarapa DHB. no consultant to supervise me, and to be needing to take leave, he said “If you plan and we need to work smarter, nurture I attended an all-girls school in the UK I did my psychiatry training in Leeds honest that was not an uncommon practice. to have any more children, Dr Marks, them, and ensure a quality, safe service. and was told that because I was good and came to New Zealand for a one- However, I enjoyed living in New Zealand please talk to your colleagues first”. Any and decided to stay and train in paediatrics. I do have a connection with the suffrage at science perhaps I should be a nurse. I year locum for my first consultant post senior hospital manager who said that to a in 1994, in Wellington. I fell in love with In 1980 I was able to attend some movement. Elizabeth Garrett Anderson, went to Sheffield medical school in 1982. young woman doctor now would be outed. both New Zealand and my husband, sessions at the annual scientific meeting of the first woman to qualify as a doctor in We were the first intake where women Balancing work and family has been tricky; who’s a Kiwi. I’ve worked in New the Paediatrics Society, held in Auckland. the UK (https://en.wikipedia.org/wiki/ were the majority of medical students however, being a mother has made me a Zealand for most of my career apart Dr Bonnie Camp, who pioneered Elizabeth_Garrett_Anderson), was the there, just slightly at 52%. One of the better paediatrician. I was slightly stunned from eight years in Australia. Developmental Paediatrics at the niece of Richard Garrett. My great-great- things I particularly noticed throughout Liz Almond when my six year old son said to one of University of Colorado in Denver, was the grandmother married Richard Garrett my time at medical school was the lack One of the things I noticed was that his little mates about me: “Don’t bother invited international guest speaker. One on her return to England after her first of female role models, especially in there was less sexism in New Zealand I also encountered more sexism in the asking my Mum, she’s always working”. It evening when I was on call, I went to get husband died in the Australian Gold Rush. hospital medicine. Hardly any of the than I had experienced in the UK. For workplace and generally in society. made me stop and think about my ‘work- And Elizabeth had a sister, Millicent, who example, when I was a registrar there, my dinner and there was Bonnie Camp, consultants were female. You could It felt refreshing when I came to New life balance’. was a leading campaigner for women’s I remember the reaction when I wore sitting there eating dinner with the junior literally count them on the fingers of Zealand. I preferred the work environment My team now is all female. We’re a very suffrage in the UK https://en.wikipedia.( trousers to work one day. Women doctors. No one wined and dined guest one hand. here and I haven’t struck major issues as speakers in those days or put them up in small team, five of us filling just over 2 FTE, org/wiki/Millicent_Fawcett). always wore skirts, and there were During my registrar training, there comments about me being radical by a woman in medicine. I suspect psychiatry five star hotels. She talked about her work and we all have children. I think the really I’m now at the winding down stage. I used were a few women working in psycho- wearing trousers. I remember one of the may be more supportive of women than in developmental paediatrics, and I was important thing is to have a supportive to say that I would retire when my son geriatrics and child psychiatry, but male consultants saying in a meeting other specialties. inspired to pursue this as a career. partner. My husband’s not a doctor and finished medical school. However, I’ve no women in adult psychiatry. It’s that every time he was allocated a Medicine generally needs to be more I returned to the UK for a couple of he’s always been able to be flexible and continued working for the time being, interesting talking to current medical female registrar he wanted them to family-friendly and support a balanced years to obtain subspecialty training in share the childcare. because I enjoy the intellectual stimulation students today and finding that they take a pregnancy test at the start of life. That means more flexibility around Developmental Paediatrics. I came back My son graduated from Otago medical of work. I now do clinical work a couple of still feel there is a lack of female their run because he was sick of them careers, which will benefit men as well in 1984 to take up a post at the Mangere school in 2016 and women then made days each week and plan to stop before role models. going on maternity leave. In Australia as women. psychopaedic hospital. It was the newest up about 60% of the students. When I too long. You don’t want to go on working of the psychopaedic hospitals at the time, was at medical school there were 20% and then have people saying, oh, she’s and it had a mix of children and younger women in the class – it was a quota! The really past it. Timing is everything.

I remember one of the male consultants saying in a meeting that every time he was allocated a female registrar he wanted them to take a pregnancy test at the start of their I think the really important thing is to have a supportive partner. My husband’s not a doctor run because he was sick of them going on maternity leave. and he’s always been able to be flexible and share the childcare.

8 THE SPECIALIST | OCTOBER 2018 WWW.ASMS.NZ | THE SPECIALIST 9 JULIET RUMBALL-SMITH

Previously Director of Health Intelligence at Northland DHB; began new role as Clinical Chief Advisor at the Ministry of Health in September. I am a public health physician. This was the world it opened up for me, one that an easy choice of specialty for me as I I had never had access to before. We have always been interested in population went to a conference and could share health and equity – however, my training a room to keep the costs down! We had Juliet Rumball-Smith and early SMO years were slower than long discussions over late dinners about most. Essentially, I became distracted medicine and research and politics and by (1) research, and (2) the rocky and family, and I didn’t feel uncomfortable allowed her to come after she provided rapid arrival of four children in four about the environment or the risk of intimate financial details, and also stated years, including premature twins. Looking accidental subtext. Most importantly, she that she had paid for her plane ticket and back, those early years in our family demonstrated a completely different style would be coming irrespective. were characterised entirely by trying of leadership, one that felt accessible The point of this story is that 25 years to cope, with the growing of these four and achievable. The year was a lightbulb later I started at Otago University, and cherubs and two careers, and the added moment for me – was this the sort of the Governor-General, Prime Minister, challenge of doing so in a metre of snow familiarity and openness that my male and Chief Justice of this country were all and frequent ice storms (Montreal and colleagues had been having all along? It women. It seemed like the suffragists and Toronto). We returned to New Zealand was a big part of my decision to try and society had achieved their goal. However, a little bruised, and the warmth of promote mentoring for women working in later that year, I sat next to a fellow Northland - both environment and people medicine, through the organisation medical student in a lecture who stated - was just what we needed. Wa-hine Connect (www.wahineconnect.nz). unashamedly that his future doctor wife DOES INCREASED USE My time as a Medical Officer of Health You ask: ‘how would I like to see medicine would give up her career to look after the here in Te Tai Tokerau showed me first- as a profession for women in the future?’ hypothetical children, because she would OF PRIMARY CARE REDUCE hand and daily the impact of poverty First, I want us to realise that women are be ‘better at it’. Twelve years after that, my on health; I saw it in rheumatic fever, allowed to have different styles of care, medical husband requested some time off extracted teeth, and large families in small and ways of approaching team-work to look after the children, and the manager PRESSURE ON HOSPITAL mouldy houses. I also lived the importance and leadership. We should value these asked: ‘why can’t your wife do it?’. of true collaboration across the sector differences, understanding that these Gender-based biased attitudes and and the benefits of enhanced holistic approaches have been shown to be behaviour let us down as a medical SERVICES? community-based care. Hence my growing highly effective, and can produce better profession. However, they also let down interest in policy and strategy, and I was outcomes for patients and organisations. the broader community: the taxpayer LYNDON KEENE | ASMS DIRECTOR OF POLICY AND RESEARCH lucky to be able to focus on this during a Second, we should insist on higher heavily subsidises our medical training, and none of us get through medical one-year Harkness Fellowship to the US. standards of behaviour in our workplaces school/house surgeon years/specialty I am sad to leave behind Northland, but I – from meeting conduct and those training without the support of wha-nau am looking forward to the challenge of the poorly-worded jokes, right through to nternationally, sitting behind much of the discussion about how to improve health systems is the question, sometimes explicit but and community. I truly believe that New Ministry of Health and the opportunities our entitlement to harassment-free Imore often not, of how to contain cost. Given that hospital services are the biggest cost item, the question inevitably becomes Zealand society see the benefit of a of my new role. workplaces. [Note: many of my medical one of how to contain hospital costs. One obvious answer – to reduce the need for hospital services – usually leads to policies aimed diverse medical workforce, and assume Ten years ago my husband received an friends and acquaintances posted at strengthening primary care, which is emphasised in government health policy, including the Government’s recently commenced that their New Zealand medical workforce email on his personal account, the sender ‘ metoo’ on their Facebook pages. Others review of the health and disability system. In an environment of constrained government spending this often means shifting # is treated respectfully, and without bias. sweetly suggesting that I ‘step aside’ and paused and gave it some thought – Did resources from hospitals to primary care. Calls for such a shift are common in health systems discussions. I think they would be surprised to hear it count if you were so busy you barely ‘focus on my husband’s career’. I think this about the patient that tried to kiss us, Studies have shown that a ‘strong’ primary focused on prevention. • lack of practitioner time type of overt bias is less common now, and noticed? What was the difference those comments on our ‘saucy boots’ health care system has the potential to although we still have a way to go, our between sexual harassment and the The evidence from New Zealand and • lack of practitioner confidence in the (footnote: they really weren’t), or how contribute to population health at the overseas shows that while in theory effectiveness of interventions (due in workplace ‘gender manners’ (ie, openly garden-variety misogyny we get most often we are talked over in meetings. disrespectful behaviour, those funny-not- days? Did it count if it was a patient? individual and population levels. It can help primary care services are well placed to part to conflicting evidence and the I am also confident that as mothers to prevent illness and death. Nevertheless, non-generalisability of evidence) funny jokes, interview questions about our Food for thought…] and fathers, brothers and sisters, they implement health improvement policies, the evidence also shows clearly that baby-making plans) have improved. But My mother wasn’t allowed to go to medical expect the gender parity seen in medical in practice there are many shortcomings. • lack of confidence in providing the the bias is still there, and we see its impact school – my grandparents couldn’t afford school to continue, and to be evident attempts at prevention in primary care are A study in the Netherlands, which has right advice in the low numbers of women in leadership having little impact on reducing pressure it – and considering she was only allowed in the proportion of women who are seen substantial increases in the rates of • lack of patient compliance and and governance positions, the gender to finish high school because ‘the wool surgeons and clinical directors and Chief on hospital services. Whether in New hospital admissions since 2000, identified perceived lack of motivation pay gap, the ‘motherhood penalty’, etc. I price had gone up’, she felt grateful to Medical Officers (just a few examples). Zealand, Australia, the United Kingdom, 24 specific facilitators for implementing still feel uncomfortable on occasion. I am • practitioner attitudes, and go to university at all. At age 30 she was Irrespective of ethics or the benefits of acute hospital inpatient admissions have health promotion activities in primary getting better at calling it out – but it is awarded a fellowship from the American diversity or natural justice – for the sake increased well above the population • financial disincentives. very difficult to do this in response to the care, against 41 ‘barriers’, many of which Association of University Women to do of respecting the investment made by all growth rate, despite increased rates of are cited in other international studies. Regarding the latter, while the introduction subtler forms of bias. New Zealanders into our workforce and research at Cornell University. They primary care consultations and policies The most cited barriers relate to: of capitation funding (via Primary Health Recently I had my very first senior female revoked it immediately when they their trust in us; for this reason alone, we boss/mentor and was astonished at discovered she was pregnant, and only need to do better.

Mitigating these barriers requires political commitment to an inclusive, long-term strategy, Gender-based biased attitudes and behaviour let us down as a medical profession. with the necessary resources, aimed at systematic continuous improvement.

10 THE SPECIALIST | OCTOBER 2018 WWW.ASMS.NZ | THE SPECIALIST 11 12 THESPECIALIST reducing pressurereducing onhospital services. Evidence shows attempts prevention at that on impact in primary care arehavinglittle Further, awell-functioning primary careprimary workforce shortages. the barriers to access andto address the most urgent needisto remove continuous improvement. Arguably resources, aimedatsystematic long-term strategy, withthenecessary political commitment to aninclusive, simple, short-term It task. requires Mitigating thesebarriers isnot a LONG-TERM STRATEGY REQUIRED pharmacological treatment. provided withspecific psychological or with severe conditions, onlyhalfwere of intervention. Even amongthose with mental illness received someform decade ago, lessthanathird of those in general practice conducted over a treatment of common mental disorders care inAustralia, butinastudy of the little data onmental healthinprimary nutrition orweight counseling. There is only 3.4% of GPencounters involve Australians are overweight orobese, and cholesterol. Whileover 60%of levels of bloodpressure, bloodsugar seeing aGPhadrecommended less thanhalfof people withdiabetes saw aGPhaditadequately controlled; withhighbloodpressurethan 30% who recommended cholesterol levels; less a general practitioner (GP) reached people withhighcholesterol whosaw studies: in2016 of lessthan20% primacy care isillustrated inAustralian prevention andpromotion in activities The of impact thesebarriers to IMPACT OFBARRIERS receiving it. of earlyhealthcare intervention are not some of those whomaybeinmost need many New Zealanders. Whichmeans create significant access barriers for of care primary services inmany areas), charge, inturn(and limited availability from patient charges. The patient continue to derive of part theirincome becauseeffect, inpart general practices Care Strategy show ithashadlittle care, evaluations of thePrimary Health a populationhealthapproach inprimary Organisations) was meant to encourage Some of those whomaybeinmost needof carearenot intervention health early receiving it. | OCTOBER 2018 led ‘micro interventions’, whichare as aconsequence of clinically- specific, bottom up. Integration can beachieved is possible onlyifitcomes from the integration consistently indicate it The experiences from successful keeping peopleoutof hospital. of care, isthebest approach for provide goodpatient-centred continuity careprimary andsocialservices, to integration between hospital services, There isstrong, mounting evidence that referral rates to specialist services. variation care inprimary practitioner by themany studies ontheoften-wide integration of services isunderscored The needfor greater collaboration and current fundingandcaseload structure.” and thatthisisvery difficult withinthe GP to appropriately managetheircare, with both apsychiatrist andthetreating can require weekly case conferencing “In somecases … very complex patients New Zealand College of Psychiatrists: report from theRoyal Australian and and psychiatrists, ascommented ina greater collaboration between GPs health care, for example, requires rapidly growing pressures onmental specialists. The well-documented careprimary practitioners andhospital health professionals, especiallybetween clinical timefor collaboration between population alsorequires additional complexity of illnesswithanaging multidisciplinary teamwork andgrowing The increasing dependence on care services. to theworkload of primary health improvement, aswell asadding are clearlyimpediments to thegoalof rates (see ‘Vital Statistics’ page25) increasing acute hospital readmission and hospital treatment,alongwith tests, first specialist assessments, On theother hand,delays indiagnostic contributing to healthimprovement. effective hospital treatment isclearly not considered avoidable, timelyand of hospitalisations are for conditions improvement. Giventhelarge majority succeed intheoverall goalof health accessiblefunctioning, hospitals to care service isdependent onwell- the determinants of illhealth. requirements, healthfundingneedsand distributed clinical leadership, workforce include thetopics of integrated care, shortly. Further Research Briefs will secondary care willbepublished onllne carein primary andtheeffects on the evidence onprevention activities An ASMS Research Brief examining broader issues. headway without alsoaddressing these hospital care willstruggle to make services to reduce theneedfor acute improve theeffectiveness of health The evidence indicates efforts to basic food items. foods, andamandatory limitonsaltin consumption of alcohol andunhealthy aimed atreducing smoking and interventions are tax andregulation effectiveness preventiveof 150 health Australian study evaluating thecost- In addition,top of thelist of afive-year than those indeciles1and2. times more likely to endupinhospital and 10beingnearlytwo-and-a-half children aged0-4 years indeciles9 child hospitalisation, with New Zealand likelihood of potentially preventable have asignificant influence onthe Poverty anditsflow-on effects can such aspoverty andpoorhousing. the well-known determinants of illhealth, health system. This includesaddressing need for hospital care lieoutsidethe the greatest onreducing impact the But policieswiththepotential to have SOCIAL DETERMINANTS OFHEALTH necessary timeneededfor leadership. of clinical staffing toallow the in turn,isdependent ontheadequacy Effective distributed clinical leadership, component of successful integration. clinical leadership isacritical A strong commitment to distributed a process of learningandadapting. with thecontext of local needsthrough available evidence andtailor itto fit multidisciplinary teams to usethe developed over timeby enabling R A options were much more likely to be also believed thatleaders whochose the follow theAoptions. Eighty-eight percent medical leaders inNew Zealand would a subsequent question 94% believed most the Boptions to However, bethebest. in Eighty-six percent of students believed problem (figure 2). leaders could applyto dealwiththe students two sets of options thatmedical annual increases infunding.Ithengave the funding, withpatient needoutstripping nine years orsoof restricted health This schematicisillustrative of thepast Zealand to corresponding increasing patient need(figure 1),showing growing unmet patient need. no previous discussion,Ishowed themaconcept graph relating annuallyincreasing resource allocation inhealthcare inNew MEDICAL LEADERSHIP – MEDICAL LEADERSHIP 2010 HEALTH NEED PROF MURRAY BARCLAY |ASMS NATIONAL PRESIDENT Leadership inMedicine. Istarted by pollingthestudents usingsoftware for instant audience feedback (Polleverywhere). With ecently, Iwas invited to speakatanational meeting of theNew Zealand Medical Students Association onthetopic of 2011 2012

RESOURCE (WORKFORCE AND BUILDINGS) THE ‘RIGHT’THING? HARDTOWHY SO DO 2013 FIGURE 1

PATIENT NEED

UNMET NEED 2014 2015 2016 hospital buildings withinadequate space, clinician burnoutandbullying,crumbling our publichospitals, ie, increasing rates of New Zealand seniormedical staff andin problems we are now observing amongst unmanageable. This leadsto therange of it isnot given, andworkload becomes If increased resource isnot requested options are becoming very clearto see. The consequences of choosing theA therefore very illuminating. hospital Their answers management. were workforce andsohadnot beenexposed to students hadnot yet entered thehospital chosen asleaders andpromoted. These 2017 2018 FIGURE 2:TWO SETS FOR OFCHOICES CLINCAL LEADERS • • • •

resilience techniques Teach mindfulness, Strive for more efficiency budget set Be guidedby the increase inresource Accept there willbeno A line management (ie, thelinemanager repeatedly turneddown atany point of there isahistory of businessplansbeing when oneisalready overworked. Also, if prepare, timethatisoften difficult tofind These take significant timeand effortto usually require detailed businessplans. to mind.Firstly, requests for more resource complex, butsomepotential factors come the better options? The answer islikely leaders to choose whatare supposedly So why isitsohard for somemedical resulting from allof theabove. inevitably, worse qualityof patient care inequity inpatient care andultimately, • • • •

o management, - thisneed Advocate strongly for e - - TE - - need Calculate health care care principles using patient-centred Make time to innovate of patients andstaff Request resource onbehalf

ministry, public t medicines equipmen spac F WWW.ASMS.NZ | B t

THE SPECIALIST

13 73% Work through infectious illness 78% At the very least, the new Act should specify that those that work in the public health sector should have the right to speak publicly and engage in public debate on issues within their 85% Work through illness expertise and experience. 92%

65% Report witnessing bullying to some degree 70%

32% Self-report as bullied to some degree 40% REVIEW OF THE

39% Score with work-related burnout STATE SECTOR ACT 47% ANGELA BELICH | ASMS DEPUTY EXECUTIVE DIRECTOR

44% Score with personal burnout 59% he Government has announced were ASMS members when they of the SSC for collective bargaining in Ta review of the State Sector Act, rallied public support against the the core public service were attempts to 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% signalling a shift in the way the public marketisation of the public health address it but have never worked. The Men Women service operates. service. This was heavily reliant proposal for a senior leadership service, FIGURE 3: DISPARITIES BETWEEN MALE AND FEMALE SMOS BASED ON ASMS SURVEYS OF MEMBERS on the courage of senior doctors as proposed by Minister Hipkins, will State Services Minister Chris Hipkins speaking out publicly individually and almost certainly meet the same fate. announced plans to review the Act at the collectively (for example the Patients start of September: https://www.beehive. are Dying Report by senior doctors at These concerns have been raised govt.nz/release/joined-more-convenient- Christchurch Hospital). repeatedly, for example in the Schick services-reach-public-service-reform- report in the 1990s, the ethics project in plan and the full text of his speech at the Prior to the 1987 State Sector Act, there the 1990s and the State Sector Code of launch of the consultation process is at were separate wage fixing regimes conduct promulgation and in the Crown https://www.beehive.govt.nz/speech/ in the public sector and the private Entities legislation. launch-consultation-process-public- sector. The 1987 Act abolished the service-reform. separate legislation covering state CONSTRAINTS ON CHIEF servants including senior doctors and EXECUTIVES is choosing the A options), this negative practice to ensure better patient care regarding career advancement that may BACKGROUND dentists. The Association was formed The limitations on the power of the reinforcement further deters from doing provision. Again, advocating for patients is make it difficult to do the ‘right’ thing. as a result. DHBs are defined under the The 1987 State Sector Act was part Chief Executives have been delivered the ‘right’ thing for patient need. So, the A not always easy. However, there are serious consequences Crown Entities Act as crown agents of the wave of neoliberal reforms through unions’ collective bargaining options are likely easier, especially when Lastly, and perhaps most importantly, from taking the ‘easier’ options. and are covered by the State Sector that broke the old public service. The (though in many state agencies these choices are likely to be appreciated hospital leadership structures and the On a related note, ASMS research in Act. At present the main impact of by those higher up the chain. central tenets of the movement were this does not reach to second, third pressures of clinical leadership may confuse the last three years has shown that the the proposed changes is that DHB that private sector organisations were or even fourth tier managers) the Secondly, advocating for patients by the leader regarding who they are really negative consequences of an overstretched employees are bound by the Code of more effective and efficient than those pointing out that more resource is required working for. The medical students could see senior medical workforce are even more Conduct for the State Sector which agencies with responsibility for that the B options listed above would be to provide appropriate care for them is severe for females than for males in every that were publicly run, that the profit was issued by the State Services oversight (Treasury, Department of not always seen as a doctor’s duty. Patient chosen by someone who is clearly working area studied (figure 3). Forty percent motive offered innovation and efficiency Commissioner in 2007. Prime Minister and Cabinet, and need is sometimes left to non-clinical primarily for their patients and their clinical of ASMS members are female. ASMS is in contrast to an ethic of service to the the State Services Commission), the administrators to determine, or to the levels team. The A options would more likely therefore actively studying reasons for public and the collective good which The scope that the SSC has outlined whistle-blower legislation and the be attributed to a leader who is working of line managers up as far as the Chief these inequities and looking to take positive lead to stasis and complacency. State for this consultation document is legislative framework that covers all primarily for their line managers and maybe Executive, or Health Minister. But who best steps to improve conditions for female Sector agencies were accordingly limited and reflects the concerns the employers. This system has prevailed understands the needs of patients and the finance team. Perhaps the ideal clinical members. However, benefits from this work Sate Services Commissioner has had leader is working for both, but there is an set up to mimic as closely as possible over a massive failure of stewardship. what is required to provide appropriate are likely to be seen by all members, not about the operation of the Act. These argument that the clinical leader should private sector firms with a powerful The examples that come to mind care? Surely it is the clinical staff who see just female. As one part of this programme, are essentially the same concerns that primarily be responsible for assessing fixed term Chief Executive answerable are decaying hospitals and schools, patients on a daily basis and are trained to in the coming months ASMS will be were raised when the Act was first assess their medical requirements. Patient patient care requirements and then conducting research on salary variance, for outputs (later and less sharply non- existent or unpoliced regulatory passed in the teeth of the considerable advocacy seems to be something that providing this information to those with the which will include a member survey. Good focused outcomes) GAAP (generally structures, huge unmet need in health, opposition from state sector unions and doctors may or may not see as a duty, and purse strings to aid resourcing decisions. participation will be important to ensure accepted accounting principles) and backed up wage expectations due were raised repeatedly since but never is generally not a topic that is taught at In summary, there are a range of reasons valid results. Participation in previous accountabilities under the Public to a public-sector wage freeze and medical school, but may need to become including time, work pressure, negative surveys has been fantastic and it would be Finance Act that fostered privatisation, resolved. The concerns are essentially the continued existence of a gender more routine and embedded in medical reinforcement and possible concern great to continue this. contracting out, outsourcing and that the Act’s structure in the public pay gap after 56 years of equal pay militate against cooperation between service militates against integration legislation. There is also a list of between state sector agencies and agencies. ‘Tomorrows Schools‘ which set disasters from Cave Creek to Pike River. does not of it itself foster an ethic of up each school as a separate entity is public service. There were a couple of The blame is laid on governments now regarded as part of that wave. attempts in the original 1987 Act to who deliberately ran down the state. Patient advocacy seems to be something that doctors may or may not see as a duty, and is This neoliberal wave of ‘reform’ introduce integration between public Core public service Chief Executives, generally not a topic that is taught at medical school, but may need to become more routine finally broke on the intransigence of sector agencies; a Senior Executive however, have never come out publicly and embedded in medical practice to ensure better patient care provision. health professionals, many of whom Service and the legislative responsibility to say that the money wasn’t enough to

14 THE SPECIALIST | OCTOBER 2018 WWW.ASMS.NZ | THE SPECIALIST 15 ASMS interpreted the State Sector Code of Conduct as putting an obligation on our members to speak out on matters involving their expertise.

REMOVAL OF PATHOLOGY FROM THE LONG-TERM SKILL SHORTAGE LIST IAN POWELL | ASMS EXECUTIVE DIRECTOR & LYNDON KEENE | ASMS DIRECTOR OF POLICY AND RESEARCH deliver the services required. (A handful Relations Act which probably trumps the potential to override the right to of health sector Chief Executives the Code. speak out as set out in Schedule 1B to have made that call). Doubtless these the Employment Relations Act. During SMS has written to the Minister it was no surprise when pathology was Australia, New Zealand would need to The State Sector Code of Conduct conversations may have been had in the early consultation the CTU unions for Economic Development, David recognised in HWNZ’s first Health of the increase its pathologist workforce by 28% specifies under the heading ‘Impartial’ A the best traditions of ‘speaking truth proposed to the SSC officials that they Parker, requesting his intervention in Health Workforce Report of 2013/14 as a - from 288 to 369 (as at 2016). that: to power’ with ministers in private but included the wording of Schedule 1B the decision by the Ministry of Business, specialty with ‘critical shortages’ the over-powerful chief executive, the We must: of the ERA in the new Act and have it Innovation and Employment (MBIE) to INCREASING DEMAND HWNZ has identified pathology as a code of conduct, the way the OIA apply to all those who work in public remove pathology from the Long-Term • maintain the political neutrality highly vulnerable specialty because there Ministry of Health pathology workforce has been used essentially to protect services. The suggestion was received Skill Shortage List. are relatively few trainee pathologists projections, based on workforce exit the reputation of the Chief Executive required to enable us to work with with something of a sense of panic. The removal of pathology from this list per current practising pathologists over and entry trends, indicate the pathology or Board, short termism and the current and future governments The proposals in the document do is a mistake and will not only add further workforce will increase by about 13% overwhelming group-think that over the age of 50. The data from the Medical • carry out the functions of our not address the real problems in pressures to a workforce already under in the next five years. However, an powerful chief executives engender Council of New Zealand’s (MCNZ) organisation, unaffected by our the Act head on, though an explicit stress but could also impact on a wide Australian study shows that for more than has meant that in most state agencies, Workforce Survey 2016 indicates 55% of personal beliefs requirement for stewardship may be a range of other health services dependent a decade the number of pathology tests most of the time, critical comment and practising pathologists were aged 50-plus welcome development. on an effective pathology service. has grown by an average 5.4% per year. attention to the counterfactual has • support our organisation to provide and 26% were aged 60-plus. But the ratio of trainees per older specialist indicator, While some of this growth will be due been neglected. robust and unbiased advice State Sector unions criticised the It undermines Health Workforce New concerning though it is, understates to enhanced diagnostic technologies, it purpose, principles and values as Zealand’s efforts to respond to the long- • respect the authority of the the fragility of this workforce, which is also reflects the increasing needs of the STATE SECTOR CODE OF CONDUCT uninspiring. There was considerable term needs of an increasingly fragile government of the day. workforce, and ASMS has asked the Minister compounded by several factors: aging population and greater focus on The 1987 Act gave the State Services comment that doctors, nurses and prevention. It is estimated that 32% of the ASMS interpreted the State Sector to reverse the decision immediately. Commissioner the right to issue a code teachers, though probably comfortable THE LONG-TERM WORKFORCE increase in pathology requests by medical Code of Conduct as putting an of conduct to cover all of the state with the proposition that they serve the Pathology is one of Health Workforce SHORTAGES practitioners is due to preventative health obligation on our members to speak services. This power covers both the public, would not think of themselves as New Zealand’s (HWNZ) top four ‘hard-to- treatments.2 New Zealand is experiencing out on matters involving their expertise Workforce data from the Royal College of compulsory education sector and the public servants staff specialties’ identified for the 2018 similar increases in health service demand. public health service. In 2007 the State equally – it doesn’t matter which party intake of the Voluntary Bonding Scheme, Pathologists of Australasia (RCPA) show At the very least, the new Act should Services Commissioner issued such a was in power. which aims to encourage graduate there were 288 pathologists practising in The functioning of most health services specify that those that work in the code. It did not cover the compulsory doctors into particularly vulnerable New Zealand in 2016, or approximately is dependent on a well-functioning Nevertheless, the way DHBs have public health sector should have the 1 education sector but did cover the specialties. Like most of the New Zealand one pathologists for every 16,295 pathology service. An estimated 70%– operated the Code particularly around rights set out in Schedule 1B (the Code public health service. The Association specialist workforce, pathologists have people. This is lower than every State 80% of all health care decisions affecting elections has had a chilling effect. of Good Faith for the public health was consulted at the time (but as been in short supply in New Zealand and Territory in Australia apart from the diagnosis or treatment are influenced by There has also been reluctance to sector) of the Employment Relations Act 3 somewhat of an afterthought) and got for many years (among the worst), so Northern Territory. To be on a par with laboratory medicine results. comment by members when funding or to speak publicly and engage in public some changes. The legal advice we had contracting issues will affect continued debate on issues within their expertise at the time was that the right of senior employment or the viability of a service. and experience as employees. doctors at DHBs to speak out was protected both in our MECA (which is The inclusion as part of the principles These rights could easily be extended probably of equal status to the Code) of the Act of ‘political neutrality’ and to teachers and scientists in the Crown The removal of pathology is a mistake and will add further pressure to a workforce already and by Schedule 1B of the Employment ‘impartiality ‘as a value would have Research Institutes. under stress.

16 THE SPECIALIST | OCTOBER 2018 WWW.ASMS.NZ | THE SPECIALIST 17 HWNZ has identified pathology as a highly vulnerable specialty because there are relatively few trainee pathologists per current practicing pathologists over the age of 50.

THE SMALL SCALE OF PATHOLOGY growing specialist discipline within the by 4% between 2011 and 2015, and half of DISCIPLINES pathology profession worldwide. New all its specialists aged 50 years and over Zealand is being left behind. – the highest percentage of any specialty Pathology comprises 10 disciplines, in the UK.4 though New Zealand has nine (there are • There were seven pathologists no oral pathologists). The main discipline practising in a genuinely ‘generalist’ Not only should MBIE’s decision be – anatomical pathology – accounts for role. This small workforce is also aging reversed immediately, ASMS has just over half of the workforce, with the and as there have been no general suggested that its processes and criteria remainder making up the rest. The loss pathology registrars in New Zealand for reviewing the skills shortage lists are of one or two pathologists, especially in for over a decade, it is expected this themselves reviewed. We understand disciplines like forensic pathology, general discipline will disappear completely HWNZ is moving towards a model of pathology and immunopathology, where from New Zealand once these current health workforce planning which takes there are just 5-7 pathologists, can have an pathologists retire in the next few years. into account New Zealand’s health needs immediate, significant impact on the service. and unmet needs, and the workforce And currently there is just one genetic • There were seven immunology required to address those needs. There is pathologist and one virology pathologist. pathologists, and four trainees. As has been the case previously, access a lot of merit in this approach, which MBIE RCPA workforce data for 2016 show: to specialist immunological services might like to consider. 2018 ASMS BRANCH is restricted to three major cities, and • The were 18 chemical pathologists, 1 HWNZ. Voluntary Bonding Scheme Terms characterised by significant waiting of which (in the previous year) 30% and Conditions for New Graduate Doctors times for consultation and follow-up OFFICERS’ WORKSHOP were aged over 61. There were just two 2018. https://www.health.govt.nz/our-work/ treatment and management services. trainees in this discipline. health-workforce/voluntary-bonding-scheme/ LYDIA SCHUMACHER | ASMS COMMUNICATIONS ADVISOR • There were five forensic pathologists DEPENDENCY ON OVERSEAS voluntary-bonding-scheme-terms-and- (recent media reports indicate seven RECRUITMENT conditions-and-payment-application#2018 in 2018; RCPA data show there were SMS President Murray Barclay welcomed ASMS branch officers from across the country to Wellington on 31 August 2018 for In 2015 nearly one in five pathologists 2 CIE. The Economic Value of Pathology: Achieving nine in 2007) and this workforce the annual ASMS branch officers meeting. practising in New Zealand had gained better health, and better use of health resources, A faces further pressure with a proposed their specialist (vocational) registration Centre for International Economics, April 2016. Senior Industrial Officer Lloyd Woods and Review, about the review followed morning that shape speciality choices and inflect fragmentation of the service. In 2015 overseas. It is a specialty in high demand Industrial Officer Sarah Dalton began tea. This presentation was informative, the daily experiences of women throughout two pathologists were aged over 60. 3 Report of the review of NHS pathology services internationally. MCNZ data show New the meeting by explaining the role of a and members had a chance to ask their medical careers. Her research will There are only two trainees who will not in England. London, England: Department of Zealand’s main source of overseas doctors branch officer and the ways that ASMS questions. Afterward the branch officers be explored further at the ASMS Annual qualify for another 3-4 years. Health, 2006. is the UK, which is itself facing recruitment Industrial Officers can assist our members. worked in groups to share their feedback. Conference and will be published in full in a The benefit of JCC meetings and having • There were only two trainee genetic and pressures and looming retirements, 4 General Medical Council (UK). The state of ASMS Principal Analyst (Policy & Health Dialogue in 2019. a wide representation of specialities at pathologists. Genomics is the fastest with the pathology workforce contracting medical education and practice in the UK 2016, Research) Dr Charlotte Chambers the meetings was discussed, and a case This was followed by a report from Industrial presented preliminary findings from a study was shared from Northland DHB Officer Steve Hurring on a new mapping qualitative study exploring why younger where these benefits are coming into play. system being implemented at ASMS which women members may be more prone to Burning issues for our members such as will allow us to understand members and experiencing burnout than their male recovery time, safe shifts and gender pay their specialties more efficiently. counterparts. Her research suggests audits were also discussed. An estimated 70%-80% of all health care decisions affecting diagnosis or treatment are that understanding this requires a much The day wrapped up with a discussion influenced by laboratory medicine results. A presentation from Heather Simpson, broader perspective of the gendered about ways that branch officers could Chair of the Health and Disability System nature of medicine including the factors network between DHBs.

18 THE SPECIALIST | OCTOBER 2018 WWW.ASMS.NZ | THE SPECIALIST 19 PHOTOS FROM THE ANNUAL ASMS BRANCH OFFICERS WORKSHOP

20 THE SPECIALIST | OCTOBER 2018 WWW.ASMS.NZ | THE SPECIALIST 21 THE CURSE OF DEFERENCE IAN POWELL | ASMS EXECUTIVE DIRECTOR

here is a curse in the senior medical a profession is. The fundamental ethical begins with the second paragraph of the Tand dental professions employed by standard of ‘first do no harm’ in respect Preamble to the MECA which states: district health boards. It is not a curse of managerial or political decisions that Senior medical and dental officers driven by a supernatural power, although compromise access to and quality of care are a distinct, vocationally trained, perhaps this can’t be ruled out. It is the trumps relationships with these decision- occupational employee group. curse of ‘deference’. makers who lack the same ethical code. District health boards (DHBs) as employers benefit from these Deference is an interesting word of French CORE PROFESSIONAL EMPLOYMENT origin from the mid-17th century meaning employees having significant RIGHTS influence in their internal decision- respectful submission or yielding to the making. The parties recognise judgment or opinion of another. Its usage The distinct duties and responsibilities that both senior medical and peaked in the first half of the 19th century of DHB-employed senior medical staff dental officers and DHBs have protect and promote ‘first do no harm’. followed by a gradual decline until around different roles, responsibilities and These are contained in the legal document the 1930s, where it plateaued. distinctive features. that provides the core minimum terms and Deference might appear to be the conditions of ASMS members employed The MECA then proceeds, in Clause 2 courteous behaviour well suited to by DHBs – the multi-employer collective (Time for Quality), to state that “managers professionals. Being courteous and agreement (the MECA). will support” senior medical and dental treating others with respect are good; officers (SMOs) “to provide leadership deference to the extent of submission is The context, protection and promotion of in service design, configuration and best a bridge too far in the context of what these distinct duties and responsibilities practice service delivery.”

22 THE SPECIALIST | OCTOBER 2018 WWW.ASMS.NZ | THE SPECIALIST 23 SMOs have accountabilities well beyond their responsibilities to DHBs as their employers and to ordinary employment relationships established under the Employment Relations Act. VITAL STATISTICS

YEAR TO JUNE HOSPITAL ACUTE DISCHARGES READMISSIONS 2013 811,064 89,898 2017 912,749 107,415 % Increase +12.5% +19.5%

Population growth for this period: 7. 2%

SOURCES: Ministry of Health 2018 Statistics New Zealand 2018 Note that that it states that SMOs and interests of the public in the health that go well beyond their responsibilities will provide leadership, supported by service, DHBs respect and recognise the to DHBs as their employers and to managers, not the other way around. right of SMOs to “…comment publicly ordinary employment relationships and engage in public debate on matters established under the Employment Clause 39(a) states that DHBs recognise relevant to their professional expertise Relations Act. This is explicitly recognised the “…primacy of the responsibility” of and experience.” by DHBs in our MECA. SMOs “to their patients and to their role as a patient advocate.” This is in the The clause covers the situation where Too often, regrettably, these expectations context of where this responsibility clashes such comment might be about, and be captured as legal rights in the MECA do with the responsibility to the DHB; the critical of, the DHB. That is, the concern not translate into consistent behaviour. ASMS 30TH ANNUAL former explicitly trumps the latter. behind the comment should have been This is largely due to an excess of discussed or raised with the DHB to deference to those who, while their The next two sub-clauses (b and c) of avoid the circumstance where the chief positions should be respected and treated CONFERENCE Clause 39 recognise that SMOs are executive or senior manager only learns with courtesy, do not merit it because they responsible and accountable to the of the concern for the first time through lack the expertise and experience in what THURSDAY 29 & FRIDAY 30 NOVEMBER 2018 Medical and Dental Councils, including the media. However, the permission of the SMOs do. their relevant policy statements and THE OCEANIA ROOM, TE PAPA, WELLINGTON DHB for SMOs to make such comment is guidelines. This responsibility and not required. When initiatives such as reviews arise accountability extends to the ethical relevant to the expertise and experience codes and guidelines of relevant colleges Elsewhere, in Clause 41, where SMOs of SMOs, it should be them who lead and professional associations. have serious concerns over actual or the exercise rather than allowing patient safety risks that can’t be resolved management to dictate and marginalise Separately the clause on job descriptions satisfactorily with the DHB, then they them to a limited, reactive role. (48), which require mutual agreement, are entitled to an agreed dispute says there must be a statement in each resolution process. Essentially, the MECA requires, enables SMO’s job description that he or she is and enhances distributed clinical “…required to undertake their clinical SMOS ARE NOT IN AN ORDINARY leadership. But it requires the confidence responsibilities and to conduct themselves EMPLOYMENT RELATIONSHIP of SMOs to behave consistently to achieve in all matters relating to their employment, it. Recently, in a proposed review of As employees, SMOs are in an in accordance with best practice and the surgical journey in a public hospital employment relationship with their DHBs relevant ethical and professional where management sought to impose a - but it is not an ordinary employment standards and guidelines, as determined rigid, clunky decision-making structure, I relationship. Much of the work they do is from time to time by…” their relevant advised members working in the theatres beyond the skill level and knowledge of college or professional association. to have the confidence to take it over, those that employ them. DHBs as their use their expertise to come up with Significantly, the same clause acknowledges employers are dependent on them. recommendations that make good clinical © TE PAPA adherence to the DHB’s policies and As a consequence of the level of and systems sense, and forward them to procedures but with the qualifier that these professionalism required to perform the chief executive. DINNER AND PRE-CONFERENCE of course, to enjoy some of Wellington’s ASMS delegates to attend its 30th can’t be “inconsistent” with other provisions their duties and responsibilities to FUNCTION fine hospitality! Annual Conference. Register your of the MECA, including that discussed This requires five ‘c’ words – confidence, the necessary standards, SMOs have immediately above. collectiveness, collegiality, concerted A pre-conference function will be interest today to [email protected]. accountabilities (including legislative LEAVE action and cogency. held at The Boatshed on the evening Registrations close on 12 October. Clause 40 (public debate and dialogue) accountabilities such as the Health Clause 29.1 of the MECA includes of Wednesday 28 November, and states that, in recognition of the rights Practitioners Competence Assurance Act) It is doable. Be bold and just do it. provision for members to attend a conference dinner will be held Association meetings and conferences on Thursday 29 November at Te on full pay. Wharewaka o Po-neke. DELEGATES REQUIRED These are a great opportunity to TOI MATA HAUORA The MECA states that SMOs will provide leadership, supported by managers, not the other mingle with conference delegates and The ASMS makes all travel and way around. others in a relaxed social setting and, accommodation arrangements for

24 THE SPECIALIST | OCTOBER 2018 WWW.ASMS.NZ | THE SPECIALIST 25 This started an ugly process that Authority to discuss our injunction, ACC to an acceptable outcome for the was wrong from the outset and that informed us that they were withdrawing CEA (albeit not getting everything eventually we won with no members the proposal and would table a new one we were pushing for) but as quid pro being disestablished or required to for consultation “that would meet the quo the complete withdrawal of any do EOIs. union’s needs”. This was another victory. disestablishment process for Medical Advisors in the CSD proposal. It was Firstly, we objected to the two-week On 23 July they released the agreed that ‘the sinking lid’ would consultation period and took ACC to revised proposal that stopped the deal with any supposed over-staffing. urgent mediation to discuss this and disestablishments but still had all staff Membership had increased by seven concerns in general about the lack going through an EOI process, at the members (19%) in the meantime and of consultation. We got a two-week end of which redundancies would apply membership feedback has been very extension (although ACC claimed this to those who ‘missed out’ based on was because of staff feedback and some very inappropriate criteria. We positive. The CEA and agreement to nothing to do with the ASMS). reinstated the injunction process. stop the CSD disestablishments etc were both ratified by members. Next, we took an urgent injunction to At the same time as all of this was going the Authority based on the proposal on we had been battling to conclude With ACC you can never be sure what being unlawful and breaching health bargaining for the replacement the future holds, and it is quite possible and safety. “Disestablishment” means Collective Employment Agreement that in future we will see new efforts to dismissal and an employee can only (CEA) and our members had, through a downsize the MA roles and, given our be dismissed for disciplinary reasons secret ballot, voted strongly in favour of experience so far, we could even see or through redundancy. For 50 MAs taking strike action. This was planned them try to contract out all medical out of 60 it was clear that no actual for five half days on strike over five work. This would be against the wishes redundancy could apply, hence it consecutive weeks. The ASMS office of the current Government and the was unlawful to go through a “mass and communications team swung into public in our view but in any event, they disestablishment” process. Further to action and we had very good media will be in for a huge battle if they go that, every employer has an obligation cover and continual contact with down that line. to keep employees safe and in forcing members. The first half day was very We have made clear to the ACC 50 of 60 through disestablishment Angela Belich and Lloyd Woods hand out pamphlets at ACC successful and, as we understand it, management that the Collective and an onerous EOI process, the every member covered by the collective Agreement could have been resolved ACC was callously causing stress and agreement and due to work that day in January without such drama if they distress for no reason. This obvious (to was taking action. The second half day had negotiated in good faith and with us) breach by the ACC had never been of strike action had a similar result, a desire to come to an acceptable challenged when the same process COLLECTIVE BARGAINING including the ASMS team distributing outcome. We have also made clear was used repeatedly at ACC in other pamphlets at the ACC head office. ACC (both through the strong actions of our areas and has been used in many was furious about this. members and through our legal action) IN THE NON-DHB SECTOR government departments over the that we will not be pushed around years. Our injunction challenged the During this period, we had several and that with proper consultation and LLOYD WOODS | SENIOR INDUSTRIAL OFFICER status quo and we were pleased when, conference calls with members and the good faith the whole battle around the having met with our ACC sister union feedback was that ACC was coming to Clinical Services Directorate could have the PSA to put our argument, the PSA realise that ASMS members were not been avoided. SMS has had members at ACC since were forced into strike action in order members at the time of writing. On Monday got quite excited about it. They were going to lie down and be bullied into a wrongful redundancy situation or the late 1990s and in the past 10 to settle the most recent agreement 24 May we received an embargoed copy supportive and agreed to join in on We have made very clear to the ACC A an unsuccessful outcome to the CEA years we have grown membership from and legal action to prevent mass of a proposal to disestablish all staff in the eventual legal action. that we want to work positively with bargaining. As a result, on Friday 27 9 to 44. disestablishment of members jobs, with CSD, including our members. This proposal them for the good of our members, ACC ON SHAKY GROUND July we contacted ACC and proposed eventual redundancy for some. then had them all undergo an Expression the ACC and ACC claimants. We look Unfortunately, it must be said that our that we get around the table to settle relationship has had rocky patches of Interest process to determine who ACC seemed shocked (and extremely forward to ACC working more positively MASS DISESTABLISHMENT (SACKING) both matters and we were pleased with starting right back in 2009 and 2010 would keep their jobs. Roughly 60 medical irritated) with our action but clearly in the future although the past suggests OF MEMBERS AND A STRIKE their agreement to do so urgently. when we had to take ACC to mediation advisors (MA) would be disestablished in understood that they were on shaky this might be a somewhat naïve hope. after its refusal to negotiate a collective All ASMS members at ACC work in the order to find perhaps 10 (6.4 FTE) to ground. At the meeting with the This was a successful initiative leading Time will tell. agreement, and most recently when we Clinical Services Directorate (CSD) - 44 make redundant.

26 THE SPECIALIST | OCTOBER 2018 WWW.ASMS.NZ | THE SPECIALIST 27 WHAT INSPIRED YOUR CAREER IN New Zealand Defence Force as a regular a positive note, we do have some terrific DENTISTRY? force consultant dentist officer. I ‘retired’ patients and enjoy wonderful collegiality. from Defence in 1998 and then spent a It’s interesting to reflect on that, but to be short period in private specialist practice honest I don’t have the slightest idea! I’d WHY DID YOU DECIDE TO BECOME until returning in 2005 to the public received an invitation to study towards ACTIVELY INVOLVED WITH ASMS? health environment as a full time SMO at honours in chemistry at university but that Hutt Valley DHB. Generally, I’ve had very Some time ago, around 2009, I took didn’t really inspire me, so I somewhat an interest in going along to the Joint good employers over the years. opportunistically decided to apply for Consultation Committee meetings F I S admission to dental school. That was in I enjoy being able to operate in a system between ASMS and the DHB’s V E 1976 and I still can’t really explain why, that isn’t entirely driven by commercial management. I had known Steve Purchas E there was no great insightful reason for for a long time, from university days in M UT interest, although some commercial rules IN doing so. still apply, for example, oral health care fact, and he was actively involved with and rehabilitation for New Zealand adults ASMS. When he decided to step down as The better question is probably branch officer at the next ASMS elections, what inspired me to continue. As an remains not fully subsidised at the public expense. Apart from that, I get a buzz I put my hand up and was elected as Vice undergraduate there was a fantastic sense President. I think this was around 2012. out of treating the underdog, working WITH of camaraderie in one’s class with only Sadly, during my first term, the ASMS as part of a larger team, working with 60 fellow students. I have since worked Hutt Valley branch president passed medical colleagues and dealing with predominantly in the public sector, initially away, and I took over that role until the in the hospital dental unit at the School vulnerable patients; these factors all help following election (I think 2015) where I NEIL of Dentistry/Dunedin Public Hospital. I’d in preventing one from getting into too was returned as branch president. I’ve just credit my career from that point forward much of a silo and too narrowly focusing been re-elected as branch president for to my first boss, he was an extraordinary one’s approach. the next three years. humanitarian. We were dealing with some STEPHEN I would like to see more of my colleagues of the most vulnerable people in society WHAT ARE SOME OF THE MOST actively engage with the union, rather and seeing his approach to that was CHALLENGING ASPECTS OF than just signing up when they’re in strife. inspiring. He was a terrific mentor and PRACTISING DENTISTRY IN THE eschewed interest in the business and CURRENT HEALTH ENVIRONMENT? I was also part of the recent MECA commercial aspects of dentistry. negotiating team. That was a really It’s tough working in the public system. interesting experience, seeing aspects of Similarly, I was involved with a number There aren’t enough resources and, DHB engagement. Although this was at of respected senior colleagues during however well intentioned, there are times unpleasant and acrimonious I wouldn’t in my early employment. Their approach, inequalities with accessing the system and shy away from being involved again. professionalism and lack of interest in meeting people’s expectations. People commercial spoils was inspiring, and have to reach thresholds, and there’s a WHAT HAVE YOU GAINED OR the fact is, they always put their limit on service funding. LEARNED FROM YOUR ASMS patients at the centre of what they did. INVOLVEMENT? Patient-centred care is nothing new! Hospital dentistry is a secondary level service with at times a tertiary level of I’ve found it interesting to see the union’s After three years, because there was no service provided. We provide care to involvement in disputes and pay and defined career pathway at that time (a patients that can’t be safely managed in rations, as it is referred to. ASMS is an time when most young dentists headed the community at a primary care level, interesting union in the respect that we to the UK) and limited post graduate or are more appropriately managed in a are actively engaged in more than pay opportunities existed, I moved into private secondary level facility with all the support and rations, we do things like engagement practice. I ended up in Australia in 1984 services available. Often we receive in process and quality improvement in and for a while I questioned whether I referrals from primary care requesting the health system. It has been informative wanted to continue in dentistry, I was management of patients whom could be and very useful to learn about aspects disillusioned really, I struggled hard to of employment law, particularly around managed within the community, often the reconcile the provision of dental care with rights and resolution and to apply this to reason for referral is largely based upon the necessary business considerations. supporting colleagues in an informal way a patient’s ability to pay and because However, a new opportunity came along when there have been issues. we have limited capacity to meet such to undertake post graduate training in requests they are declined. Frustratingly, Observing ASMS’ work has nurtured hospital-based dental practice (these in New Zealand there is no publicly my enthusiasm further. I’ve enjoyed the days called Special Needs Dentistry), so funded or subsidised system for adults opportunity to learn about industrial I moved back to New Zealand and the that enables them to receive affordable relations and see the ways ASMS works University of Otago in 1991 with three routine dental care and maintenance in with members to try to improve things in young children in tow. the primary sector. DHBs, as well as offering advice or direction That was quite a big thing to do in those to colleagues when the need arises. I do the triaging and often have to send days. Unlike the vocationally-based medical I’ve always had a bit of a traditional patients back if they don’t qualify for model, post graduate training in dentistry union leaning, and after seeing the work treatment. That’s really disheartening was entirely self-funded and not associated an industrial officer does, I’ve certainly with employment or remuneration: it cost because they might end up being ignored. learned a bit. Given the opportunity to a lot. I completed my Master’s Degree in It comes down to resource constraints; turn back the clock to 1976 I think I may restorative dentistry in 1993. there’s simply not enough of us to go have considered a career in a similar around and we can only afford to provide area. I value ASMS as a collegial support care to the medically compromised and WHAT DO YOU LOVE ABOUT YOUR JOB? network which supports your day-to-day most vulnerable high needs patients in work, as well as being there if there are NEIL STEPHEN IS A DENTAL SPECIALIST AT HUTT VALLEY DISTRICT HEALTH To give some history, I’ve completed a our community. This really is the reality of industrial difficulties to address. ASMS has BOARD AND ASMS’ HUTT VALLEY BRANCH PRESIDENT. post graduate degree and been in the working in the public system, but to end on a real impact.

28 THE SPECIALIST | OCTOBER 2018 WWW.ASMS.NZ | THE SPECIALIST 29 We respond quickly and in a welcoming and friendly manner, and this is often a great start to a new doctor’s orientation to New Zealand.

ASMS FREE SERVICE LLOYD WOODS | SENIOR INDUSTRIAL OFFICER

id you know that ASMS provides step, recruitment devices (where Da service checking job offers that applicable) and protections means advantages job applicants but also we can avoid (for them and the affects all SMOs/members? This service DHB) the problems that come up is free to all, including non-members. downstream otherwise. Many ASMS members had their first Job offers are often wrong and we contact with the ASMS before they ever have seen numerous applicants get DID YOU KNOW ABOUT… SICK LEAVE DID YOU KNOW ABOUT… COVER FOR and senior managers. We always discuss took on their first medical job in New the right deal only after our advice. ABSENT COLLEAGUES things that are topical and relevant to Zealand due to somebody advising them Many would not have realised Sick leave is on full pay regardless of if your work as an SMO, and we greatly to send us their job offer for checking. their rights to superannuation or you are on ACC or not or whether the If your service has been correctly service value your input at these meetings. relocation cost reimbursement, injury was in work time or not. Full pay sized the annual and CME cover of We see job offers from RMOs for their first for instance. applies for the whole period of sick leave colleagues can be expected to be covered DID YOU KNOW…? SMO appointment, prospective SMOs/ doctors from all over the world, and also Clearly it is advantageous to the and is your normal pay all inclusive. by colleagues but generally any other As a DHB employee, you’re entitled to leave must be covered through locums, current members moving to a new job applicant to ensure everything DID YOU KNOW… ABOUT THE reasonable leave on full pay “on the extra duties payments or the work is not (including within the same DHB). is correct but it is also equally EMPLOYER SUBSIDY FOR YOUR bereavement of someone with whom you covered at all. If you have not been service We respond quickly and in a welcoming important for existing colleagues. SUPERANNUATION? have a close association”. sized it is possible that even annual and and friendly manner, and this is often a We have picked up inequities and Clause 17.1 of the DHB MECA specifies CME leave does not have to be covered Your entitlement is found in MECA Clause great start to a new doctor’s orientation issues for existing members that that your employer will make the required depending on vacancies and staffing. If in 27.1 and is not limited in time (eg, to only to New Zealand. only came to light due to seeing a feel free to send the paperwork through. employer contribution in respect of any doubt talk to your industrial officer. three days) or to the death of a close new job offer. We welcome this work because ensuring Otherwise – please - whenever possible, of the superannuation schemes operated or immediate family member. Each case DID YOU KNOW… ABOUT JOINT that new employees (or employees taking If you are looking at changing your role advise job applicants to send their job by the National Provident Fund or the should be considered sensitively and CONSULTATION COMMITTEE on new roles) have the proper salary (temporarily or otherwise) in your own DHB, offer to us for checking. Government Superannuation Fund to recognise your particular culture, family MEETINGS? which you belong. If you do not belong to responsibilities and travel requirements. one of these, then Clause 17.2 of the MECA ASMS organises Joint Consultation There is no obligation on you to ‘make up’ any clinics, after-hours call or weekend entitles you up to a 6% employer subsidy Committee (JCC) meetings three times a shifts missed during bereavement leave. matching your contribution to an approved year with your DHB’s management team. superannuation scheme, and ASMS These meetings are a good chance to More information is in clause 27 of the We have picked up inequities and issues for existing members that only came to light due to encourages members to take advantage of put issues that matter to you and your DHB MECA: https://www.asms.org.nz/ seeing a new job offer. this. https://www.asms.org.nz/clause-17/ colleagues in front of the chief executive clause-27/

30 THE SPECIALIST | OCTOBER 2018 WWW.ASMS.NZ | THE SPECIALIST 31 EACH ISSUE OF THE SPECIALIST WILL FEATURE A PHOTOGRAPH OR DOCUMENT FROM THE ASMS ARCHIVES. YOU CAN FIND MORE SLICES OF HISTORY ON THE ASMS WEBSITE (WWW.ASMS.NZ) UNDER ‘ABOUT US’.

THE PROBLEMS OF TREATING THOSE CLOSE TO YOU DR TIM COOKSON | MEDICAL CONSULTANT, MEDICAL PROTECTION

n a recent Health Practitioners Disciplinary Tribunal (HPDT) decision, a hospital doctor had his registration cancelled for (among Iother things) prescribing inappropriately for his wife. The severity of the penalty was because he forged a colleague’s signature on a number of the prescriptions. He was also found guilty of writing prescriptions for codeine phosphate for his wife signed under his own name. There was no suggestion that any of the prescriptions was for his own use, and the Tribunal recognised that his wife had a significant medical condition and barred publication of any details of that condition. But the Tribunal found he was a danger to the public which needed protecting from him. Is this an isolated incident or something prescriptions and checks are done which defined as anything that is done for much more common? In the year to confirms the relationship. Occasionally it a diagnostic, preventative, palliative, March 2017 the Medical Council of is colleagues or even disgruntled family cosmetic, therapeutic or other health- New Zealand’s Complaints Triage Team members who complain to MCNZ. related purpose. Family member includes reported receiving 17 complaints involving The current MCNZ statement on not only spouse or partner, children allegations of prescribing for self or family. providing care to yourself or those and siblings, but also members of your The notification is usually when either a close to you is strict, even if it is not extended family and those of your partner pharmacist or Medsafe recognise that strictly adhered to by the profession. It or spouse. Other individuals included in the surname matches on a number of is also rather encompassing, with care this net are those with a personal or close

32 THE SPECIALIST | OCTOBER 2018 WWW.ASMS.NZ | THE SPECIALIST 33 TOI MATA HAUORA The current MCNZ statement on providing care to yourself or those close to you is strict, even if it is not strictly adhered to by the profession.

ASMS STAFF Executive Director Ian Powell Deputy Executive Director relationship with you – ie, friends and operation on a family member they answer is on a case-by-case basis, Angela Belich close colleagues. You must not (MCNZ should take special care in doing so. with a trend towards lower tolerance COMMUNICATIONS emphasis) prescribe medication with a where psychotropic medications There are also very big cultural risk of addiction or misuse; psychotropic or drugs with potential to cause Director of Communications differences in expectations, with doctors medication; controlled drugs and a few addiction are prescribed. Although the Cushla Managh in some cultures not only expected to other situations. There are exceptions statement says we must not prescribe provide care for their families, but liable Communications Advisor in emergency situations and in small psychotropic medications to family, to be ostracised if they refuse to do so. Lydia Schumacher communities where access to other it merely admonished a doctor who The rationale put forward by MCNZ for INDUSTRIAL providers is limited. this limitation on doctors providing care prescribed antidepressants to his wife without any other doctor involvement, SO WHY DOES IT HAPPEN? for those close to you is that you may Senior Industrial Officer lack clinical objectivity, may not get all despite the fact that she went on to try Henry Stubbs So if this is all so clear, how is it that this to commit suicide. At the other end of the relevant information, and that you Senior Industrial Officer practice continues to be so common the spectrum a GP had charges laid in may over or under-treat accordingly. ASMS SERVICES TO MEMBERS Lloyd Woods amongst the medical profession? We Clearly this view is not universally the HPDT for prescribing antibiotics to can be excused for some confusion. shared, so what is the evidence that we colleagues and the Tribunal found him As a professional association, we promote: it also publishes the ASMS media Industrial Officer Less than 10 years ago it was still guilty of professional misconduct for Steve Hurring are causing harm by treating those close • the right of equal access for all statements. possible for a retired doctor to get this. This decision was overturned by to us? MCNZ, despite expecting doctors New Zealanders to high quality Industrial Officer a limited APC that would allow the High Court. We welcome your feedback because it is to make decisions based on good health services Sarah Dalton prescribing for oneself or family under vital in maintaining the site’s professional evidence, does not provide any evidence. Complaints to MCNZ are almost always certain circumstances. Then it changed • professional interests of salaried standard. Industrial Officer They do quote the other jurisdictions related to prescribing, but there are and not only were you not able to treat doctors and dentists Dianne Vogel that share the same view though. many other therapeutic interactions ASMS job vacancies online self and family etc. but also colleagues, • policies sought in legislation and that occur where prescriptions are not jobs.asms.org.nz Industrial Officer whether or not you were close to them. In practice it is not hard to find government by salaried doctors Ian Weir-Smith involved. According to the statement, We encourage you to recommend that examples of where care provided in and dentists. Fortunately, MCNZ recognised that this manner is not appropriate. Last I am supposedly not able to advise my your head of department and those Industrial Officer this meant that no doctor could get any week a male patient presented with uncle to stop smoking (a preventative As a union of professionals, we: responsible for advertising vacancies Phil Dyhrberg medical care if the logic was taken to measure with evidence to support it). seriously consider using this facility. urinary symptoms. He had already • provide advice to salaried doctors POLICY & RESEARCH the extreme, and that restriction has spoken with a very close doctor friend In reality I am confident that I would and dentists who receive a job offer Substantial discounts are offered for bulk Director of Policy and Research been removed in the latest statement. who decided that he had a UTI and not be criticised if my uncle complained from a New Zealand employer and continued advertising. It would be assumed that if MCNZ about this to MCNZ. However, I am Lyndon Keene prescribed antibiotics. No notes were • negotiate effective and enforceable has taken such a firm line against this written, no investigations done, his certainly not going to tempt fate ASMS Direct collective employment agreements Principal Analyst (Policy & Research) practice, that this would be universal symptoms did not improve, and he took by prescribing any psychotropic In addition to The Specialist, the ASMS also with employers. This includes the Charlotte Chambers amongst medical jurisdictions – not a completely unnecessary course of medications to my wife (even though has an email news service, ASMS Direct. collective agreement (MECA) covering so. Some developed countries such as antibiotics. This was clearly not good she has a different surname) as I have SUPPORT SERVICES employment of senior medical and How to contact the ASMS Germany and Holland have no such management, and my patient was no desire to appear before the Tribunal dental staff in DHBs, which ensures Manager Support Services concerns, with German doctors only more at risk of harm than good as a and have my registration cancelled. As Association of Salaried Medical Specialists Sharlene Lawrence minimum terms and conditions for more being recommended not to charge result of his friend’s intervention. a profession we need to recognise that Level 11, The Bayleys Building, than 4,000 doctors and dentists, nearly Senior Support Officer family members for the care provided. the rules have changed, our families 36 Brandon St, Wellington RESPONDING TO THIS ISSUE 90% of this workforce Maria Cordalis In Singapore it is not recommended, and those close to us will be better Postal address: PO Box 10763, but equally it is recognised that this So how does MCNZ treat the cared for if we adhere to those rules, • advise and represent members when The Terrace, Wellington 6143 Membership Officer will occur, and if a doctor does a major complaints it receives about this? The and we will be safer too. necessary Saasha Everiss P 04 499 1271 • support workplace empowerment F 04 499 4500 Support Services Administrator and clinical leadership. E [email protected] Angela Randall W www.asms.nz OTHER SERVICES www.facebook.com/asms.nz As a profession we need to recognise that the rules have changed, our families and those www.asms.nz Have you changed address or phone PO Box 10763, The Terrace close to us will be better cared for if we adhere to those rules, and we will be safer too. Have you visited our regularly updated number recently? Wellington 6143, New Zealand website? It’s an excellent source of Please email any changes to your contact +64 4 499 1271 [email protected] collective agreement information and details to: [email protected]

34 THE SPECIALIST | OCTOBER 2018 WWW.ASMS.NZ | THE SPECIALIST 35 Our commitment

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