CMO Bulletin October '98 Vol: 2, No: 2
Newsletter of the Career Medical Officers Association Inc.

There is a lot happening at the moment and there are several important issues that I would like to bring to the attention of members for this edition of the Bulletin.

They are:

1. Industrial Convention
2. Education
3. Web Sites

Industrial Convention:

Some of you will be aware of the forthcoming convention at Rozelle Hospital, hosted by ourselves and with top level presentations from the major medical industrial groups, government, the Illawarra MMO Association and the CMOA. There are full details elsewhere in the Bulletin (including an Agenda) but I would like here to give an overview of what we should expect from this meeting. As many of you are no doubt aware, there are inadequacies in the current award structure and there are also problems with the implementation of this award. It is due for review in 1999 and now is a very opportune time to bring up problems and plan for an improved award next year.

The major problems that seem to be affecting CMOs are:

* Keeping CMOs on a level below their entitlement.
* Generally low remuneration rates.
* Poorly explained employment contracts and lack of long term security.
* Use of Temporary Resident Doctors (TRDs) when CMOs are available.
* Overtime anomalies-the pegging of CMO rates to lesser Registrar rates, and other professions with substantially higher rates.
* Maternity and Paternity leave.
* "In Charge" allowance.
* Availability of study leave and educational expenses.
* Length of Annual Leave

There may be other items that you feel are important-if so please bring them up at the convention or contact myself or others on the committee if you cannot make the meeting.

Another major factor in the industrial forum is whether we should be pushing for a tie between education and experience on the one hand, and the industrial award on the other (as has occurred recently with the Illawarra Multiskilled Medical Officer group). This seems to be inevitable at some stage and it is important that we are directly involved in any discussions along these lines as soon as possible.

Education:

The first item is a very pleasing piece of news-the acceptance of the Royal Australian College of Pathologists of the CMOA into their electronic CME program. Those who were at the AGM in February will know how exciting this is-the updated program is still in development phase, but is expected to be running early in 1999. CMOs who would like to be involved should notify me so that we get some idea of numbers.

The other issue is the accreditation by the CMOA of educational units where appropriate-if we wait for someone else to give us certification or acceptance we will wait a long time - there is nothing to prevent us from running educational programs and giving some form of accreditation or certification. My personal belief is that we should be working on this now.

Related to this is the maintenance by CMOs of a "Portfolio"-perhaps in special book form-to outline positions held, experience gained and educational courses and qualifications attained. Who can put such a book together for us?

CMO Web Sites:

The last item to bring to your attention is the presence of two web sites on CMO matters. The first is a CMO Information site with a great deal of information on awards-CMO, RMO and Specialist-and also links to industrial and other sites. The other is the official CMOA site. This latter has material on the CMOA, past Bulletins, upcoming events, links to medical sites and a facility for putting comments, suggestions and criticisms that can be accessed by all CMOs. Both of these web-pages are maintained by David Brock, an energetic and skilled CMO from Tweed Heads and I ask all CMOs with Internet capability to check out these sites and make a habit of reviewing them on a regular basis. All contributions (information, ideas, suggestions etc.) are greatly appreciated.

The sites are:

"OFFICIAL CMOA Web-site": http://www.cmo.asn.au/

"CMO Information Site": http://www.ozemail.com.au/~davbrock/cmo/cmo.htm

See you at the convention.

Well, and haven't we just had an election. Well, you might not be startled to hear from the Shadow Minister for Health, Mr Michael Lee. But even if you missed all the excitement (yawn), you must at least be encouraged to find out that when an election is round the corner, it turns out that Mr Wooldridge can answer a letter from the AMA after all! Odd, just when we were all thinking he was the victim of some sort of selective, multi-media deafness and paralysis, his inattention to requests for communication had been so profound on other occasions. Indeed one could be forgiven for thinking him a victim of some sort of mutant form of creeping MS - not multiple sclerosis so much as Ministerial Silence, perhaps?

Anyway, a snippet from each of the contestants for your edification. (Copied under the provisions of the copyright act - for purposes of study only.)

From Mr Wooldridge

"I note the contents of the paper provided by the AMA proposing a scheme for access to supervised medical practice under the Approved Placement provisions of the Health Insurance Act 1973. I am sympathetic to a number of these proposals and wish to confirm my undertaking that, subject to the re-election of the government, I will ensure that discussions are intitiated with the AMA to develop these proposals with the aim of having agreed programs in place in early 1999. My approach to these discussions will take into account first and foremost the public interest, as well as the existing portfolio budget paramenters"

(Even facing a possible life in opposition, you can see what a warm and caring guy he is. Ed.)

And from Mr Michael Lee.

"Labor will commission a genuinely independent review of the medical work-force and the doctors in training numbers. The Department of Health and Family services will not dictate the conclusions. In addition to the review Labor will by early 1999 relax the current restriction on access to Medicare provider numbers in the following circumstances: * the provision of assistance at operations and in areas of medical special interest. * Private hospitals accident and emergency departments, intensive care units and related medical services: and * general practice locum and deputising services to provide supplementary medical resources in rural and urban medical practice."

As they say in the movies-you pays your money and you takes your chances.

Book Review:
The Reflective Practitioner by Donald A Schon

Reviewed by Mary G T Webber

Donald A. Schon is Ford Professor of Urban Studies and Education at the Massachusetts Institute of Technology, and has a long interest in relationship between the kinds of knowledge honoured in academia and the kinds of competence valued in actual professional practice. In The Reflective Practitioner he both gives an outline of the development of this relationship and then propounds some new ways of thinking about it. The book is one you should read for yourself, as its thinking is too detailed to benefit from such a short review, however, some initial examination might encourage you.

Since the Reformation, the scientific movement, industrialism and the Technological Program have become dominant in Western society, and a philosophy has emerged "which sought to both give an account of the triumphs of science and technology and to purge mankind of the residues of religion, mysticism and metaphysics which still prevented scientific thought and technological practice from wholly ruling over the affairs of men." p32. According to this view the only significant statements about the world were those based on empirical observation, and all disagreements about the world could be solved, in principle, by reference to the observed facts. Propositions which were neither analytically nor empirically testable were held to have no meaning at all. They were dismissed as emotive utterance, poetry or mere nonsense. Thus we have Positivism, in which the heart of scientific inquiry consists in the use of crucial experiments to choose between competing theories of explanation. Where Positivism led, the professions have followed, until we seldom question whether this is the only kind of learning or knowing.

"According to the model of Technical Rationality-the view of professional knowledge which has most powerfully shaped both our thinking about the pro-fessions and the institutional relations of research, education and practice-professional activity consists in instrumental problem solving made rigorous by the application of scientific theory and technique." p21

Thus there are thought to be three elements to professional knowledge:

1. An underlying discipline or basic science component, on which the practice rests or from which it is derived.

2. An applied science or engineering component, from which many of the day to day diagnostic procedures and problem-solutions are derived, and

3. A skills and attitudinal component, that concerns the actual performance of services to the client, using the underlying basic and applied knowledge.

From this point of view, real knowledge lies in the theories and techniques of basic and applied science, and the "skills" should come later, a phenomenon we see institutionalised in the division of medical training into pre-clinical and clinical components. It is assumed that one can-not learn skills of application until you have learned applicable knowledge and that indeed "skills" are an ambiguous secondary kind of knowledge, an artistry that is difficult to define and of lesser prestige and importance thereby (witness the dominance of research over practice in the rush to a PhD as an entree to the surgical training programme).

The impetus to Professor Schon's work is of immediate relevance to professionals working in current practice, ie: that over the last decades both the public and the professions have suffered a progressive crisis of confidence as their applicability to the complex problems of the real world is called into question. What is fundamentally expected of the professions (of which medicine can be regarded as the quintessential example) is in the text outlined in some detail and its shortcomings of delivery discussed and illuminated.

"On the whole, assessment is that professional knowledge is mismatched to the changing characteristics of the situation of practice-the complexity, uncertainty, instability, uniqueness and value conflicts- which are increasingly perceived as central to the world of professional practice." p14.

In short, as the tasks change, so will the demands for useable knowledge, and the patterns of task and knowledge are inherently unstable. Problems are interconnected, environments are turbulent and the future is indeterminate just in so far as managers can influence it by their actions. The professions have suffered since the triumphant sixties from a crisis of legitimacy rooted both in their perceived failure to live up to their own norms and in their perceived incapacity to help society achieve its objectives and solve its problems. "Increasingly we have become aware of the importance to actual practice of phenomena of complexity, uncertainty, instability, uniqueness and value conflict - which do not fit the model of Technical Rationality." p39

If it is true that professional practice has at least as much to do with finding the problem as with solving the problem found, it is also true that problem setting is a recognised professional activity. And it can be seen that some professionals display what can only be called artistry in problem setting- a capacity for "reflection in action"-an unstructured, almost subconscious, and largely unexamined kind of improvisation learned in practice in the real world. Well-formed instrumental problems are not given but must be constructed (without recourse to selective inattention to inconvenient or conflicting data) from messy problematic situations.

Reflection in action? This notion is beautifully explained in the book by an illustration from an experiment in how children of different ages solve non-obvious puzzles. Faced with a set of blocks to balance on a pole (which have been non-obviously weighted to alter their balance characteristics), the children above a certain age first tried the obvious geometric solutions to balancing them and then, when these repeatedly failed to work, "abandoned their earlier theories in action, they weigh all the blocks in their hands so as to infer the probable point of balance. As they shift their theories of balancing from a "success orientation" to a "theory orientation", positive and negative results come to be taken not as signs of success or failure in action but as information relevant to a theory of balancing." p59 The "knowing in action", or "knowledge-in-action" which the child may represent to himself in terms of a "feel for the blocks" is merely a verbal description for the child's intuitive and non-verbal set of solutions to a non-obvious problems.

Schon proposes that a great deal of knowing is tacit, implicit in our patterns of action and in our feel for the stuff with which we are dealing. On the one hand specialisation increases the facility with which solutions to familiar problems may be enacted, but has the disadvantage of decreasing the number of occasions for "surprise" and running the risk of the practitioner limiting their actual capacity for surprise. Surprise, Schon propounds, is the key element for growth in practice, the trigger for "reflection in action". There is some puzzling or troubling or interesting phenomenon with which the individual is trying to deal. As he tries to make sense of it he also reflects on the understandings which he surfaces, criticises, restructures and embodies in further action-his knowing is inherent in his intelligent action and process. Skilful action often reveals a "knowing more than we can say." In much of the spontaneous behaviour we reveal a kind of knowing which does not stem from a prior intellectual operation.

Schon further proposes that such learning and development can be consciously embarked upon-that meaningful learning can be assayed in act of doing the job. When the practitioner reflects in action in a case he perceives as unique, paying attention to phenomena and surfacing his intuitive understanding of them, his experimenting is at once exploratory, move testing and hypothesis testing.

When you think about it, and it does take some thinking about, it's quite subversive stuff, especially when applied to the poli-tical realities of current medical practice.

Highly recommended.

Saturday 19th September 1998 - Attended by John Egan

This was the third DIT conference organised by the AMA and chaired by the very capable Choong-Siew Yong (who made a brief presentation to us at the AGM in February) to provide a forum for those interested in the conditions, practices and education of doctors in their formative years. The participants include Medical Student Representatives, JMO and RMO representatives, Registrar Representatives, ASMOF, HREA, and of course the AMA and the CMOA.

Because of strong interest in the CMOA and Career Medical Officers at the last forum in May 1998, I was invited to address the group on Post-Graduate Medical Training in association with Professor Peter Thursby, President of the NSW Branch of the AMA. Prof. Thursby's presentation covered the current "pyramidal" structure of post-graduate medical training-where the many that start a particular program are reduced to the few who finally attain the heights of specialist (and now generalist) practice-and the need to make the process more "rectangular", more fair and more accountable. Sweet words indeed for CMOs.

My own presentation focused on who we are, what we do and what we see as our future, particularly in regard to Post-Graduate Training. The major points that I tried to get across were; the present skills and experience of CMOs, the potential of this type of doctor and the exciting possibilities for a career in this type of medicine given the right structures and support.

The AMA and HREA have made a bilateral arrangement for industrial cover of doctors in training, however Registrars and CMOs are in a relative limbo with all the major industrial bodies vying for their business. CraigThomson, who is a senior industrial officer with HREA and also a lawyer, pointed out that while HREA had started out as a "blue collar" union it was very interested in pursuing a combined approach with the AMA to provide good cover to hospital medical officers. Currently this union covers nearly all hospital employees except nurses-this includes physiotherapists, pathology technicians, maintenance staff, etc. To achieve the above end the AMA is to have an industrial officer on site with combined AMA/HREA responsibilities-this DIT Liaison Officer is Jenny Cahill who comes from the ACT with a background in media studies.

Tony Williams represented the Doctors Health Advisory Council. He works as a Psychiatrist, is Chairman of the Health Committee, NSW Medical Board and a member of the Doctor's Mental Health Working Group. He, in collaboration with others in this group, has produced a draft document on the causes, consequences and possible strategies in treating doctors with significant mental health problems. Although the initial impetus was the spate of suicides among doctors, the group has looked into the much wider issues of working hours and conditions of all doctors (both junior and senior), poor performance, substance abuse, medical registration and the like. One consequence of Tony presenting to the DIT Forum was the co-opting of myself to the committee (there was no CMO representative and given our lack of a career structure we may be more at risk than other medical groups).

Erich Janssen works with the Federal AMA and has done considerable work on the Safe Hours Project undertaken by the Association. He told us that we all know that, by and large, doctors work too long and too hard and that this cannot be a good thing. The trouble is to prove that this is a dangerous practice - to ourselves as well as our employers. There is documented evidence that many of our current practices are wrong. This documentation comes from non-medical (aviation, heavy industry etc.) and medical sources. The difficulty has been to gather this information and relate it to the Australian experience. A lot of this ground work has now been completed and recent publications (including the Consultation Draft National Code of Practice-Hours of Work and Rostering for Hospital Doctors: Sept 1998) and programs have been announced.

The final part of the conference discussed ways of bringing the Provider Number legislation to the fore with a Federal election looming rapidly. Although all thought that this was important, there was little belief that this would be a significant issue for the electorate at large.

Overall a good forum and one that CMOs should continue to support.

CMOA Committee 1998:

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