Bulletin October '98 Vol: 2, No: 2
Newsletter of the Career Medical Officers Association Inc.
(Click on the title to move to that section)
|President's Address||by John Egan|
|Industrial Update: The RMOs Dispute||by Mary G T Webber|
|Minutes: 7th Meeting of the CMOA||Tweed Heads Hospital,
28th August 1998
The REFLECTIVE PRACTITIONER
by Donald Schon
Mary G T Webber
|The "Doctors In Training" Forum||Attended by
|CMOA Committee 1998|
|Address for Correspondence|
|Submitting Items for CMOA Bulletin|
|Credits:||Editor: Mary G T Webber
Cartoons: Kieb Coaxuan
Design & Typesetting: Karyn at Flying Colours Printing (02) 9829 1514
Web-page layout: David Brock for the CMOA
|The views expressed within this publication are those of the authors, who enjoy freedom of speech and use it regularly. They are therefore occasionally neither wise nor politically correct. Neither do they necessarily represent the view of the CMOA.|
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.
1. Industrial Convention
3. Web Sites
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
* 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.
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.
The published minutes of the previous meeting were read and received, and our usual brand of spirited discussion was launched over finger food and a couple of beers-a welcome change of pace after a day of listening to a certain amount of back-slapping by the surgical community at the 10th anniversary EMST conference up the road at Surfers.
As ever the primary business hanging over the collective heads of CMOs in general are the paired industrial and educational imperatives. These are the two issues that almost define our dilemma-finding ways to demonstrate a commitment to continuing education across so diverse a group, having suitable opportunities made actually available in ways that reflect real world issues of life, family and interests outside medicine, and having both actual experience and educational commitment recognised both by colleagues and employers in bankable ways.
Interest continues in the interchanging of GP and CMO roles. As opporutnites open up in the private sector, providor numbers, VR, credentialling, billing, quality of service etc are big issues.
We noted an interest in finding and making contact with the new College of Rural Medicine, currently rumoured to be developing a fellowship in Rural Health.
The Continuing Professional Development Programme still very much on the agenda-communication is underway with Louise Garland from the College of Pathologists, who is interested and talking to Peter Love, our education officer, and Brooke Murphy of the University of Sydney spoke at the AGM. There were some queries from David Brock at this meeting as to the validity of the overall process-like why are we bothering? How does it fit into the reality of working and what actual good will it do anyone in the real world? The query was a valid one-the modality we choose to engage in has to be valid in that same "real world". The advantages of this programme (CPDP) over any other is that is responds to our central dilemma as CMOs-it grows flexibly out of our individual working experience and reflects that in a meaningful way. It doesn't matter where you're working, in what goegraphical location or what field of practice. The central phil-osophy is that work itself has value as a learning experience. It is also piggybacked onto a respected College and therefore represents an unassailable modality of documentation for this small and struggling group of independent thinkers. And we will have to document continuing ed. within the forseeable future. Everyone will. Better to be ahead of the curve than trailing it. It also has some recognisable political usefulness-the possibility exists for development of a CMO number implying registration with CPDP to be useful much like a GP number for purposes of documentation.
A copy of The Bulletin will be sent directly to David Brock for addition to the web site -which Dave has kindly agreed to take over and run. We need to raise the profile of the CMOA and also to encourage all our acquaintances to get connected and stay that way. We need to link our site into the main medical nets. Issues to be considered include the contents of the official site, perhaps a register of members and their E-Mail addresses, which parts are privately (password) protected and which are public information. The Bulletin would also sit in the public end. Behind the password would be hot gossip, and other stuff as yet to be determined. A down-loadable membership form is a good idea.
Motion: Dave Brock to become the web meister for the CMOA and to liase with approriate technical support to promote this activity. Proposed: John Egan, Seconded: MaryGT Passed: Unanimously
Once again we noted that only through the commitiment and volunteering of the time and expertise of individuals will our endea-vours be crowned with success. Yea, Dave!
Shortcomings of the CMO award-especially the capping of penalites and overtime at registrar rates. Again, Dave et al had been through the award and noted that leave is reserved therein for the association to apply for variations. Two in particular are of interest-the Grade IV initiative-and the barriers to overtime etc. Portability of Grades is also an issue. Such matters need to be brought up with ASMOF at the earliest opportunity and on an ongoing basis. The industrial convention-reflects need for our own policy "this is what we want" - work it out, give it to ASMOF and tell them to go fight for it. Ron Strauss and John Egan to talk to ASMOF. Aim to create our own specific industrial policy for the end of 1999, when the award is subject to a comprehensive review-an opportune time to change the award to something rather more coherent.
Things we need to do: Review the history of the award, review of its current provisions, review current difficulties, examine the proposed changes-eg. current best practice for OH&S, strategies for change, the tying in of the educational structure to the award in priniciples.
Motion: Joe Ogg to be the OH&S person for the CMOA. Proposed: Dave Brock Seconded: Kate Tree. Passed: Unanimously.
Also Ron Strauss to formulate a list of questions for the medical defence organisations with Warwick Barnes for publication in The Bulletin.
Follow-up on Warwicks letter to the last Bulletin - noted that Medical Defence Union (MDU) rules disadvantage CMOs working in hospital indeminfied positions - that the reduced yearly rate now effectively implies an exit fee - because we're not "full member rate payers". Needs looking into and comparison with the competition.
Still suffering from scattered points of reference and multiple databases and officers scattered around the country. MaryGT to tackle the issues of receipts and improving organisation.
John mentioned that he would not be standing for re-election next February. We thank him for his pivotal role and incredible efforts over the last two years.
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.
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:
|President: John Egan
Vice President: Stephen Delprado
Secretary / Editor: Mary Webber
Ph (H): 02-6361-2018
Ph (W): 02-6360-5227
Ph (M): 015-906-105
Treasurer: Michael King
Public Officer: Jenny Virgona
Education Officer: Peter Love
|Industrial Officer: Rami
Media & Publicity Officer: Kien Coaxuan
National Coordinator: Warwick Barnes
Webmaster: David Brock
CMOA Official Website:
|Submitting Items For CMOA Bulletin
This is your journal. You are welcome to submit letters, articles, papers, photos, cartoons, quotable quotes, in fact just about anything that its legal to print. CMOA Bulletin will only be as good as your contributions make it, so get to your word processor.
All items submitted should be either sent on disc, or e-mail to the Editor, whose mail and e- mail addresses are on page 2. Just about any PC or Mac Word Processing format is OK. When submitting items on disc, please label your disc, and provide a printed copy if possible.
Please contact the Editor if you wish to submit material generated in other types of software applications. Illustrations should be in black ink, on plain white paper with nothing on the back. Photographs can be either black & white or colour. Typed copy is acceptable if you have no other means available, and we can't seriously expect our publisher to read doctors' handwriting - so don't even think about it.
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