Qld Report into Career SMOs

THE CAREER PATHS, TRAINING NEEDS AND FUTURE ROLE OF NON-SPECIALIST SENIOR MEDICAL OFFICERS IN QUEENSLAND

NB: this copy has been provided to inform and stimulate debate within the medical profession only. As it has been scanned from the original, it may contain typographical errors. Therefore all information should be checked with an original copy obtained from Queensland Health

Because of the limitations of scanning software, information provided in charts and graphs are not reliably transferred. Consequently sections 3, 4 & 5 are not available in this copy. Send requests for a complete copy to Dr Michael Catchpole, Principal Medical Adviser, Qld Health, GPO Box 48, Brisbane, QLD 4001

The contributions of the following individuals and organisations are gratefully acknowledged:

1. The Medical Training Review Panel, whose financial support made the project possible;

2. Dr John Frith of the University of NSW School of Community Medicine, for time and effort spent in mentorship of the study;

3. Dr Julie West, organisational psychologist, for reviewing the design of the first surveys;

4. Dr Richard Ashby, Fellow of the Australian College of Emergency Medicine and Member of the AMWAC Emergency Medicine Work force Working Party that resulted in the production of the AMWAC Report into Emergency Medicine (1997), for his valuable comments;

5. Dr Jeff Ramin, Acting Censor of the Qld Branch of the Australian College of Emergency Medicine, for his time and effort in clarifying Registrar training and membership numbers;

6. The time and effort of all those senior medical officers, Registrars, medical superintendents, and directors of emergency services and other staff of Queensland Health who participated in the study; and

7. The Health Work Force Planning and Analysis Unit of Queensland Health, for access to their databases and software, and their provision of facilities from which the study operated.

TABLE OF CONTENTS

EXECUTIVE SUMMARY

SECTION 1: BACKGROUND

SECTION 2: LITERATURE REVIEW

2.1 THE SENIOR MEDICAL OFFICER WORK FORCE
2.2 THE SENIOR AND TRAINEE EMERGENCY MEDICINE WORK FORCE
2.3 FINANCIAL IMPLICATIONS
2.4 IMPLICATIONS FOR RURAL WORK FORCE RECRUITMENT
2.5 PRACTICALITIES OF REPLACING SMOS WITH FACEMS
2.6 THE NEEDS OF SMALLER REGIONAL CENTERS
2.7 TRAINING AND EDUCATION REQUIREMENTS

SECTION 3: AIMS & OBJECTIVES

SECTION 4: METHOD

4.1. GENERAL

4.2. SURVEY INSTRUMENT DETAILS

1. Medical Superintendent Survey
2. Directors of Emergency Medicine Survey
3. Initial Survey of Senior Medical Officers (SMOs)
4. Second Survey of Senior Medical Officers
5. Survey of Registrars in Emergency Medicine
6. Survey of Rural SMOs and Medical Superintendents

4.3. DESIGN

4.3.1. Survey Design
4.3.2. Sampling Methodology
4.3.3. Ranking Scales and Measures

4.4. DATA ANALYSIS

4.4.1. Calculation of Response Rates
4.4.2. Statistics

4.5. ETHICS

4.5.1 Beneficence vs Adverse Effect
4.5.2 Privacy and Confidentiality
4.5.3 Informed Consent

4.6. DEFINITIONS AND TERMINOLOGY

4.6.1 Rural Practice
4.6.2 Brisbane vs Non Brisbane
4.6.3 Senior Medical Officer (SMO)
4.6.4 Future Fellow of the Australian College of Emergency Medicine

SECTION 5: RESULTS

5.1 RESPONSE RATES

5.1.1 Emergency Medicine SMO Survey One
5.1.2 Emergency Medicine SMO Survey Two
5.1.3 Emergency Medicine Registrar Survey
5.1.4 Rural SMO Survey

5.2. MEDICAL SUPERINTENDENTS: OPINIONS OF SMOS AND PLANS FOR EMERGENCY SERVICES

5.2.1 Public Hospitals
5.2.2 Private Hospitals

5.3. DIRECTORS OF EMERGENCY MEDICINE: OPINIONS OF AND PLANS FOR THEIR SMO WORK FORCE

5.3.1 SMOs

5.4. GENERAL DEMOGRAPHICS

5.4.1 Age
5.4.2 Sex
5.4.3 State or Country of first medical qualification
5.4.4 Qualifications

5.4.4.1 General
5.4.4.2 FRACGP

5.4.4.2.(i) Male vs Female
5.4.4.2.(ii) Private vs Public Sector
5.4.4.2 (iii) Brisbane vs Non Brisbane

5.4.4.3 Management Qualifications
5.4.4.4 Obstetrics

5.4.5 Experience

5.4.5.1 Emergency Medicine

5.4.5.1(i) Male vs Female
5.4.5.1(i) Public vs Private
5.4.5.1(iii) Brisbane vs Non Brisbane
5.4.5.1(iv) Age Differences

5.4.5.2 Rural Practice

5.4.5.2(i) Male vs Female
5.4.5.2(u) Private vs Public
5.4.5.2(iii) Brisbane vs Brisbane

5.4.5.3 Urban General Practice

5.4.5.3 (i) Male vs Female
5.4.5.3(ii) Public vs Private
5.4.5.3(iii) Brisbane vs Non Brisbane

5.4.5.4 Other Experience

5.5. CAREER CHOICES

5.5.1 Future SMO career intentions on entering rural practice

5.5.1.1 Male vs Female
5.5.1.2 Age Differences
5.5.1.3 Public vs Private
5.5.1.4 Brisbane EM vs Non Brisbane EM vs Rural
5.5.1.5 Rural SMOs: past vs current career intentions

5.5.2 Job Designation While in Rural Practice

5.5.3 The Role of Rural Scholarships in the experience of current SMOs

5.5.4 Early Career Advice Received from colleagues

5.5.4.1 Do Not Delay Specialising

5.5.4.1(i) Age Differences
5.5.4.1(ii) Sex, Sector Worked, and Location

5.5.4.2 The Advice Not To Go Into Rural Practice First If You Wish To Specialise

5.5.4.2(i) The Main Source of Advice
5.5.4.2(ii) Age Differences
5.5.4.2(iii) Sex, Sector of Work, & Location

5.5.5 Reasons why Qld SMOs did not become specialists

5.5.5.1 Age Differences
5.5.5.2 Male vs Female
5.5.5.3 Private vs Public
5.5.5.4 Brisbane vs Brisbane

5.5.6 Aspects of The Work Of A Hospital SMO That Are Attractive Compared To General Practice

5.5.6.1 Male vs Female
5.5.6.2 Private vs Public
5.5.6.3 Brisbane vs Non Brisbane
5.5.6.4 Age Differences

5.5.7 SMO Perceptions About The Future

5.5.8 Recruitment Of SMOs To Rural Towns

5.6. TRAINING

5.6.1 Interest of Emergency Medicine SMOs in Re-training
5.6.2 Areas Of Work That Rural SMOs Would Like To Work If They Returned To An Urban Or Provincial Centre
5.6.3 On-going Training for non-specialist Hospital Medical Officers
5.6.4 Medical Training Review Panel Recommendations

5.6.4.1 Generalist First Two Years
5.6.4.2 Rural Term
5.6.4.3 Community Term
5.6.4.4 Better Documentation
5.6.4.5 More Structured Training PGY3 and Beyond

5.7. ROSTERS AND ATTITUDES ABOUT WORK

5.7.1 Working Sessions Outside of Emergency Medicine on a Regular Basis
5.7.2 Night shifts
5.7.3 Maximum on-call rosters
5.7.4 Weekend and Evening Shifts
5.7.5 Caseload Mix

SECTION SIX: DISCUSSION

6.1. GENERAL DEMOGRAPHICS
6.2. THE CAREER PATHS OF SENIOR MEDICAL OFFICERS
6.3. THE EMERGENCY MEDICINE WORK FORCE

6.3.1 The future of SMOs in Emergency Medicine
6.3.2 The attitude of Future FACEMs and SMOs to work conditions

6.4. TRAINING NEEDS OF THE SMO WORK FORCE

6.4.1 General
6.4.2 Re-Training and Training Interests
6.4.3 Response to the MTRP Recommendations
6.4.4 Other Recommendations For Training
6.4.5 Where To From Here

SECTION 7: CONCLUSION & RECOMMENDATIONS

REFERENCES

APPENDIX ONE: SURVEY INSTRUMENTS

This report details the findings of six cross-sectional surveys by interview and mail of medical superintendents, directors of emergency medicine, senior medical officers, and emergency medicine Registrars. The aims of the study were to determine the demographics of the SMO work force in Queensland; explore the possible existence of an SMO career path; explore the training needs of the Queensland SMO work force; and explore the current and potential future role of SMOs in health service delivery in Qld.

There were 149 funded SMO positions in Queensland Health in March 1999. Seventy of these were in designated emergency services₁where they make up the majority of senior medical staff. Another 35 fill 'niche' positions such as palliative care, sexual health, and community services. The remaining 44 are located in small rural and remote centres. In addition there are 94 medical superintendent positions in small rural and remote centers that have similar duties to those of many SMOs.

Most emergency SMOs interviewed were young (mean 42.5) and occupied permanent positions. 69% had a postgraduate qualification 73% had more than three years emergency medicine experience and 71% had rural experience since their third postgraduate year. In contrast, 69% had less than 1 year urban General Practice experience. Only 14% of emergency and rural SMOs originally intended to specialise when they first entered rural practice, and only 12% originally planned to become urban GPs. This and the other results suggest that an SMO career path already exists in Queensland between rural practice and the urban or Regional SMO position.

The position Queensland Health takes on the recommendations of the 1997 AMWAC Report into the emergency medicine work force will need to be considered carefully fromtwo perspectives. First, SMOs make up the majority of the senior emergency work force, but the AMWAC report fails to account for this. Replacing SMOs with FACEMs would have significant financial costs - the difference in remuneration alone would add approximately $2.8 million dollars to the recurrent labour budget. In addition, 14 out of 15 hospitals who had SMOs in emergency indicated that they wished to retain their present SMOs in their current role. Also, the AMWAC report recommends that the number of new Registrar positions be severely curtailed by 2003, but fails to explain who will take over the work they currently perform in emergency departments. Second, the majority of SMOs work in emergency departm ents, so any decision about the future role of SMOs there could significantly affect the career paths and training needs of SMOs.

A number of options for the future of the SMO work force in emergency were examined. The two that are most practical in light of all the variables were:

The Health Insurance Amendment Act (Vol.2)1996, requires Medical practitioners to complete a recognised medical training programs (or be undertaking such an approved program) to be eligible to provide services that attract Medicare benefits. The number of entrant training positions on the RACGP training scheme has been reduced to 400 nationally. One anticipated result of this is that there would be an excess of new graduate doctors and of immigrant doctors who have passed the Australian Medical Council (AMC) who are unable to enter general practice in the location of their choice. The alternative for these doctors is to either enter specialist training, or work in the hospital system as non-specialist doctors.

To prepare for this possibility,the Medical Training Review Panel (MTRP) has undertaken to document the extent of the need in the hospital system for a non-specialist Senior Medical Officers, and assess their career and training needs (First Report, 1997; Second Report, 1998).

In 1997 the Australian Medical Work force Advisory Council published its report and recommendations for the future of the Emergency Medicine work force (AMWAC, 1997). It is relevant to this study because non-specialist career Hospital Medical Officers (classified as Senior Medical Officers in Queensland) make up the majority of the senior emergency medicine medical work force in Queensland. In addition, 51 O/o of SMOs working in the public hospital system work in designated emergency departments around the state. Thus the report has direct implications for the future and training of this work force, particularly as it fails to consider their current and future role in its deliberations.

These issues will be explored in more detail in the literature review that follows.

The most recent publication giving an estimate of the numbers of salaried non-specialist doctors not training for a speciality is Medical Labour Force 1995 (Australian Institute of Health and Welfare₁1997). According to this report, which is based on data provided by the Medical Registration Boards in each state, there were 3067 salaried non-specialist doctors in Australia in 1995. At the time, this represented 10.8% of all doctors actively working in medicine (AIHW, 1995: 71). The AIHW divides these doctors into two groups: junior doctors (resident medical officers and interns), and hospital career medical officers (CMOs). The AIHW (1995) definition of CMO fits the description of that group of doctors working in Queensland who are classified as Senior Medical Officers (SMOs).

According to the AIHW there were 1068 of these CMOs doctors in Australia in 1995, of whom 144 worked in Queensland. The number has not changed significantly, at least in Queensland - in March 1999 there were 163 permanent resident doctors working as SMOs in Queensland. Queensland Health's human resource databases (Work force Planning and Analysis Unit, 1999; personal communications with medical superintendents) revealed that in March 1999 about 85% (138) of these worked in Queensland public hospitals. The remaining 25 worked in Queensland private hospitals, mostly in their emergency departments and intensive care units (Personal Communications, Medical Superintendents, March 1999).

Of the 138 permanent Australian resident public hospital SMOs, 51% (70) worked in emergency services. A further 25% (35) SMOs worked in a wide variety of areas outside emergency, including orthopaedics, sexual health, drug rehabilitation, cancer screening, community and community mental health services, and palliative care. The remaining 17% (23) worked in small rural hospital practice (Smith 1999). There are in fact 44 FTE funded SMO positions in these small towns, but 7 (16%) were vacant and a further 14 (32%) were filled by Temporary Resident Doctors (TRDs). In other words there are actually 184 funded SMO positions across the state, but there is currently a shortage of permanent resident doctors willing to fill 48% of the rural positions.

There are an additional 43 doctors working part4ime on a sessional or hourly basis as VMO General Practitioner. These VMOs work in very similar roles to the SMOs, but as a general rule the hospital work is either supplementary to private General Practice or a temporary job while taking time out from full-time work to raise a family.

In addition, there are currently 94 medical superintendent positions across Queensland in small rural and remote communities where the incumbent is often the only experienced doctor or shares this responsibility with one or two SMOs. Much of their work involves a mixture of that experienced by urban General Practitioners and hospital SMOs, as well as some procedural work and administrative responsibilities. Only 70% (66) were filled by permanent Australian Residents in March 1999. Of the rest, 19% (18) were filled by TRDs, and 12% were actually vacant or temporarily covered by PHOs or RMOs rotating from larger centres (Smith, 1999).

Despite the similarities, there is no evidence in the literature of a career pathway link between the populations of the urban SMOs and the SMOs and medical superintendents of small rural and remote towns. However it is significant in terms of training needs and the career pathway of this group that 25% of all SMO positions are in small rural or remote towns.

The Australian Medical Work force Advisory Committee (AMWAC) report The Emergency Medicine Work force in Australia (1997) recommends an increase in the FACEM (Fellow of the Australian College of Emergency Medicine) work force from 237 in 1997 to 1176 in 2010. However, AMWAC also point out that this target will be reached easily if the annual number of new trainees continues at current rates. In fact, AMWAC suggests that current intakes of trainees should only be continued to 2000, after which the number should be gradually reduced to a maximum of 25 new trainees per year by 2003. If this does not occur, it forecasts that an oversupply is a strong possibility. In 1999 in Queensland alone there were 76 FTE Registrars (doctors occupying Registered training positions) and a further 15 doctors who are not currently occupying Registrar posts but have passed at least the primary exam and often all of the practical training.

A major flaw in the AMWAC report methodology is that it ignores the role that Senior Medical Officers currently play in emergency medicine, at least in Queensland. Its general description of the evolution of emergency services suggests that there has been a direct and gradual transition from the early 1980s when casualty departments were largely staffed by un-supervised junior medical officers in a processing role to the employment of trained specialists in emergency medicine as they became available (AMWAC 1997:12). In contrast₁other literature suggests that this transition has not been quite so direct, and that until very recently the majority of hospitals looked in other directions to achieve better outcomes while the number of trained specialists available was low.

For instance, the report General Practitioners in Hospitals (School of Medical Education UNSW, 1993: 41) found that 80% of the hospitals that responded to its survey employed General Practitioners in their accident and emergency departments as late as 1993. Queensland was no exception, but the GP role quickly gave way to the Senior Medical Officer position in the early 1980s (Catchpole, 1999).

Although the number of FACEMs is increasing rapidly in Queensland - there were 39 in 1995-1996 (AMWAC 1997) and there are 55 in 1999 (ACEM, 1999) - it still relies heavily on its SMO work force for the delivery of emergency services. This is demonstrated by the fact that there are 95 SMOs currently working in emergency medicine in Queensland (Queensland Health Databases 1999; Census of Queensland Branch of ACEM). The majority of Queensland public hospitals with designated emergency services have a senior emergency medicine work force that either consists entirely of SMOs, or a mix of SMOs and FACEMs (Work force Planning and Analysis Unit, 1999). While this is not true of the largest hospitals in Brisbane, Gold Coast, Townsville and Cairns, at least two of these hospitals still utilise VMO General Practitioners in specific aspects of the traditional 'casualty' department role.

The omission of the SMO's contribution to the senior emergency work4orce from explicit consideration in the AMWAC emergency medicine work-force report, suggests an assumption by members of that review’s working party that the SMO group would be replaced by specialists. Because this assumption has implications for Queensland Health, it should not be accepted without full and explicit consideration of future models of care and definition of the role and training needs of the non-specialist career medical officer.

The first implication is that of cost. Currently the majority of the senior emergency medicine medical work force in Queensland consists of career hospital medical officers classified as Senior Medical Officers (SMOs). The difference in the award remuneration package between Fellows of the Australian College of Emergency Medicine (FACEMs) and SMOs is significant - roughly equivalent to $40,000 per full time staff member. There are currently about 70 FTE SMOs working in public hospital emergency departments around the state. A decision by Queensland Health to replace them all with FACEMs would therefore add approximately $ 2.8 million to its recurrent base medical staffing budget.

Better knowledge of the skills and qualifications of the current SMO group would help Queensland Health make a decision about the model it should adopt in the short and long term. For instance, how rapidly should the SMOs be replaced, if at all? However, to date the group has not been investigated in detail.

The problem of staffing rural and remote Queensland hospitals and communities with doctors is well known, and chronic in nature. Queensland currently relies heavily on the use of Temporary Resident Doctors (TRDs), and its Rural Scholarship scheme to help with the problem. For instance, in March 1999 79% of principal house officer and resident house officers in small rural and remote towns were rural scholarship holders. A further 8% were TRDs. Of the 44 FTE funded SMO positions in these small towns in March 1999, 7 (16%) were vacant and a further 14 (32%) were filled by TRDs.

Nevertheless a number of new Australian doctors enter rural practice each year independent of these schemes. Little is known of the future intentions and career aspirations of this group, but it has been suggested that many may eventually become career Senior Medical Officers working for Queensland Health rather than specialists or private General Practitioners (Catchpole, 1999). What is known, however, is that many Queensland rural doctors do eventually leave and return to a larger provincial or urban centre, Regardless of their initial intention on entry to rural practice. Hays, Veitch, Cheers and Crossland (1996) clearly demonstrated this in their interviews of all Queensland medical officers leaving rural and remote practices in 1995 and early 1996. All of their respondents initially found the work varied and interesting and the lifestyle for a young family attractive. In addition, career opportunities for partners did not appear to be an issue. However, over time,

Hays et al (1996) also demonstrated that there was a trend to re-locate southward and towards the coast, but that this did not necessarily mean Brisbane. The majority of practitioners moved into areas defined as 'rural major' by the Rural, Remote and Metropolitan area (RRMA) classifications. The main attractions to such areas were the reduced workload, the ability to share on-call, reduced after-hours work, more uninterrupted family time, better professional support and more continuing Medical Education (CME) opportunities support than available in their. previous place of practice.

Hays et al (1996) go on to suggest that expectations about 'retention' should reflect this, and that planning for medical services should aim to retain doctors in the medium term only. They further suggest that such a period of rural service could be made part of a longer term career structure (Hays et al, 1996: 41), and advertised as such.

If many of current emergency medicine SMOs had similar rural experience, then the closure of SMO positions in Emergency Medicine may inadvertently exacerbate the rural doctor shortage at point of entry into rural practice. Alternatively, if the SMO position does represent a career pathway for rural doctors, this knowledge may actually assist with the rural recruitment problem. Further investigation is needed to help determine this.

Better knowledge of the skills and qualifications of the current SMO group would help Queensland Health make a decision about the model it wants to adopt in the short and long term. However₁the group has not been investigated in detail by any study to date.

Eighty-five percent of SMOs working in emergency services for Queensland Health occupy full time permanent positions (Work force Planning and Analysis Unit, 1999). A decision to replace them other than through natural attrition would involve consideration of the implications of the relevant industrial award. If they are mostly young and settled in their current geographical location it is unlikely significant numbers will vacate their positions through natural attrition in the medium term.

Better knowledge of their career aspirations should also be investigated, because it may be that a significant proportion would be willing to take on FACEM training with little or no added expense to Queensland Health. In addition, there are a number of niche medical services for which a specialty in the traditional sense of the word does not exist, but which Queensland Health is committed to providing. Examples include drug rehabilitation₁palliative care, cancer screening and sexual health. About 25% of Queensland Health's SMOs are already employed in these niche positions (Work force Planning and Analysis Unit, 1999), and it may be that many of the current emergency SMO group would be interested in being re-positioned into these jobs.

In addition, if it proves to be true that many SMOs have significant generalist experience in a number of locations and practice settings, they may be ideal candidates to encourage to work in medical administration or corporate health or public health. The willingness of this group to be re-trained, and the conditions which would be conducive to this move should therefore also be examined.

More information about the attitudes of both the emergency services SMOs and the future FACEMs (those currently enrolled with ACEM) with respect to a number of variables would also help these deliberations. For instance, if the large majority of both groups are very unwilling to work night shifts this may render the 24 hour model endorsed by AMWAC for the tertiary hospitals impractical. While there is an argument that market forces will be a strong determinant of this, the situation in which the number of specialists eventually exceeds the number of potential positions in any specialty has no precedent in Australia.

There would also have to be strong support for the pure FACEM model from the medical superintendents and Directors of Emergency Medicine for it to be adopted. The attitude of these groups to this issue has not yet been investigated, either.

In several of the smaller Regional centers with emergency services, SMOs currently provide services outside of the casualty area, by virtue of the fact that they are too small to attract the requisite number of specialists to provide a reasonable on-call roster in a number of clinical areas, The training and experience that the ACEM requires its candidates to complete outside of emergency - for instance in anaesthetics and medicine - make FACEMs ideally placed to provide such services. Nevertheless there is no evidence that FACEMs would be attracted to working in such a model. This should also be investigated.

Alternatively, it may be that many SMOs also have the generalist experience necessary to equip them to work in these towns, or could be given the experience with much less difficulty and expense by Queensland Health than the resources required to produce a FACEM. The attitudes of the SMOs about a career option like this should also therefore be investigated.

Despite training and education requirements of senior medical officers being a topic of interest for quite a number of years (Doherty, 1988), little progress has been made in actually establishing a training/education program for this occupational group. Nevertheless, the Medical Training Review Panel (MTRP) has made considerable headway in establishing a suggested basic framework for such training as part of its larger set of recommendations for postgraduate medical training as a whole (MTRP 1997).

The Hospital Pilots Restructuring Program Report (1994) identified the steps involved in production of an appropriate training program for SMO's, but did not progress from that point. Dr P. Livingstone, Director of Queensland Medical Education Centre (QMEC) believes it would take QMEC about 18 months to fully develop such a program. He has suggested that such a program should culminate in a University based Masters of Hospital Medicine degree. He also suggested that attaining such a degree could be reflected in the SMO's award as an incentive (Livingstone, 1999a).

The AHMAC Medical Work force Working Group commissioned KPMG management consulting to provide an extensive report on non-specialist career paths for medical practitioners in hospitals. They reported in May 1995. They looked at the potential contribution of permanent SMO's rather than residents or Registrars, and interviewed nearly 1000 doctors across the full range of practice settings. Ninety-two percent of respondents thought or believed that there should be a non-specialist career pathway. KPMG encountered indifference and some hostility from the colleges with Regard to their involvement in the future of SMO's.

The Hospital Pilots Restructuring Program (1996) produced a career pathway for SMO's. This emphasised the multiple entry points to these positions, with doctors entering and leaving the hospital system perhaps several times. While this certainly reflects that there is not a linear progression from RMO to PHO to SMO, (NSW Medical Staff Monitor, 1997) is this because a clear linear pathway does not exist? The structure also does not identify a clear progression from rural GP to urban SMO.

This is yet to be demonstrated one way or the other by any study. The training needs of non-specialist career hospital medical officers is dependent on both a better knowledge of the group in question, and an understanding of the career pathways that are in fact possible or that already exist. There is little evidence in the literature to date of either.

Each SMO interviewed is a unique individual, with his or her own set of experiences, training, interests, and attitudes. Nevertheless, the results of this study suggest that many of the current SMOs share a number of things in common.

First, the majority of the Queensland SMO work force are relatively young (mean age = 42.5 years), male (85% of the sample), and gained their first medical qualification in Queensland (69%). Eighty-five percent work in permanent positions for Queensland Health. Furthermore, the majority work in emergency departments (51%), where they constitute the majority (63%) of the senior emergency medicine medical work force.

The majority (74%) of emergency SMOs work for Queensland Health. Most SMOs in this group have a postgraduate qualification: 69% have one or more formal postgraduate qualifications. The most common qualification was the FRACGP (39%), a Diploma of Obstetrics (22%), and/or some other clinical diploma (39%).

The majority (73%) of emergency medicine SMOs have more than 3 years of emergency medicine experience, with 55% having 5 to 10 years experience. In addition most (71%) have worked in small rural and remote centre practice at some stage in their careers beyond their third postgraduate year, with 22% staying on for more than 5 years. In contrast, the majority of SMOs have little urban general practice experience (69% had less than one year, and 85% had three years or less).

When the data were stratified by age, sex, sector of work, and location of work (Brisbane vs Non Brisbane) a number of variations in the characteristics of those SMOs sampled were revealed which may be worthy of further investigation to determine if a cause-effect relationship exists between them or not. The main ones concern the relationship between sex and sector of work, and qualifications and experience. For instance, some SMOs in all age groups possessed the FRACGP, but no female SMOs and few men working in the private sector as SMOs had this qualification. The same applied for possession of an obstetrics qualification. Another example is the fact that the proportion of public system SMOs with rural experience (79%) was greater than the proportion of private SMOs with rural experience.

The results suggest that there are a group of doctors who make a conscious decision not to specialise and not to become general practitioners in private practice. For instance, 23% of emergency SMOs interviewed rated 'did not want to specialise' as a key reason why they are now SMOs. 'Family and other commitments precluding further study' and 'an ambivalence to the further time and study commitment involved' were also common key reasons. Both reasons were rated as very important by 39% and 31% of the SMOs interviewed, respectively. In contrast, only 10% rated 'missed out on a training place' as important.

While 33% gave 'originally intended to become a GP' as an important original reason for not specialising, there were a number aspects of. SMO work 65% or more of the same group selected as more attractive than that experienced in general practice work. These included 'the casemix experienced (90%), 'the chance to maintain acute hospital skills' (94%), the 'availability of clinical support services in decision making' (63%), and 'the availability of professional support in decision making' (69%).

The results also provide support for the idea that there is a career pathway for SMOs from rural practice to provincial or urban hospital practice, although the progression is not necessarily one of junior doctor to resident medical officer to senior medical officer. For instance, 71% of the emergency medicine SMO sample had rural or remote practice experience beyond their junior (first three post-graduate) years, either as a medical superintendent (32%), SMO (23%) or GP (25%).

For the majority of those emergency and rural/remote doctors sampled, the decision to follow this pathway was not made at the point of entry to rural practice - 36% did not have any firm plans and 25% were interested in rural practice in the long term. In contrast, only 14% indicated that they eventually planned to specialise, 12% were interested in urban general practice in the long term, and 14% were interested in becoming an SMO in a provincial or urban center.

The number of rural SMOs and medical superintendents in the sample intending to eventually make a career as an SMO in a provincial or urban center increased from 10% to 30% when asked what their plans were now. This suggests that the attitude of rural doctors changed after they had been in rural practice for a while, which is consistent with the literature about rural doctors. An example is Hays et al's (1996) study of why rural GPs leave their practices. According to this study the nature of the rural work remained interesting and varied to the doctors interviewed,but continued overwork, long after hours commitments, poor access to locums, and the educational opportunities for older children gradually persuaded these doctors that their professional life was less flexible than they would have liked (Hays et a1, 1996:39).

The results of the current study suggest that SMOs in hospitals with emergency departments find a number of features of SMO hospital work more attractive than general practice Although the mix of reasons selected as most important varied from individual to individual, the most frequently selected were 'the casemix experienced' and 'the chance to maintain acute hospital skills' - 90% and 94% of the sample, respectively. It may be that SMO work offers more of a chance than urban general practice to do many of the tasks and maintain much of the variety of rural practice, without many of the disadvantages outlined above. Hay et al (1996) suggest that many of the doctors they interviewed had Regrets about leaving their rural communities and wanted to retain the rural professional life while finding a more 'urban-style' family life (Hays et al 1996:40).

It may be to the advantage of Queensland Health to formalise this pathway, recognising it and promoting it to young doctors. For instance, doing so may be a way of improving recruitment to those multi-purpose SMO jobs that exist or could be created in provincial centers which are not large enough to attract the requisite number of specialists for a reasonable roster. Examples of such towns include Gladstone, Bundaberg, Mount Isa, Maryborough, Hervey Bay, Gympie, Innisfail, Warwick, and Atherton. Most of these towns currently find it difficult to recruit enough SMOs. For the reasons discussed above, the majority of the doctors in the Hays et al(1996) study moved to practices to larger rural / provincial centers closer to the coast, rather than to fully urban centers. The results of the current study provide support for the idea that this trend may hold true for other doctors as well: 48% of current emergency SMOs and 70% of curre nt rural SMOs and rural medical superintendents interviewed indicated that they would be interested or would have been interested in such a position at some stage in their career.

The Australian Medical Work force Advisory Committee (AMWAC) report The Emergency Medicine Work force in Australia (1997) recommends an increase in the specialist (FACEM) work force from 237 in 1997 to 1176 in 2010. However, AMWAC also point out that this target will be reached easily if the annual number of new trainees continues at current rates. In fact, AMWAC suggests that current intakes of trainees should only be continued to 2000, after which the number should be gradually reduced to a maximum of 25 new trainees per year by 2003. If this does not occur, it forecasts that an oversupply is a strong possibility.

Daly, Bricknell, and Catchpole (1999) assessed the AMWAC work force number forecasts and their specific implications for the Queensland setting. With the help of the Censor of the Queensland branch of ACEM they estimated when each Registered trainee was likely to qualify, and incorporated this along with different attrition rate estimates for emergency SMOs and FACEMs to forecast likely scenarios for Queensland. Their calculations suggest that the AMWAC report may in fact have underestimated the number of new FACEMs likely to qualify in Queensland by 2007.

Daly et al (1999) also suggest that there is a major flaw in the calculations of the AMWAC report, in that it fails to mention the role of emergency SMOs at all in its calculations of need and work force supply numbers. This is despite the fact that SMOs make up 63% of the total senior medical work force in emergency departments in Queensland, and 51% (70) of funded public hospital SMO positions.

One interpretation that can be made from this omission is that SMOs should be replaced by FACEMs. Yet the results of the current study suggest that the majority (85%) of emergency SMOs have permanent status in their local hospital. They are also relatively young. In addition, 14 out of 15 hospitals with SMOs in emergency were satisfied with their performance and wished to retain them. The natural attrition rate is therefore unlikely to have a significant impact on their numbers in the short term. This suggests that unless Queensland Health actively decided to make these SMOs redundant or re-deploy them to other areas of work to make way for the increased number of FACEMs, the potential oversupply of FACEMs forecast by AMWAC will occur much sooner than 2007.

Another question left unanswered by the AMWAC report is who will carry out the services currently provided by the 60 emergency medicine Registrar posts if the number of trainee positions is reduced to 25 nationwide by 2003 as recommended. One possibility would be to replace them with career SMOs. As mentioned earlier, the results of the current study suggest that many of the current emergency SMOs have at least one relevant post-graduate qualification and broad rural and emergency medicine experience. In addition, 90% of the rural doctors interviewed are interested in working in emergency medicine as SMOs should they return to an urban or provincial center to live. The alternative is the use of itinerant doctors, doctors with Temporary Resident Visas, and overseas emergency medicine trainees. The disadvantage of the latter is that supply is dependent on Commonwealth policy changes and international trends.

6.3.2 The Attitudes of Current Emergency Medicine Registrars and Senior Medical Officers with Respect to Work Conditions and Rosters

Knowledge of the attitudes of the work force to workplace conditions has the potential to improve decisions about work force planning The results of this study suggest that the future FACEM group (the current Registrars) and the current group of emergency SMOs are similar in their attitudes to having to do work outside of the emergency department, night shifts, and evening and week-end shifts. In contrast, their attitudes differ when they are asked to consider the maximum frequency they would be willing to participate in an on-call. The Registrars were asked to consider how they would feel about these variables as qualified FACEMs, rather than as trainees.

For instance, a large proportion of SMOs (65%) and future FACEMs (70%) stated that they would be very willing to work Regular shifts outside of emergency medicine if required. There was no significant difference between the attitudes of these two groups (chi sq = 1.579; DF=2; p>0.05). This suggests that both groups would be equally flexible about doing this.

The majority of both SMOs (50%) and future FACEMs (82%) were very willing to work evening and week-end shifts if required. These shifts in combination with night on-call represent the most common model currently operating in emergency departments across Queensland. While a large proportion of both groups were willing to do this, the future FACEMs were significantly more willing (Chi sq=11.648; DF=2; p<=0.003).

Most of the doctors in both samples were unwilling to do night duty, Regardless of age. Seventy-seven percent of SMOs and 62% of future FACEMs gave this a score of 1 or 2 on a willingness scale of 1 to 5 when asked to imagine themselves at less than 50 years of age when faced with the prospect. The difference between the two groups was not significant (chi sq = 0.170; DF=2; p<=0.9). The proportion of the SMO group that was unwilling to do it stayed at 77% when they were asked to imagine themselves faced with the prospect at 50 years or older. In contrast, the proportion of the future FACEM group unwilling to do it increased to 82% when asked the same thing. This change in attitude was very significant (McNemars Test = 1.0; DF=1; p<=0001). These results suggest that the 24 hour roster model advocated for tertiary hospitals by the AMWAC report into emergency medicine may meet widespread resistance from the staff affected. It does not necessarily mean that recruitment difficulties will be an issue, however. This will depend on other factors too, including whether the forecast oversupply of FACEMs eventuates or not.

When asked to consider the maximum frequency of night on-call they would be willing to work if required at under 50 years of age the SMOs and future FACEMs sampled differed significantly (chi sq=7.458; DF=2; p<0.02) Most Registrars (76%) indicated that that they would be willing to be on-call every 4 to 5 days, whereas the SMOs were more variable in their responses.

However, when both groups were asked to consider the maximum frequency of on-call roster they would be willing to work when they were 50 years or over, 54% of future FACEMs and 66% of SMOs indicated a maximum of once a week. The difference with age is significant for both groups (SMOs p<=0;002; Registrars p<=0.001).

Finally, the results suggest that many future FACEMs are not interested in working in an emergency department in which up to 50% of their caseload is category 4 or 5. Forty two percent of those sampled found the prospect very unattractive, and a further 26% were ambivalent about it This is suggestive of a potential problem for work force planners, because at least 50% of cases making up the current caseload of most emergency departments in Queensland are categorised as 4 or 5.

One solution would be to get SMOs to treat only the category 4 and 5 cases. However, the results of this study suggest that this would be very unpopular with this occupational group: 72% scored this option 1 or 2 on a willingness scale of 1 to 5.

As 51% of Queensland Health funded SMO positions are based in emergency services, the training needs of the Queensland SMO workforce is to a large extent dependent on the position Queensland Health takes on the recommendations of the 1997 AMWAC Report The Emergency Medicine Work force In Australia: Supply Requirements And Projection 1996-2007. As discussed earlier, it recommends that all senior positions in emergency be staffed by Fellows of the Australian College Of Emergency Medicine (ACEM). If Queensland Health decides to replace its emergency SMOs with FACEMs as they become available, then the training needs of the emergency SMOs will depend on either the area of medicine where they are re-deployed to maintains an SMO work force in emergency medicine, or whether or not Queensland Health decides to retain their services at all. If, however, Queensland Health decides that there is a continued need for SMOs in emergency services in some capacity, then a significant proportion o f any training effort should be expended on emergency medicine skills.

Another 25% of public SMOs work in a variety of areas outside of emergency services in provincial and urban centers. Examples include palliative care, sexual health, cancer screening, women's health, orthopaedics, anaesthetics, and paediatrics. No formal specialist College exists for some of these work areas. Interviews with medical superintendents indicate that the use of SMOs in the areas is largely dependent on local factors. For instance, sometimes the health service district has had chronic problems recruiting the relevant specialist. Also, several provincial hospitals are of a size that find it more useful to employ someone willing to do Regular sessions across a range of specialty areas. As a result, assessment of these needs is very dependent on local needs analyses.

The remaining 24% of positions are in rural and remote practice areas, where the SMO may be the only other senior medical staff person in addition to the medical superintendent. The training needs of the latter while in rural practice have been identified in a number of other studies, so were not examined in this one other than to examine future practice intentions. However, as discussed earlier, the results of this study provide some support for the existence of an established but informal career pathway between the rural SMO and medical superintendent positions, and urban and provincial SMO positions. As a result, any education program should attempt to take this possible career move into account.

The success of any training program will depend on the interests of the participants to whom it is marketed. The results of this study suggest that many of the current emergency medicine department SMO work force would be willing to either enter FACEM training or be retrained to work in other areas if they could be maintained at the SMO scale: every doctor surveyed indicated a strong interest in at least of one of the options. Similarly, every rural SMO or medical superintendent interviewed indicated that there was at least one area outside of emergency medicine that he or she would be interested in working in should he or she return to a provincial or urban center to work as an SMO.

If Queensland Health was to accept the recommendations of the AMWAC Report into Emergency Medicine (AMWAC, 1997) and choose to replace all SMO positions in emergency with FACEMs, it seems likely that retraining to other areas of need would provide a viable means to retain the generally broad experience and skills of its current SMOs.

The fact that 50% of the sample of emergency SMOs indicated that they would be willing to take on FACEM training while maintaining their SMO classification suggests that conversion is a potential option. This is reinforced by the fact that 75% of those SMOs and medical superintendents currently in rural and remote practice also indicated a strong interest in working in emergency medicine should they return to a provincial or urban center. This option is attractive because it minimises the need for re-deployment and makes use of the emergency experience and other qualifications held by many SMOs. However, this depends on the number of new Registrars allowed to enter training in the near future from other backgrounds. Both Daly et al (1999) and the AMWAC report on the future of the emergency medicine work force (AMWAC, 1999) agree that this number should be significantly reduced if an oversupply of FACEMs is to be prevented.

In general, both groups of medical officers surveyed agreed with all of the 1997 recommendations made by the Medical Training Review Panel (MTRP, 1997) for postgraduate medical officer training.

It is not possible to directly extrapolate the views of these two groups to the general Australian population of medical officers because the descriptive nature of the study and the specific population of doctors sampled. Nevertheless, the results suggest that many doctors would agree that there is a need for such changes to be made to postgraduate medical officer training It also suggests that there would be some degree of support for these MTRP recommendations should they be implemented.

The recommendation that was met with the most ambivalence was the one that suggested that all postgraduate medical training should include a community term. It was also the only recommendation in which the two groups varied significantly in their support of it. The fact that SMOs were significantly more likely to favour this option may reflect a more generalist orientation of this group to the practice of medicine. There is no direct evidence for this, because this variable was not evaluated for both these groups. Nevertheless, two of the four most common reasons the SMO group gave for not specialising were that they either originally intended to become a GP or wanted to stay in generalist hospital practice.

The results of this study suggest another variable that may have contributed to this ambivalence. This is the advice received from other doctors by many of the individuals in both groups when they were new graduates. For instance, 48% of emergency medicine Registrars and 43% of SMOs were advised not to delay entry to a specialist training program if they wished to become a specialist. The most common source of this advice was specialists, who were responsible for 61% of the cases in which this advice was received. Moreover, 75% of the SMOs who reported receiving this advice were aged 34 years or less. This last result may be affected by re-call bias. Nevertheless, it suggests that the advice was still being received by young doctors in the recent past. The same general trends were seen in the results when the same two groups of doctors were asked if they had received the advice not to go into rural practice first if they wanted to successfully specialise. These results support the view of 1 998 MTRP report Trainee Selection in Australian Medical Colleges, which states that:

6.4.4 Other Recommendations for Ongoing Training for Non-Specialist Hospital Medical Officers

The results of this study suggest that there is strong support amongst non-specialist hospital doctors for more structured training opportunities for hospital doctors beyond their third postgraduate year but not on a vocational training program. For instance, 80% of SMOs questioned were very interested in the idea of a compulsory continuing medical education points requirement similar to that used by the RACGP.

Another popular option was a clinically based Masters degree for generalist medical practice: 57% of SMOs questioned said that they would have been interested in such an option at some stage in their career.

Overall the results of this study combined with previous literature suggest possible starting points for an improved and more structured postgraduate medical education system for senior medical officers. The next step would be to decide:

Sue Phillips, the Executive Officer of the Commonwealth Department of Health and Aged Care (Phillips 1999) favours the use of Postgraduate Medical Education Councils (PGMECs) in each state to oversight and provide direction and on-going evaluation of this process. The membership of this body is currently under review (Livingstone 1999). However, the stakeholders who could and probably should contribute to the development of such a program, irrespective of membership of the PGMEC, include:

· The Queensland branch of ACEM, particularly if Queensland Health decides to maintain a role for SMOs in emergency services in some capacity; and

· The Rural Doctors Association of Queensland,as the representative of the needs of those 24% of Senior Medical Officer and 94 medical superintendent positions in rural and remote practice locations in Queensland.

However, as the major employer of SMOs, it is in Queensland Health's interest to actually initiate, contribute resources to,and drive the development of this program with the Postgraduate Medical Education Council. It is important that such a program reflect the current and future needs of. Queensland Health in terms of the skills and knowledge that are developed. If SMOs continue to be used in their current locations, the program should include a strong emphasis on skills in emergency medicine, rural practice, and niche areas such as palliative care, sexual health, alcohol and drug rehabilitation and community health services. Much of the training could occur 'on-the-job', because the majority of SMOs interviewed indicated that they would be willing to participate in PHO-type terms but paid as SMOs to develop new skills or update old ones.

Finally the training program should eventually lead to the development of a formal qualification recognised by the public health care sector, and be rewarded in the relevant award for the active contribution someone with such a qualification could make to the delivery of quality health care. The possibility of allowing credit towards such a qualification for other qualifications already gained and for relevant experience should also be considered.

There were 184 funded SMO positions in Queensland Health in March 1999. Seventy of these were in designated emergency services, where they make up the majority of senior medical staff. Another 35 fill 'niche' positions such as palliative care, sexual health, and community services. The remaining 44 are located in small rural and remote centres. In addition there are 94 medical superintendent positions in small rural and remote centers that have similar duties to those of many SMOs.

The position Queensland Health takes on the recommendations of the 1997 AMWAC Report into the emergency medicine work force will need to be considered carefully from two perspectives.

First, SMOs make up the majority of the senior emergency work force, but the AMWAC report fails to account for this. Replacing SMOs with FACEMs would have significant financial costs - the difference in remuneration alone would add approximately $2.8 million dollars to the recurrent labour budget. In addition, 14 cut of 15 hospitals who had SMOs in emergency indicated that they wished to retain

their present SMOs in their current role. Also, the AMWAC report recommends that the number of new Registrar positions be severely curtailed by 2003, but fails to explain who will take over the work currently performed by these positions in emergency departments.

Second, the majority of SMOs work in emergency departments, so any decision about the future role of SMOs in emergency could significantly affect the career paths and training needs of SMOs.

This has the advantages of maintaining a career path for SMOs and potentially helping future rural recruitment drives. Its disadvantages are that it eliminates a popular career direction for SMOs and does not solve the problem in emergency services created by the reduced Registrar numbers anticipated

1. The rural practice to urban or provincial SMO career path should be formally recognised and be actively promoted in future rural recruitment drives;

2. A formal training program suited to the needs of SMOs should be established as soon as possible. Initially it could take the form of a compulsory CME requirement, but it should eventually lead to a formal qualification. This should be recognised by the public health care sector as making an active contribution to the delivery of quality health care, and be rewarded in the relevant award;

3. The Principal Medical Adviser Dr Michael Catchpole should drive the development of the SMO training program for Queensland Health, in conjunction with the Postgraduate Medical Education Council;

4. A cost analysis of the various options for the SMO training program should be undertaken in the near future, and used in a submission to the MTRP for assistance with funding;

5. A review of the entire emergency work force and the model of care currently in place should be initiated as soon as possible. The model derived from this review should be in line with the zonal model, and address role delineation of services across the professions – not just medicine;

6. This model should be developed by Queensland Health in conjunction with Queensland Emergency Medical Services Advisory. Committee.

Australian Institute of Health and Welfare (1996). Australian Medical Work -force Benchmarks A Report for the Australian Medical Work force Advisory Committee, Australian Government Publishing Service,Canberra.

Australian Institute of Health and Welfare (1997). Medical Labour Force 1995, Australian Government Publishing Service, Canberra.

Australian Medical Work force Advisory Committee (1997). The Emergency Medicine Work force In Australia, AMWAC Report 1997.1, Sydney.

Catchpole, M. (1999). Health Advisory Unit, Organisational Development Branch, Queensland Health (personal communication), Brisbane,May.

Daly, M.,Bricknell, B., and Catchpole, M (1999). Planning The Senior Emergency Medicine Work force in Queensland: An Exploratory Study (In Press). Health Advisory Unit, Organisational Development Branch, Queensland Health, Brisbane,

Department of Health and Family Services (1994), Rural, Remote and Metropolitan Areas Classification (RRMA), Australian Government Publishing Service, Canberra.

Doherty, R. (1988), Australian Medical Education and Work force Into the 21st century, Australian Government Publishing Service, Canberra.

Hays, RB., Veitch, PC., Cheers, B., and Crossland, U. (1996). Why Rural Doctors Leave Their Practices: A Qualitative Interview Survey of Queensland GPs, Centre for General Practice, North Queensland Clinical School, The University of Queensland.

KPMG Management Consulting (1995). Report on Non-specialist Career paths For Medical Practitioners in Hospitals (Unpublished. Report), Canberra, AHMAC.

Livingstone, P (1 999a). Executive Director of Queensland Medical Education Centre (OMEC) (Personal Communications), University of Queensland, Brisbane

Available from Dr Michael Catchpole, Principal Medical Adviser, Health Advisory Unit, Organisational Development Branch, Queensland Health, Brisbane.

Medical Training Review Panel (1997). First Report, Australian Government Publishing Service, Canberra.

Medical Training Review Panel (1998a). Second Report, Australian Government Publishing Service, Canberra

Medical Training Review Panel (1998b) Trainee Selection in Australian Medical Colleges, Australian Government Publishing Service, Canberra.

Medical Staff Monitor (1997). Summary of Survey Of Non-Specialist Medical Work force In NSW public hospitals where interns and RMOs are allocated (Unpublished Report), Sydney.

Phillips, S. (1999). PGY3+ Project Summary: Analysis of existing data on RGY3+ or Non-Specialist Medical Practitioners (Unpublished Report), Commonwealth Department of Health and Aged Care.

Ramin, Jeff (1999). Acting Censor of Qld branch of Australian College of Emergency Medicine (personal communications), Gold Coast.

Strategic Human Capital Management (1996) Non-Specialist Medical Work force in Public Hospitals: Hospital Pilot Restructuring Program: Final Report (Unpublished Paper commissioned by the Commonwealth Department of Health and Family Services to evaluate the Hospital Pilots Restructuring Program.

School of Medical Education (1993). General Practitioners in Hospitals, University of NSW, Sydney.

Smith,T (1999). Faxed current list of staffing complement of all rural and remote public hospitals in Queensland to Dr Michael Catchpole, May 1999. Available from Theresa Smith, Coordinator, Southern Rural Coordination Network, Qld.

Van Konkelenberg, R., and McAlindon, A. (1993) Hospital Non-Specialist Medical Work force Survey, Australian Government Publishing Service, Canberra.

Work force Planning and Analysis Unit (1999), Human Resource Databases, Organisational Development Branch, Queensland Health, Brisbane.

DISCLAIMER
this information is intended for use by medical professionals only
all information is a guide only and not to be relied upon by any party