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| Even the stretchers are positioned backwards in the recovery room. |
Introduction and disclaimer
Example #1:
When applying for all the administrative stuff, the Australian Health Practitionner Regulation Agency (AHPRA), which is their national regulatory board, asked for photocopies of my original medical degree and other relevant documents to be notarized and stamped by a notary public, and then electronically scanned and sent by email to them. So they wanted me to prove that copies were true to the originals, then these notarized copies were again copied by scan, with no proof that they weren't tinkered with.
Example #2:
AHPRA asks for passport sized ID photos to be sent by mail. They lost Chris's photos and did not admit to it. They also asked him for high school transcripts to prove that he went to high school in Englsih. They had received his passport info, medical degree and certifications from Canadian medical schools and organizations. But they needed proof that this Canadian trained, born, and raised doctor went to high school in English. For some reason, they did not ask me for high school transcripts (ie, my name doesn't sound that Chinese but my husband's does). They might have freaked out if they saw my French-language high school transcripts.
Example #3:
Opening a bank account requires: ID, proof of a job, proof of an address in Australia. So logically, I bring my passport, job contract, and tenancy agreement. I then give the bank my money to hold safely. The next day, the bank says they need "bond papers", which requires me to give a lump sum of money to the treasury to insure that I won't wreck the apartment. So they lock my bank account and the money I thought I could keep securely, because a signed tenancy agreement with the landlord's signature is not enough. I thought I was stuck because I no longer had access to the money I could have used to pay the bond. I then went to my hospital administration office and get the person working there (a university student on a summer job) to sign a form saying that I am employed at the hospital and living at this address. That letter alone holds more weight than a tenancy agreement in the bank's eyes, and they finally unfreeze my account.
Example #4:
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| "Dim Sims" |
But I digress... this is the background with which I started my "Great Australian Adventure". These experiences coloured my initial experiences doing my fellowship in Australia.
Anaesthesia training in Australia
Australian anaesthetists undergo a different post-graduate training system than in Canada. Aside from the half of them who are U.K.-trained, the Australians go through roughly 7 years of post-graduate training before they are "fully qualified". Their training is overseen by the Australian and New Zealand College of Anaesthetists (ANCZA). After medical school, the trainees do one year of "internship". They then apply to do general "resident medical officer" (RMO) jobs in different specialties for at least 1 year. Many people do more than 1 year of RMO work. After the first 2 years of general post-graduate training, they can apply to ANCZA to complete a 5-year specialist training program. Once in a specialist program, trainees are known as "registrars". They are designated as "junior" or "senior" depending on their stage.
ANCZA training is broken down into 6 months of "introductory training", 1.5 years of "basic training", and 3 years of "advanced training". They have 2 major exams: "primary" and "fellowship". Both consist of written and oral sections. The primary exam is done at the end of basic training. It is focused on basic anatomy, physiology, pharmacology, equipment, and statistics. I hear that it is the most difficult exam and 40% of applicants fail the first time. The fellowship exam is done in the 4th year of training, so one year before fully completing the program. Although the 5th year of training is still a "senior registrar" year, it is also known as the "provisional fellowship" year in which subspecialty training can be done. So a fellow here is still a "senior reg".
2. Trainees are "real doctors"
As a contrast to Canada, Australian doctors are still seen as "real doctors" by the public. So the registrars are seen as doctors and usually perform with little supervision and often don't need to report to their consultants before making big decisions.
For example, senior registrars in surgical specialties will book operations without seeking approval from their assigned consultant. They also perform simple operations without the consultant ever seeing the patient or the outcome. They have their own assigned "registrar lists" of operations. This means the consultant doctor doesn't have to be in the hospital while the registrar is operating.
The same holds true for anaesthesia trainees. But there is a discrepancy between normal working hours and out-of-hours supervision. During the daytime, the trainees are heavily supervised. There is usually one consultant and one registrar assigned per operating theatre. After hours and on weekends, the consultant goes home, and the registrars run the theatres.
At my institution, they have an interesting way to handle weekend coverage. On the weekends, the fellow and the consultant start the morning running one theatre each. There is a junior registrar who carries the pager. At noon, a senior registrar comes in to relieve the consultant. The consultant then goes home if everything is under control, and is on-call from home until the next morning.
3. Safe work hours and the 40-hour work week
Trainees in Australia follow normal work hour rules. Gone are the days of 24-hour shifts. Trainee doctors are employees of the government. The government is obliged to pay "penalty rates" to their employees if they work more than the standard 40 hours per week. This usually means 1.5x on Saturday, 1.75x on Sunday, and 2x on public holidays. So it is cheaper for the government to employ more doctors than to pay fewer doctors overtime.
This has led to staggered registrar shifts, which are usually no longer than 10-12 hours. Overnight, the junior registrar is the only anaesthetist in the hospital from 8pm to 8am unless they are running a theatre. If they need to do so, they call the senior registrar who is on-call from home.
Overall, compared to the Canadian system (or at least in Toronto), it seems like the Australian training system is longer in number of years, but they work fewer hours per week. In the end, they all seem to be very well-trained.... aside from the fact that they always need an anaesthetic tech to set up their equipment.
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| A consultant chillaxin' on the massage chair in the "tea room" |
4. Redundancy: Power in numbers = more safeguards?
There are always lots of people around.
On weekends at this institution, we run 2 theatres: one for orthopedic trauma and one for all the other urgent cases. There are always at least 3 people from the anaesthesia department around. In addition, for every theatre running, there has to be one anaesthetic technician, as per ANZCA guidelines. The techs need their breaks too though, so they need a relief person.
So for 2 operating theatres, by noon on a Saturday or Sunday, we have the following staff:
1 consultant, 1 fellow, 1 senior registrar, 1 junior registrar, 3 anaesthetic technicians... and a partridge in a peartree. The senior and junior registrars would also each be relieved by the night-shift people.
Total = 7 people from anaesthesia for 2 operating rooms. My guess is that this gives the consultant some comfort to go home. Plus, although the theatres are supposed to start at 8am, the surgeons are usually not around, so we usually don't really start until after 8:30am.
This is a contrast to where I was working in Toronto. We would start with 1 operating room, with 1 staff and 1 resident. We would only open a 2nd OR if we really had to, and call in another staff anesthesiologist for that one. We would also only call an anesthesia assistant if we had horrible difficult airway issues and poo were to hit the fan.
So for 2 operating rooms by noon on a weekend, we would have:
2 staff anesthesiologists and 1 resident. = 3.
5. Redundancy: Power in numbers or too many resources and money spent?
Some people may like to get paid to do nothing. I thought I would, but I don't. Overstaffing seems to be a more common occurence than understaffing in these parts.
This past wednesday, I had a half-day for office work, followed by an ERCP list. In fact, the ERCP list was staffed by both me and a consultant anaesthetist (and a tech as always), for 2 procedures in which we just had to provide sedation. Redundancy. A consultant, a fellow, and a tech for 2 sedations. If the endoscopy suite were quite remote from the main theatres, it might be justifiable, in case you need help quickly. But it is actually located directly between the theatres and the anaesthesia department.
The next day, 2 theatres were closed due to "lack of funding", which probably means "no nurses". I was rostered as "available" but not assigned to do any work. I was expected to be in the department so I was there all day. I also noticed at least 4-5 consultants in their offices in plain clothes.
If this situation were to happen in Toronto, we just wouldn't get paid in a fee-for-service model since we are not doing clinical work. However, in the public health care system in Western Australia, all doctors including consultants are salaried. Seeing the salary vs. fee-for-service models, there is definetly a difference in motivation and efficient use of resources. Indeed, I get the impression that this is a very wealthy state and government if they are paying doctors to sit around and wait. It's a far cry coming from a Canadian province where the government decided to unilaterally cut doctors fees.
Surgeons are not doctors
There is a reason why surgeons loose their medical title "Doctor" and become "Mister" instead.
The surgeons here only take care of surgery. They don't write post-op orders. If they are in the public system, they have RMO's around to manage the ward patients. So at the end of an operation, the anaesthetist writes orders for IV fluids, analgesia, and anti-nauseants, which continue unless written otherwise. The surgeons will review their patients only the next day.
The senior orthopedic surgeons are a different breed. They really want to be technicians and only technicians. The head honchos refuse to come to the theatre to perform a pre-op checklist with the nurses and anaesthetists. They believe their only duty is to show up once the patient is asleep and fix some bones. Because of this culture, the trainees don't learn how to prepare patients for surgery. They often don't order bloodwork, ECG's, or tell their patients to fast for 8 hours before surgery. That's the job of the anesthetist. This has lead to the culture where all patients going for surgery need to be seen pre-operatively by an anaesthetist, no matter how uncomplicated they are.
Ortho vs. Anaesthesia: an international new classic with some truth to the story.
I have a new appreciation for our Canadian surgeons. Even our orthopods are called "Doctor". They know how to order blood. Kudos to my colleagues who yield both knife and pen.
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