One might be forgiven for thinking that there is something terribly amiss with the state of training at Dunedin Hospital.
The decision by the society of orthopaedic surgeons not to allocate trainees to Dunedin Hospital next year was met with a flurry of hyperbole and ill-informed comments.
I in no way wish to minimise or trivialise this decision as it has been taken very seriously and we will work hard to ensure that trainees will be again allocated to Dunedin.
Although the result is basically the same, it is important to note that the orthopaedic posts were not disestablished. The Dunedin training posts are still accredited for training.
The orthopaedic decision came not long after the decision to dis-accredit the training positions in the Intensive Care Unit (I wonder how many are aware of the fact that Auckland Hospital ICU has also lost its accreditation) thus heightening the perception of ''all is not well'' at the hospital.
Also I think a lot of people have wrongly linked the training positions to the medical school and have voiced concerns regarding the future of the medical school.
The training positions are postgraduate positions and not university ones.
The training posts and trainees are administered by either various branches of the Royal Australasian College of Surgeons/Physicians or professional bodies of the different craft groups.
At present, Dunedin Hospital has 112 accredited training positions at registrar (postgraduate) level.
These are training positions for junior doctors who are working through training programmes to become specialists in their fields.
Dunedin is also a training centre for many other health professionals (nursing and allied health) but my comments are purely directed towards ''doctor'' training.
Accreditation of training positions is quite a dynamic process.
Each training hospital is usually inspected on a regular basis - five-yearly cycles for most surgical specialties for routine inspections or more often if there is seen to be issues. There are various factors to look at when accrediting a post.
I am the chairman of the Board of Cardiothoracic Surgery for the Royal Australasian College of Surgeons and have inspected the majority of cardiac surgery training posts in Australia and New Zealand.
The range of factors we look at include educational facilities, workload, trainee welfare, physical facility and learning opportunities.
We also talk to all staff who interact with the trainees including consultant staff, nursing staff, allied health staff and administration.
It is not rare to dis-accredit a post for a whole host of reasons and then reaccredit when the reasons have been addressed.
In my experience the reasons for dis-accrediting a post are almost never due to poor-quality outcomes but more to do with the trainee's environment.
In the case of our ICU posts, the college has for some time expressed concern about the adequacy of the physical environment we have and in fairness we have been telling the college for some time that we intended to do something about it.
However, the college noted the lack of progress and ran out of patience.
The college was also concerned about the delay in appointing a clinical leader to the intensive care unit, which was due to unfortunate circumstances in that the person appointed then had a significant family illness to deal with and was delayed in arriving in Dunedin.
With regards to the orthopaedic posts, the society felt there should be a dedicated orthopaedic trauma list and that the trainees needed more supervision during training.
The role of the colleges/societies in training is pivotal. Training is becoming more complex and more closely supervised.
Junior doctors are less autonomous and start surgical training usually less experienced than in days gone by. As is the case in any profession, the presence of a trainee (apprentice) is positive for all in the department.
Their quest for knowledge and experience keeps everybody up to date and is stimulating.
It also means the trainee has a genuine interest in the field and is not just providing a service. It is a win/win for all concerned.
Training posts have to be balanced against the fundamental purpose of the hospital, which is to deliver healthcare.
Trainees do take longer to carry out certain tasks and this adds to the cost but this is something that is accepted and is allowed for in service planning and delivery.
Each profession must have a succession plan and prepare younger colleagues to step up at the appropriate time. Medicine is no different.
The balance between training needs and service delivery needs is becoming increasingly difficult to manage.
Using orthopaedics as an example, providing extra lists and more supervision comes at increased cost and unless you have been on another planet for the past few months, you will know this is a cost the DHB cannot afford without dis-investing in some other service.
Colleges and societies also tend to espouse the Rolls-Royce approach when a Toyota is perfectly satisfactory for most needs.
This can result in extra cost to the DHB, a cost it may not normally incur. There is a danger that the demands of training may push some DHBs towards employing ''fellows'', which is common practice in Australia.
These are overseas trained doctors who want to pursue a career in surgery and are not on a formal training programme.
They are capable of doing the work but at the end of the day the hospital has no commitment to them.
They often return to their country of origin but some elect to stay and are often in a state of professional limbo as there is no career path for them. This is not satisfactory for the doctor or for the country.
Hospitals are there primarily for healthcare delivery and in the course of achieving this provide the training opportunities for junior doctors to take advantage of.
It is very important that the needs of delivering healthcare must be the DHB's prime consideration and it would be very dangerous to have training needs drive expenditure in the DHB.
While training and preparing junior colleagues for the future is an inherent part of being a professional, this cannot be done at the expense of and potential detriment to healthcare.
It may well be that the various societies and colleges, in some fields, may set expectations and standards, particularly with regard to physical facilities, that are not realistic in our environment - most colleges/societies are based in large metropolitan areas. If this is the case, the ability of hospitals to train specialists will be compromised.
Having trainees is a privilege. Their presence enhances the general environment of the hospital and the desirability of the hospital as a place to work.
We have 112 such posts at present in Dunedin Hospital and we are very proud of our record with regards to the trainees' success in completing training.
Despite comments to the contrary from those who should know better, Dunedin is, and will remain, an excellent place in which to train in a wide number of medical and surgical specialties. I have no doubt
the ICU will regain its accreditation and that orthopaedic trainees will be allocated to Dunedin in the future.
I also have no doubt that for myriad reasons some training positions in other specialties will come under scrutiny due to the dynamic nature of accrediting training posts.
Dick Bunton is medical director of patient services and acting chief medical officer of the Southern District Health Board.
