The power of Aussie rules

More specialisation means fewer specialists provide narrower care for a greater number of people....
More specialisation means fewer specialists provide narrower care for a greater number of people. Photo from Getty Images.
Dunedin surgeon Mike Hunter, in the third of a six-part series, looks at neurosurgical specialisation, pressure for centralisation and the Australian influence. Mr Hunter is clinical leader in intensive care and responsible for rescue helicopter medical retrieval.

Specialisation versus generalism

Increasing specialisation in surgical training has been a trend for decades, with increasing narrowing of practice into subspecialties.

This trend provides the critical context to the debate over neurosurgery.

More specialisation means fewer specialists provide narrower care for more people, which means surgeons need a bigger population catchment for an adequate number of procedures.

Just how many procedures constitute an "adequate number", however, is far from settled.

Almost all colleges representing specialists and responsible for training are transtasman organisations.

For surgery, this is the Royal Australasian College of Surgeons.

It is important to understand that the college is numerically dominated by Australians and sociopolitical concerns in Australia (particularly those that affect the incomes of surgeons) hold far more sway than any consideration of consequences for the New Zealand health system.

The college is unquestionably dominated by individuals who tend to come from big metropolitan hospitals.

In turn, the dominant opinions and attitudes are by-and-large big-city, super-specialised and Australian.

There is no question that specialisation has brought dramatic benefits, and some extraordinary capabilities, but should we be only producing surgeons of this ilk?

It seems to me in many instances that training is more about making new specialists "in my own image" than about the mixes of skills and breadth of knowledge that are most appropriate and needed in provincial centres or smaller cities in New Zealand (or those in Australia, for that matter).

In other words, training and specialty roles are determined from "top down" rather than "bottom up".

Communities and DHBs are expected to configure their services and expectations around the types of specialists who have been trained rather than vice versa.

In fact, most subspecialties have actively discouraged general surgeons from their work, saying the public deserved a "better standard".

No longer are we producing general surgeons with a wide range of skills capable of managing any common surgical emergency.

The irony is that the Christchurch neurosurgery proposal seeks to reverse this trend virtually overnight, purely on the basis of expediency.

The training arguments

House surgeons and registrars are all employed by DHBs, whereas training requirements and assessment and examinations are controlled by the specialist colleges or societies.

For surgical disciplines, this is almost always the Royal Australasian College of Surgeons based in Melbourne.

Its training rules and requirements are devised without any direct involvement of DHBs, medical councils or government agencies.

However, the Medical Council accepts the Australasian qualifications as appropriate for vocational registration as a surgical specialist (consultant) and usually international medical graduates have to prove their training is equivalent to that.

It is important to note that accreditation of hospitals for training is a powerful tool which has frequently been used to force DHBs to upgrade certain aspects of their service, improve working conditions for surgical staff, and reconfigure services and staffing arrangements.

If training accreditation is withheld or withdrawn, it becomes very difficult to attract and employ registrars but also consultants.

While the outcome of such pressure has often been good, there have been many examples of inappropriate use of this sort of muscle for ends which are more about the interests of the specialists than any actual benefit to training.

Because these are mostly Australasian organisations, the rules and their implementation are dominated by Australian viewpoints, as they (Australians) are always the majority voice.

As a consequence, the rules reflect the Australian scene and are not always in the best interest of New Zealand.

Specialty groups in many disciplines have set rules and conditions that many New Zealand hospitals, which could offer training, cannot meet.

They, therefore, have no training registrars in those disciplines.

This means that junior staff in those hospitals who want to train in those disciplines have to leave, usually to a big city, and the longer they are away the less likely they are to come back.

This is, in my view, the single most important reason for the widespread difficulties in staffing specialties with consultants in our provincial secondary hospitals.

It is why almost all of these hospitals rely on international medical graduates, despiteapparently adequate numbers who enter specialty training.

Critical in assessing suitability for registrar training is the number of surgical procedures.

This level is largely arbitrary, set by those on the college training committee and usually based on levels where they happen to work.

Raw numbers of cases are a very blunt instrument to use for adequacy of training experience, and are at best only a surrogate measure, but they take on huge importance for hospitals and units.

The "college rules" have acquired a level of authority and impregnability that exceed their actual proven validity.

What makes matters worse is that no public voice is ever considered, either from government agencies or DHBs, in assessing how reasonable training rules are, yet services can be dramatically affected by them and the public purse has to fund the consequences.

Nor do any of our public representatives have any say in what sort or how many specialists are trained, or whether they have appropriate skill mixes for the places where they are most needed.

If the current discussion around neurosurgery and the distribution of consultants is going to be significantly influenced because of training "rules" set by the college, then it is appropriate and reasonable to examine those rules and whether they are substantiated by solid evidence or merely the opinion of a specialty group with significant vested interests over and above the public good.

They cannot be allowed to remain unchallenged if blind compliance will determine the distribution and functioning of our most vital health services to the detriment of a substantial sector of our population.

Alternatively, we may have to sacrifice training opportunities if the rigidity of the rules cannot accommodate at least some training contribution from a smaller unit.

The time for sharing the responsibility but also the authority in making such rules is long overdue.

Too often the rules are used as a lever to try to shape the public services in the interest of the specialists.

Other pressure for centralisation

The focus of the powerful Resident Doctors' Association, the union for house surgeons and registrars, on limiting working hours and rigid rules of employment make it very difficult to provide extended periods of call-in services where there are fewer registrars (trainees) despite much lighter workloads.

The rules have some merit, but also some serious drawbacks because they make it very hard in small units for trainees to get sufficient exposure to a good number of emergency cases as they are more likely to be rostered off when the patients come in.

It also means the service has to be covered at the registrar level by other surgical registrars who are not neurosurgical trainees and who are less able to do procedures or less skilled at assisting the consultant neurosurgeon.

This undoubtedly increases the time and input of the consultant.

The net effect of the pressure by the RDA for rosters to conform to rules designed to prevent overwork in busy acute services in big hospitals, coupled with the case numbers required by the specialty training body, is to inexorably increase pressure to have bigger units with more registrars.

This can only occur with more centralisation, and consequently worse access for many people.

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