Improved Facilities For Physicians Sought

Press, Volume CVI, Issue 31224, 23 November 1966, Page 27

Improved Facilities For Physicians Sought

New Zealand has fallen behind in providing research facilities for young physicians. in providing a satisfactory number of adequately paid posts, and our hospital salaries are falling still further behind those of other countries. The country is falling down the list in both infant mortality and life expectancy, sn d crude indices though these may be, they can only indicate our complacency with our present service.

As a large percentage of patients in general hospitals in New Zealand are under the care of physicians, the duties and place in the hospital context needs to be more widely understood.

The Dominion Committee of the Royal Australasian College of Physicians has defined a physician as a fellow or member of the college, with entry to membership by means of a searching postgraduate examination in internal medicine.

Three years must elapse since graduation, and courses of training in hospitals must be approved by the council of the college before admission to the examination. There are written papers on the principles and practice of medicine, including pathology, diagnosis and therapeutics followed by extensive clinical examinations and oral examinations before the censors. The usual candidate after four years of postgraduate work has about a one in three chance of passing this searching examination at his first attempt. Research and Training Once accepted as a member, the young physician is entitled to use the letters M.R.A.C.P. behind his name. More importantly, the success of his basic training behind him, he can seriously enter into specialty training. For the next year or two research and advanced training are undertaken in New Zealand or Australia before two to four years of specialty training in the United Kingdom, or the United States.

These years are spent on one of the specialties of internal medicine such as study of heart diseases or cardiology, the study of diseases of stomach and intestines, also called gastroenterology, and the study of diseases in children known as paediatrics.

Other specialties recognised by physicians are neurology, immunology, endocrinology and metabolism, respiratory diseases, renal diseases, geriatrics, rheumatology and physical medicine amongst others. Doctors practising as dermatologists or psychiatrists may also have had three or four years’ general medical training as a physician. During his eight years or so of post-graduate training which in addition to his six years of undergraduate training add up to 14 years—and is so much longer than in many other professions—the aspiring young physician must keep and feed himself and’ his family. These long years as a post-graduate student are a strong deterrent to recruitment.

Post-graduate bursary schemes by the Health Department go some way to helping, but are unnecessarily restrictive and unimaginative. A year’s service abroad in South-east Asia, or on exchange in Sydney during the four years of qualifying ser-

vice, will lead to forfeiture of the bursary. From the third postgraduate year onwards the intending physician is known as a medical registrar and later as a senior registrar in medicine, but the latter normally holds a higher qualification in medicine. He has probably passed the M.R.A.C.P. examination and is already a member of the Royal Australasian College of Physicans. Although appointment as a medical registrar indicates a training post in medicine, such is the grave shortage of first and second-year qualified men that by English and American teaching hospital standards, inadequate time, money and staff are available for training registrars. Nor are future specialists in internal medicine or physicians from underdeveloped countries being trained in New Zealand as physicians. Although teaching rounds, lectures and clinical meetings are increasingly held in major hospital centres, library facilities are still inadequate in all towns except Auckland and ‘ Dunedin, and offices for study ■and reading are too rarely i provided. A drastic increase in facilities, money and staff is necess..ry to assist the already developing organisation ■ for ! training physicians. In addiction freer exchange between centres, liberal leave for training courses and enough time for investigational projects are all urgently needed. Up to date, the training of future physicians has been haphazard, but the future needs are now well defined and need urgent attention if our hospital standards are not to fall in the future. Research It is during the second period of four years of the | total of about eight spent in ; post-graduate training that the | young physician undertakes s'me original research work: initially in conjunction with more senior physicians as senior non-medical scientists, but subsequent!}' perhaps with increasing experience in the laboratory, he undertakes original work in his own right, at the same time advancing his own specialty within the framework of medicine.

The opportunity to provide training and facilities for original research in New Zealand hospitals has been severely limited, with major opportunities only at the Otago University Medical School.

It is however increasingly recognised that the failure to provide adequate research laboratories and equipment in New Zealand hospitals has led to inadequate provision for training. This applies not only to our own post-graduate students in medicine, but also to overseas students from undeveloped countries. Hospital research laboratories are essential for adequate patient care and without them both diagnosis and the control of treatment will suffer.

Whereas before the Second World War, physicians were appointed to look after patients in the medical wards of the major hospitals on a part-time, voluntary basis. Increasing specialisation and longer training now demands that young physicians are usually appointed on a full-time basis. Salaries

The emerging pattern in New Zealand is for the fully trained specialist physician whether cardiologist, rheumatologist or gastroenterologist, to return to this country to a research or development post. After two or three years he is given beds in the ward for admission of patients under

This article was prepared by the Whole-Time Senior Medical Officers’ Association of New Zealand, and is a further one in a series from the association on the hospital specialist service in this country. Further articles on pathology, psychiatry and surgery will follow. his care, and is probably appointed on a half-time basis by the hospital board with half the salary of the equivalent whole-time salary. After perhaps 10 years of post-graduate training and age! about 35 years, our young specialist receives the sum of about £l5OO a year. The rest of his income can be made up from research grants and a developing private practice.

But it is clearly of the greatest importance for the country that these young men have the time and facilities to continue developing their specialties. This is particularly important when these may be new subjects such as nuclear medicine, clinical haematology or immunology. With the long, hard years of poorly paid training posts, it is little wonder that there is a world shortage of really well-trained specialist physicians. We must therefore be training our own young men.

Low salaries prevail in New Zealand, with young physicians of 35 and 10 years’ postgraduate training initially receiving as income about half the amount they could have earned if they had gone into general practice eight years before.

There is an officially documented shortage of physicians in England which cannot be met in spite of the recent increase in salaries to about twice the starting salary for New Zealand posts. In the United States there is still a 5 per cent deficit in clinical posts in internal medicine on medical school faculties due to the increasing number of vacancies produced by medical school expansion.

Many young New Zealand physicians fill these vacancies in England and America with distinction and present indications are that more will do so in the future unless our staff shortages in New Zealand can be remedied by reasonable conditions. Solution Suggested A solution to our New Zealand problem should include: (1) The creation of a number of new posts in each of the major hospitals for young physicians, with adequate facilities for research. (2) A major and significant increase in salaries to make them roughly comparable with Australia, England, Canada and the U.S.A. (3) A two or three-fold increase in opportunities for post-graduate leave and study leave. (4) The creation of a number of clinical supervisors for registrars or young physicians in training with special provision of tutors for Colombo Plan graduates.

In the majority of major hospital centres in the abovementioned countries, the sick man can be referred by his own family doctor to a variety of hospital centres within a reasonable distance, whereas in New Zealand there is little opportunity for an alternative opinion from another specialist physician. A heavy responsibility therefore rests on the Health Department to provide really first-class medical services. No medical service can provide adequate care without a strong cadre of well-trained young physicians, as these

men provide essential emergency care as well as the spearhead in clinical research—the application of new scientific discovery for the benefit of the patient.

They also provide a major contribution to the teaching of undergraduates, postgraduates, post-graduate students, and in the continuing education of the general practitioners.

Last, they supply a consultative and often diagnostic service to other specialist colleagues, whether they be surgeons, gynaecologists or orthopaedic specialists. Grave Decisions

Approximately 10 years after graduation our specialist in some branch of internal medicine is appointed to the hospital staff as a consultant.

The consultant physician makes decisions on serious problems—unlike administration, the problems cannot be passed on to a higher authority. The hospital system is a widely based pyramid without a top, but non-medical administrators and politicians find the concept of total responsibility hard to grasp. But it is to meet this demanding responsibility that eight years of post-graduate training are provided and should be rewarded if we are to staff our hospitals. Members of the College of Physicians are elected as fellows on the basis of professional eminence, distinction in literature or science, academic honours and public appointments. But in major hospital centres, election to the fellowship usually follows after eight to 10 years of membership. Key Role

Physicians have a key role in patient care, teaching and research, but how many citizens know of the long years of training of these key specialists. We cannot afford not to have highly trained physicians “monitoring” the middle-aged man with a heart attack, interpreting the electro-encephalograph recordings of electrical impulses from the brain, treating the child with life-threatening pneumonia or the teenager with a serious diabetic coma. Our standards cannot be adequate unless we encourage more young physicians to return to New Zealand, even if as taxpayers this may cost us more money. Everybody today, no matter how wealthy, is dependant to some extent for his future health on adequate hospital staff, for if physicians are not attracted initially to hospital posts they will not return to that community. Hospital medical salaries cost us less than onetwentieth of our defence bill, about one-thirtieth of our educational bill, or about onesixtieth of our power development bill. Yet our economy with its chronic manpower shortage depends upon a state of maximum health. Even if our economy did not depend upon an adequate supply of young physicians for patient service, research, teaching, our humanity would.