ASMS: Discussion Document Non-Clinical Activities
DISCUSSION PAPER NO.4
70/30 SPLIT: NON-CLINICAL ACTIVITIES – A VITAL PART OF ANY JOB SIZE
THE STANDARDS OF THE DOCTOR
In the last forty years the law and public alike have developed very high expectations of the medical profession and medical science. This growth in expectations has coincided with spectacular and breathtaking advances in medical science which in turn have given us new treatments, procedures and drugs. It is ironic that while good health is still largely determined by lifestyle, culture and choice (as it has been for centuries) many now believe that good health, including diagnosis, treatment and cure may be purchased from a health supermarket staffed by general practitioners and specialists!
In such a market place, the patient will become a client and consumer and the doctor nothing more than a registered purveyor of goods and services and perhaps a little snake oil!
In this market place and environment of high expectations, if the product doesn’t work, the consumer takes it back; if the service isn’t good, the customer complains.
But notwithstanding the foolish analysis and futile efforts of this country’s health reformers, the practice of medicine is not a simple commercial transaction undertaken in a market place. It is a stochastic art embraced by highly trained and caring professionals, who are all acutely aware of the very high expectations demanded of them by both the public and the law.
With few exceptions, the expectations doctors have of themselves in respect of their practice, exceed those of their patients. A doctor’s personal expectations will largely be derived from such arcane sources as the ancient Hippocratic Oath and the professional and ethical standards set by their peers, through the Royal Colleges and professional associations. By and large, if the practice of an individual doctor has been found wanting it will have been judged against the standards set by their colleagues and the wider profession. The law, the Medical Council and the Health & Disability Commissioner may supply the means of assessing a doctor’s practice or behaviour but for the most part they will have simply applied the standards derived from the Hippocratic Oath, the Royal Colleges and the profession at large.
But if these are the duties and expectations of doctor, are there similar duties and expectations for a hospital as an employer of doctors? The answer must surely be “yes”, and of course it is.
DUTIES OF THE HOSPITAL
As health service providers, hospitals have a legal duty to provide the environment that ensures their patients receive appropriate medical treatment in accordance with best practice and proper professional standards. But hospitals have another duty as employers, to provide proper facilities and other resources reasonably necessary to enable their medical and nursing employees to provide patients with appropriate treatment in accordance with best practice and accepted professional standards.
There is no doubt, from a legal point of view, that an employer’s obligation to provide adequate facilities and other resources includes the allocation of sufficient or reasonable time within an employee’s contracted hours to enable the employee to discharge all their obligations. In the case of a doctor’s employer, the obligation requires them to allow reasonable time in the course of each working day or each working week for both clinical and non-clinical duties.
THE CLINICAL/NON-CLINICAL SPLIT
The Royal Colleges and the wider medical profession have, in one way or another, long held that the proper ratio of clinical to non-clinical work for a doctor is 70% clinical to 30% non-clinical. There is room at the margins for debating what is clinical and non-clinical work but the general consensus is clear.
Clinical work is essentially patient contact: theatre lists, out patient clinics and ward time; it includes all correspondence (including telephone calls) relating to the referral and reporting back of patients seen and multi-disciplinary or team meetings associated with those patients.
Non-Clinical work is essentially work not associated with a specific patient. It may include: administration, departmental meetings, formal teaching, audit and quality assurance activities, professional development including journal reading and time to think! It should not be confused with and would not include “management” time spent by a doctor in a purely managerial of clinical leader role.
There is little doubt that if the ratio of non-clinical to clinical time is too low, it is only a matter of time before patients may be exposed to unacceptable and potentially dangerous risks. Conversely, if the clinical component of a doctor’s work load is too high or out of balance there is a heightened risk of damage to the doctor’s own physical or psychological welfare.
Each day, throughout New Zealand our members are called upon to see more and more patients suffering from more and more complex ailments. Such patients require correspondingly more complex management. The rapidly growing shortage of junior staff creates additional problems, for which there is no relief in sight. The problem is compounded by the disturbing shortage of specialists in many areas: medicine, anaesthetics, pathology, radiology, obstetrics and there is always a shortage or psychiatrists. Our members constantly have to do more, with less. All too often the clinical workload was too high to start with. But increasingly the little time allocated for non-clinical duties is squeezed in at the end of the day or “after hours”; in some cases non-clinical activities are simply curtailed.
The Association’s position is unequivocal. Fortified by the guidelines and standards of the Medical Colleges, the wider profession and the Medical Council the ASMS is now insisting that hospitals must honour their legal obligations to patients and doctors alike by ensuring a proper 70:30 ratio for clinical and non-clinical time in our members’ job size. Rostered after hours or on-call work is not included in this formula.
This is not an exercise aimed at securing more pay for our members. It is an exercise aimed at assisting members ensure their hospital employers provide the resources and environment necessary to enable them to practice medicine in accordance with best practice and the standards expected by the wider medical profession, the public and the law.
OUR ADVICE IS SIMPLE
If the time allowed for your non-clinical duties is less than 30% of your total paid hours, less the time allocated for rostered after hours call, your job size is too small and should be increased or your clinical time should be reduced accordingly.
The Association acknowledges that this is a very difficult issue to confront and resolve at a time of increasing patient demand and growing shortages of both junior and senior medical staff. However, an overworked doctor cannot do everything and should not try.
However you can do one thing. With the assistance of your colleagues in your department and the advice and advocacy of the ASMS you can ensure your employer gives you sufficient time to enable you to practice in accordance with best practice and proper professional standards.
As a doctor you may be ultimately responsible for your practice, but your employer is primarily responsible for the environment in which you practice and supplying the resources reasonably necessary for you to do so.