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Little In Health Systems Are What They First Appear To Be

One thing I quickly learnt after commencing work as the first Executive Director of the Association of Salaried Medical Specialists (ASMS) over three decades ago was that in the health sector little that happens is what it first appears. Invariably when the lid is lifted off an issue there is a layer of complexity (sometimes several more complexity layers beneath the first).

The coverage last week by Stuff and Radio New Zealand of the alleged incident at West Coast District Health Board gives the appearance that rural hospital doctors are less skilled than specialists such as surgeons and that the DHB was moving to replace specialists with these doctors. This misleading impression, which has been hurtful for these doctors, was inadvertently reinforced by some unfortunate ASMS comments in the Grey Star.

The trigger was an allegation that a rural hospital doctor had gone beyond their scope of practice (which is determined by the Medical Council). The facts of the allegation are unclear. They come from a recently appointed surgeon from northern California who has subsequently resigned. It is not clear whether there has been a formal complaint or incident report made that would require the DHB to investigate (its chief medical officer says that no rural hospital doctor is known to have worked outside their scope of practice).

But this blog is not about the allegation. It should be investigated if there is substance to it.

What is a specialist

At the heart of the issue is what is a specialist. In fact, the term ‘specialist’ has no statutory meaning in New Zealand. It is closer to being a term of convenience. The governing Health Practitioners Competence Assurance Act uses the terms vocational and general registration. Application then becomes the responsibility of the health practitioners regulatory authorities which, for the medical profession, is the Medical Council who, in turn, draw upon the expertise of the professional medical colleges.

The term specialist is still commonly used including in titles, job descriptions and salary scales. Although the words are not completely aligned, in essence a medical specialist is someone vocationally registered by the Medical Council. Further, specialists aren’t just hospital based vocationally registered doctors. They also include general practitioners.

The correct name of vocationally registered rural hospital doctors is rural hospital medicine specialists (RHMS). Rural hospital medicine, a new branch of medicine, is a division in the Royal New Zealand College of General Practitioners. The Medical Council defines RHMSs by the context of where they provide medical care – rural communities which includes professional and geographic isolation. Invariably it is practised at a distance from comprehensive medical and surgical services and investigations.

Rural hospital medicine is responsive rather than anticipatory and doesn’t continue for the same patient over time. It combines the generalism of general practice largely in a hospital setting with expanded practice scopes in obstetrics and anaesthesia. It is well suited for geographically isolated smaller hospitals serving small populations (West Coast’s population is around 30,000). Unlike rural general practice, rural hospital medicine is practised in secondary care settings (hospitals), including outpatient and inpatient services.

In 2019 there were 120 vocationally registered rural hospital medicine doctors. They are specialists in the same way as vocationally registered surgeons, physicians, pathologists and anaesthetists are specialists. RHMSs are less skilled than surgeons – in surgery – just as surgeons are less skilled as RHMSs in rural hospital medicine

Some vocational branches of medicine are more specialised (or sub-specialised) and some are more generalised. Neither is superior; both are important. I recall a now retired general surgeon saying that he preferred to work in a smaller rather than bigger hospital because of the greater range of cases that came his way.

Review

A second issue contributing to the controversy is a review currently being developed. This review is not in isolation and isn’t management driven. It is part of a continuing journey for about a decade on working through the type of specialist workforce is needed in a DHB the size of West Coast. It follows earlier reviews and experiences from ongoing continuous improvement. With the number of RHMSs now increased to around 12, the review is looking at widening their scope with a minor adaptation in obstetrics and anaesthesia along with the relationship with GPs.

This inevitably will raise boundary issues with other branches of medicine. That was the case when emergency medicine specialists arrived on the clinical scene some years ago. There were boundary issues with physicians treating patients in the wards. But this tension can be a good thing if accompanied with constructive engagement with other affected specialists. It is an essential part of the learning curve. The tension can lead to the identification of unintended consequences which can then be avoided.

The review of the role of RHMS at West Coast is significantly clinically led. Rather than call for a new review as ASMS arbitrarily has, it would be sensible to build on the foundations of the one currently underway and, if necessary through further clinical engagement, refine it to ensure that all other affected branches of medicine are fully engaged.

Adapting the role of RHMS in obstetrics and anaesthesia and further developing the relationship with GPs in positive but it will need to make good clinical sense to at least obstetricians, anaesthetists and GPs. This would be distributive clinical leadership in action.

One lesson to be learnt from this is that when critical comments are made about the skill level of a specific branch of medical doctors from a relatively young (in specialist years) by someone with no experience of this branch in her home country, previous work experience only in a much larger hospital serving a much larger population, and only around 10 weeks of working with RHMSs, it is important to drill down further before making judgment calls.

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