This is my 16th and final President’s report. I hope the readership will excuse an attempt to reflect on some of the key challenges that lie ahead for the College, its members and the women they serve. While much of the below has been discussed in previous reports, the challenges remain.
The fallacy of ‘no evidence’. It has been a source of great President frustration to repeatedly hear eminent Fellows indicate they follow a certain practice even though there is ‘no evidence’. What they actually mean is that there has not been a randomised controlled trial (RCT) to support that line of management; they certainly are not operating in an evidence vacuum. In fact, the vast majority of sound clinical management guide practice in those situations, assimilated by experienced clinicians able to apply that evidence. An RCT will often be the worst form of evidence to apply, given the impossibility of an RCT assessing low frequency (but clinically important) outcomes. If such an RCT is attempted, it is likely to be compromised by heterogeneity of populations, bias, the Hawthorn effect and practice based on evidence and the College has protocols that do not necessarily reflect clinical reality. We do practice based on evidence and the College has a key role in gathering experienced clinicians to synthesise all the available evidence and make recommendations for clinical practice. The growth in the women’s health statements and the recent expansion into patient information is a credit to all involved in the Practice and Advocacy department of the College.
Surgical procedure numbers must be linked to placement of trainees
It has been alarming to hear that many Fellows (who should know better) apparently believe that the number of accredited registrars at their hospital should equate to the number of registrars needed to fill the on-call roster. This fallacy has no credibility whatsoever. The Australian Medical Council (AMC) was very clear in its direction to the College at the time of the last accreditation visit: accredited training places must be linked to the available training. Analysis of trainee logbooks from 2015 indicates that, while many hospitals are providing excellent training, there are some health services that appear to prioritise clinical ‘service’ and have neglected surgical training. While no one disputes the increasing role of stimulation quality, qauntity is needed as well.
How can the ‘clinical service’ commitments be met in hospital where surgical training deficiencies mean that FRANZCOG trainee numbers need to be reduced?
The registrar in training is a relatively cheap way of providing a 24 hour roster, providing that the volume of trainee gynaecological surgery justifies those positions. Those hospitals that are not meeting this challenge have a number of strategies available to them, but inevitably at some cost. Trainee gynaecological surgical opportunities may be increased by: more gynaecological surgical lists, employing consultants who are pleased to use all public cases for registrar training or dispensing with an overseas Fellow who is taking precious procedural work away from local trainees.
Where an increase in gynaecological surgery training proves impossible, it may be necessary to make better use of the pre-vocational workforce or new Fellows. ‘Career medical officers’ (career hospital registrars) may have been at one time aspirational, but are rapidly becoming a workforce necessity.
The College will need to work with hospitals and other colleges to make this role a viable and prestigious career. Those that see ongoing dependence on International Medical Graduates (IMGs) to fill these positions are likely to be disappointed. With 3700 Australian medical graduates annually (compared to 1400 a decade ago), there is appropriately considerable pressure on government to reduce the intake of IMGs in favour of increasing employment opportunities for our own graduates.
Bullying and harassment
The College now has interim results of its bullying and harassment survey and I thank those that contributed. It is disappointing to learn that, as in other medical colleges, a substantial number of trainees have experienced bullying. Every Fellow and trainee must adopt a ‘zero-tolerance’ approach to bullying in the workplace. All should critically reflect on their own behaviours and those of their colleagues. Fellows are encouraged to use opportunities to upskill in this area, using available face-to-face and online resources.
Selection for FRANZCOG Training
At the time of writing, New Zealand selection is complete and Australia has just completed interviews of approximately 170 of the 226 applicants for 80 training positions in 2017. Unfortunately, many outstanding potential future specialists will miss out on selection, largely because there are simply too many good applicants.
‘Many outstanding potential future specialists will miss out on selection, largely because there are simply too many good applicants.’
All who have read these reports over the last four years will be aware of my obsession that workplace performance before application must be allowed to influence the selection process. Given that applicant-nominated referees are almost invariably very good, only institutional references are able to discriminate between applicants on the basis of workplace performance. Institutional references allow the selection process to incorporate important traits not otherwise captured in selection, including surgical aptitude and professional attributes such as diligence and reliability. It is plausible that the future workplace bully may already have demonstrated unwelcome professional attributes prior to selection. In future, a quantum reflecting both negative and positive prevocational behaviours must be included in the selection score.
It is perhaps fitting that my final comment should be on the great workforce challenge for all colleges: how to accomplish a better rural distribution of Fellows and Diplomates. There is no single solution. The Medical Deans of universities must do more to select those medical students most likely to practice in rural centres (for example, even greater reward for rural schooling). The College must continue to advantage those trainees more likely to practice rurally in its selection process. Rural training must be optimised at core and advanced levels. Finally, maximal support must be given to rural practitioners through initiatives like Rural LAP and funded CPD initiatives. My personal thanks goes to Dr Tony Geraghty who has worked tirelessly over the last four years in all these areas as Chair of the Provincial Fellows Committee.
The Ninth RANZCOG Council concludes in November and the Tenth Council begins anew. I would like to formally thank all College staff, an outstanding Board, the Council and its hard-working Committees. A special thanks to those that have provided me with magnificent support, with sage advice and wise counsel. I will resist naming them, but they know who they are!
My best wishes go to Prof Stephen Robson, the new Board and the new Council.