Port Moresby in Papua New Guinea has a population of about half a million people. Urban migration – especially by people from warring tribes in other provinces of the country, those seeking better economic opportunities, and increasing births – has seen a sharp rise in Port Moresby’s population in recent years, as well as health problems and strain on the health workforce and resources. A quarter of this population (about 125,000) is female over 15 years of age, potentially needing obstetric or gynaecological care at some point in their life.
Port Moresby General Hospital is the only public hospital in the capital of Papua New Guinea, and serves as both the University’s teaching hospital and the national referral hospital for the country.
The O&G division is run by six–eight consultants, 14–16 training registrars each year, and six–10 residents on four-monthly rotations. While the number of residents and registrars has increased slightly from what it was ten years ago, the number of births has also increased beyond the capacity of the hospital. To give some perspective, in 2009, just over 11,000 babies were delivered, rising to reach a peak of 15,000 in 2014. The following three years seemed to see a decline in births to 13,000–14,000, and while this was happily attributed to the introduction of the Jadelle implant, our hopes at seeing a further decline in births over the last two years seem to be fading. In 2019, the hospital delivered 14,500 babies.
The number of deliveries alone shows the volume of patients passing through the O&G unit. In addition to labour and delivery care, the rest of the unit, made up of some 200 beds, includes a 96-bed postnatal ward and an antenatal and gynaecology ward.
Much of the leg work and day-to-day management decisions of a patient is really dependent on the efficiency of residents who are running between and/or ringing labs, inserting cannulae and catheters, urging relatives to donate blood, preparing for presentations, and so many other things in addition to formally admitting and discharging inpatients.
Registrars do much of the clinical work assisting and supervising residents, contributing to running a service and simultaneously training as a specialist (including reading widely, preparing for seminars, and meeting postgraduate requirements). While running a service is important, it can be quite overwhelming trying to find a balance between service and training. Cultural ties are strong and the added social pressures from family, both immediate and extended, can take a toll on any clinician.
Being on-call requires both physical and mental preparation. As a resident, we did a 32-hour shift every four days – working your usual eight-hour day duties, taking the call from 4pm to 8am the next day, and continuing your normal (eight-hour day) duties the next day. One was lucky if you could have a power nap for half an hour, let alone read your own handwriting the next day. Thank goodness for the resilience of youth and being single, my peers and I survived the four months of a hectic O&G rotation at the end of which, I had made up my mind O&G was not for me.
Ten years later, as a registrar and married with young children, on-call hours had not changed significantly, but my life had. Aside from taking calls every four to six days, progressing to two registrars on-call towards the end of my training, the 32-hours had not changed. Recovery from an on-call shift took two days. Juggling between work, training and home would not have been possible without the support of family and the collegiality of the O&G family. One day every weekend was spent with my family, usually at church in the mornings, and then a lazy afternoon at home or the beach before returning to church to close the day. I found the one day each week attending church – meeting non-clinician friends who shared similar beliefs, being involved with music and children’s activities completely different from the work environment – contributed immensely to relieving the stress and pressures of work and study, and helped to reset the faculties for the coming week.
Ten years ago, I completed my O&G training and transited from senior registrar to junior consultant (glad that I no longer had to stay full time in the hospital when on-call) and visions of all the extracurricular things I could do in my ‘free’ time flashed across my mind. My visions of immense joy in this new-found freedom from 32-hour calls lasted only about a year. I soon discovered that being a consultant involved a whole new level of responsibilities apart from the routine clinical care of patients. It was a time to improve my clinical and surgical skills, but it also involved more administrative duties, training responsibilities, O&G Society duties, and responsibilities at the national level – most of it done in good faith. Continuing a weekly rest with my family, being involved with my children’s extracurricular activities (including camping and hiking) all helped keep a mental focus on things. The progression of years has brought with it more responsibilities; so much so that there are times I feel like I have three or four full time jobs. It’s during these times that too many expectations result in more mental anguish and stress and the impression of inefficiency. This is when delegation is important, and when delegation is not possible (as is often the case), it is also alright to refuse to accept extra responsibilities. I have recently convinced myself that unless it is absolutely necessary, it is also alright to not come into the hospital when not on-call.
Aside from clinicians taking care of themselves, mentally and physically, I believe it is also important that a suitable work environment is created in order for them to do so. Over recent years, the O&G unit has tried various ways of reducing or breaking up the 32-hour call period in the hope of allowing registrars more rest and better and faster recovery following on-call duties, so that they have sufficient time for their training needs. This is still a work in progress. An understanding between colleagues who are able to support each other when a need arises is crucial. And finally, the support of family cannot be understated.
Thinking within the box, that is, continuing as we have always done, will keep us where we have always been. Thinking outside the box, while good for innovation, usually results in unrealistic goals. Thinking about what we can do with the box, that is, what we can do with what we have, is more realistic. I have hope and believe that small, simple changes in the way we do things can have a big impact on practice – including improving our working hours.