26
Whose Job Is It Anyway?
Andrew Buettner
Background
This account focuses on a time of conflict and change within my workplace environ- ment over the course of a year. My workplace is a clinical department within a tertiary referral hospital. The change occurred with the movement of the department away from one largely run by long-standing visiting medical officers (VMOs) to a modern one with a completely new leadership structure. It is necessary to describe the department structure before the details of the conflict can be discussed.
The department’s business is the provision of public medical services to patients as well as the training of residents. Traditionally one or two full-time staff (director and staff specialists) ran departments. The bulk of the work was performed by VMOs. A junior consultant usually held a staff position for a few years prior to commencing his or her private practice. There was some stigma associated with retaining such a posi- tion beyond a few years, as it was often considered that the individual was unable to establish his or her own practice. Clinicians who spent the majority of their time in private practice and often regarded their public appointments as something akin to charity, held VMO positions. Indeed, in the past they were not even paid but were called
“honoraries.”
Over the past 10 to 15 years there has been a “sea change” in the structure of many departments. Fewer newly qualified consultants have sought to go out into private prac- tice and have instead opted to remain in public or staff appointments. This has hap- pened for a combination of reasons—improved lifestyle, academic interest, improved remuneration, and the decrease in private health insurance associated with the intro- duction of Medicare. The pendulum has now swung back. Most newly qualified con- sultants prefer to remain within staff positions, and there is a slight stigma associated with those who go out into private practice straightaway.
Within my own workplace, staff and VMO positions have not been as sought after as positions at other tertiary referral academic departments. This may be because the hospital does not offer all specialties. It is also associated with a fair number of night calls (frequent callouts at 2 a.m.). As a consequence, the department was largely run with a small number of full-time staff and a larger number of VMOs.
The department has had a checkered history in the recent past. It was one of the first academic departments within its field in the country. Over decades it established an enviable reputation and was responsible for training generations of doctors. After the retirement of a long-serving department head, the next three directors were all long- standing members of the department who had trained under this man. They were thus
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all similarly well known within the community. Many of the VMOs had also had long links with the hospital. A number of them had held staff positions within the depart- ment before setting up their own private practices.
Unfortunately, prior to the accession of the current director the department was sliding into oblivion. The previous director had been unable to recruit and retain staff, with posts often being filled by short-term locums, some of whom were not well respected. Long-standing and aging VMOs occupied many of the visiting posts. This led to some abuses such as inadequate supervision of junior staff and poor attendance for public clinics if more lucrative private work was available. Matters came to a head when senior hospital management forced the departure of the director.
A new, younger doctor was appointed in his place, and she set about rebuilding the department. Her first priority was attracting new staff. I was recruited to a senior posi- tion as a newly qualified consultant. I had trained within a very well-managed depart- ment and had been offered a consultant position within it. The offer of such a senior position was too good to refuse, however, so I took it.
Five months after I began, the director became ill and was off work for 4 months during which time I was acting director. Throughout this time I became enveloped in a number of conflicts, all occurring between two separate groups—a number of older VMOs and some staff specialists.
Conflict One
The conflict with VMOs involved rostering arrangements and attendance. As I have already mentioned, some VMOs had worked within the department for many years. As such they were used to things being done in a certain way. A small group of these VMOs often arrived late and performed little supervision or teaching of residents. Assumptions that I made about this group were that they regarded their public practice to be of peripheral importance to them. I found myself in the situation of having to speak to individuals about showing up on time and the importance of properly supervising residents. I found these situations very uncomfortable, as I was dealing with very senior and experienced clinicians who in some cases had practiced medicine longer than I had been alive. Without exception, the VMOs I had talks with all chose to resign their public appointments. In retrospect I feel that I could have handled the situation better, though I am sure that the ultimate outcome would have been the same.
The needs of the department at that time were to have reliable consultant staff. For some of the VMOs their time within the department was a very small fraction of their working week. They were juggling private commitments and other public appointments and often found it difficult to arrive at work on time. As long-standing staff members, they probably felt that they were due some slack in view of their past service. Undoubt- edly there would have been some resentment toward somebody who had been on the job 5 minutes telling them what to do. More recognition of their needs on my part could have led to their departing on better terms. The regret also is that the memories of these long-standing members form part of the historical record of the department, a link to the past that is now broken.
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Conflict Two
The second major area of conflict was with two staff specialists. I think of this group as the “legacy system.” They worked half-time and had either been hired by the pre- vious director or had commenced work early during the tenure of the current director when the staff shortage was acute. Whereas VMOs are responsible only for clinical duties, staff specialists are responsible for some nonclinical duties as well, such as administration, rosters, resident education, etc. These “staffies” form the core of a department. At the time of the director’s illness our staff shortages became acute, and a maximum effort was needed from all staff members. I found early on that I could not rely on these legacy staffies to do anything productive. One of these individuals was commencing a private practice outside his hours within the department and was having some of the problems of the VMOs described earlier. He had other administrative responsibilities that he never carried out despite repeated requests. My relationship with him deteriorated to the point that communication broke down. Meetings would be called for which he never showed up. He did petty things to flout my authority, such as making a display of using expensive equipment or drugs that I had previously restricted for budgetary reasons. Fortunately, the situation was resolved when he wished to change the days that he was working. I was then able to say that there was no position available for him on the days he wished to work, and he elected to resign.
The other staff specialist, who knew every aspect of his contract chapter and verse, would only work strictly within those stipulations. As a clinician he was good. He was also reliable but very inflexible. Conflict arose when I made changes to the medical malpractice insurance arrangements. As an employee of the hospital, the hospital pro- vides this insurance.This covers only our public practice, and we still need to have insur- ance for private practice. It is, however, at a much-reduced rate compared to that for someone who works solely in private. I learned that the department was paying medical malpractice insurance for its members at the much higher private practitioner level rather than at the salaried medical officer level. This benefited only those staff members who worked in private practice and to me seemed to represent a case of the public subsidizing the private system.
After a consultation with the director this practice was changed so that medical malpractice insurance was paid at a level commensurate with that for a salaried medical officer. This had implications mostly for the physician who had a private practice outside his salaried position. He maintained that his contract stipulated that he should be at the higher rate. I had obtained prior legal advice, which said that this was not the case. This staff member ultimately felt that this was the straw that broke the camel’s back and resigned.
I felt that his position was indefensible, but that the situation could have been handled better if I had made more of an effort to explain the changes before putting them in place. Ultimately though, I am sure that the same result would have happened.
Reflection
This time of conflict was difficult. All the personalities, including my own, were some- what aggressive. For my part I ascribed motives to individuals, such as greed, that the individuals concerned obviously would not have thought of in that way.
Changes to a more modern departmental structure were needed. Ultimately, staff that were unable to adapt needed to go. A more diplomatic approach on my part may 240 Section VI. Organizational and Interpersonal Conflict
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have led to their departing on better terms or over a longer time period. Of course, it also could have been perceived as a weakness and led to a continuing malaise. Some of the problems on my part arose from not managing the change well. Some of the staff obviously did not feel involved in the changes and indeed probably felt threat- ened by them. It was difficult in that there was not a respected leader in charge of the process. Being a newly qualified consultant created a bit of a credibility gap. More effort could have been made to guide staff into what were desirable behaviors. Finally, greater acknowledgment could have been made of the staff that did participate and support the department through the changes.
The return of my director from illness was welcomed. She has a smoother style and better people skills. It is still a standing joke within the department that when she is ill or takes a holiday, leaving me in charge, somebody will get the sack.
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