In an unprecedented peek behind the closed doors of NZ's hospital wards, junior doctor Rosemary Wyber reveals the delays, duplication and waste that she says are compromising the provision of good health care

As a junior doctor working a 7am to 10.30pm "long day" on a surgical ward a few months ago, I was shadowed by a fourth-year medical student. In her first clinical year, my student's days attached to house officers provided a relatively novel, unstructured, clinical experience; a chance to see what junior doctors do, as much as learning what patients need.

While I was collating admission notes, recharting medication lists and endlessly answering my pager, she said, with some frustration, that I didn't seem to be doing much real medicine. She said I seemed more like a secretary.

Having spent the past 14 hours together trying to discharge paperwork, provide scripts to patients, order radiology and plan the weekend's blood tests, I agreed that I'd not really shown her much "real medicine". Certainly, we'd done very few things that could have been signed off in her logbook of clinical skills.

Medical schools dispatch students to the wards to develop the competencies to become safe clinicians. So far, I'd shown my student the value of a well-organised jobs list, high-speed typing and some shortcuts for Wellington Hospital's clunky electronic medical records system, all of which would make her a better administrator, but not necessarily a better doctor.


Reflecting on how little real medicine I could show students, it became apparent that my house officer job in a busy tertiary hospital is, much of the time, an exercise in advanced logistics.

Working here intermittently over the past few years - between overseas practice and study - I've been a junior doctor longer than most. House officers are usually doctors in the first or second year out of medical school and rotate quarterly between different specialties and teams.

Then, with a sigh of relief, most of us choose a specialty, become a registrar, are accepted to a training programme and eventually become a fully qualified consultant.

In popular medical wisdom, the dark years as a house officer are best stoically endured, speedily exited and rapidly forgotten.

However, my less-than-linear career path has given me the unusual opportunity to experience house-officer jobs more than once. Each time I come home to New Zealand to work in a junior doctor role, I'm struck by the insidious creep of inefficiency that we absorb.

An accumulation of small and medium-sized tasks that need to be completed by "A Doctor" get shunted down the medical hierarchy until they land on the hastily scribbled jobs list of a house officer.

Some things are simple anachronisms. Hand transcribing lists of patients for planned operations each day and personally handing to the theatre co-ordinator may have been sensible when junior doctors were meaningfully involved in managing elective theatre lists. Now, waiting lists are the business of hospital managers and senior doctors.

However, I still find myself transcribing operations from an Excel spreadsheet to a hard-copy form, adding patient labels, signing the form, adding my pager number, taking the lift down four storeys and handing them to a nurse who's already made plans for the day based on the original electronic theatre list I copied the information off upstairs.

Writing out by hand these lists of patients having operations was once a check in the system; my signature is still meant to represent my authorisation that I've listed the correct patients, the correct operations and the correct order.

In truth, I've had little to do with these outpatients - I rarely have the opportunity to attend clinic or the operating theatre - so these patients are just lists of names and my hurried transcriptions are more likely to create errors than prevent them.

However, "A Doctor" must sign off on the list and, as the lowliest of the busy surgical team, it remains my responsibility, despite the massive systems changes rendering this specific task redundant.

Practising safely and getting through each day without upsetting senior doctors, nurses, administrative staff or patients is genuinely difficult. It is little wonder that house officers have few opportunities to reflect on the swathes of repetitious or inefficient tasks that consume so much of our day. Identifying and addressing issues of low system, safety or education value rarely registers on house surgeon radars.

With our collective inattention, these kinds of low-value tasks seem to be multiplying.

In most hospitals, patients having planned operations are seen by an anaesthetist in advance. Anaesthetic pre-assessment improves patient safety, efficiency and outcomes. Systems differ throughout the country but, in some hospitals, house officers are expected to review all these patients as a final check.

With each patient having already been identified as a surgical candidate (by the surgeon), fit for an anaesthetic (by the anaesthetist) and had the routine pre-operative investigations ordered (by the clinic nurses), house-surgeon involvement adds little value to the preoperative assessment.

Undoubtedly, some patients benefit from additional medical work before operations, including those with complicated conditions, many medications, medications that need to be stopped, started or changed before surgery, or those with particular questions.

Yet, when fit, young patients are having a lump excised, a hernia repaired or a gallbladder removed, there is probably little indication for a second, repetitive, clinical history and examination.

Triaging patients who need to see house officers from those who would be just as safe without seeing extra doctors has worked well overseas and in some New Zealand hospitals.

Yet it is all too easy for hospitals and senior doctors to establish a pre-operative assessment system where the house officer is "A Doctor" catch-all for potential problems. In practice, this means patients can wait hours for a desultory history and examination by a harried house officer who knows he or she is adding little benefit for the patient.

Junior doctors have little voice in identifying systems' inefficiencies and contributing to institutional improvement. It takes months to settle into clinical practice and find time for lunch, let alone a chance to reflect on our daily tasks. We rotate every 13 weeks, making it difficult to form meaningful feedback relationships with departments.

We are evaluated for our competence and depend on senior doctors for references and support, undoubtedly stifling our capacity for feedback. Similarly constraining is a fear that our comments will be misconstrued as shirking work or overlooking the educational value of our allocated tasks.

We are rarely encouraged to think beyond the status quo; we are never quizzed on a ward round about management science, so we are incentivised to use our spare time to read about anatomy instead.

Clinical knowledge is important but surgical teams tend to value house surgeons with nice handwriting, organised task lists, attention to detail and a pleasant phone manner. It is administrative skills, not clinical skills, that are best suited to the expanding litany of our paperwork: clinical notes, recording blood results, work certificates, ACC forms, letters to airlines, surgical audits and discharge summaries.

These time-consuming tasks begin to chafe without the opportunity to do them better, streamline the process or add value.

Accepting that management and administration are significant components of modern medicine - and that junior doctors are at the frontline of paperwork - we should be training, engaging and encouraging young clinicians to be part of improving the processes.

Much of our work is still conducted with faxes and pagers. The lynchpin of medical and surgical teams is a ritualised morning ward round. It's when decisions are made, plans are discussed and tasks are allocated. It's a busy time for junior doctors, responsible for finding clinical notes, documenting discussions, charting medication changes, communicating new plans with nursing staff and developing a list of bloods, scans and investigations to follow up.

Simultaneously, overnight issues become apparent to a new morning shift of nurses keen to make their own plans for the day.

A cacophony of paging ensues, necessitating the house surgeon stepping out of discussions, finding a spare phone, calling the appropriate number, establishing which patient is being discussed, where they are, what needs to be done and by when.

Often there's a delay, by which time the person who paged has been called away from the phone. Or an incoming call has been received and the line is engaged. Or the simple AA battery in the pager has run flat and the message was never received.

Our biggest hospitals are mired in infinitely complex phone tag, creating chronic, low-grade infuriation for clinical staff. The frustrations are most acute for house surgeons called away from a ward round.

When senior doctors are called away from rounds, the process necessarily pauses; when junior staff are called away by pagers sounding, the juggernaut continues and valuable information is lost.

Removed from clinical administrative responsibilities, our senior colleagues can overlook how inefficient these outdated tools make us. I believe it is no longer sufficient for doctors to be advocates for individual patients; we must also be advocates for hospitals and health systems. As junior staff, we see and experience the most egregious inefficiencies. Failing to act on our collective knowledge of the system prevents hospitals achieving their full potential.

My growing disquiet with each of my house-officer rotations makes it difficult to know how to respond to the frustration of my fourth-year medical student following me this day.

I want to be able to reassure her that the non-clinical tasks I do are all somehow meaningful; for the patient, for my professional education, or for the functioning of the hospital.

Yet it would be more truthful to admit that some of what I do is necessary and valuable but much of my day is a collection of laborious administrative tasks of unclear significance which have, over time, become house surgeon responsibilities. These tasks have sclerosed into a rigid set of responsibilities.

As young doctors, we are too busy faxing, paging, pre-assessing and charting to attend teaching, theatre or clinic - let alone advocate for a better system.

Lunches with my junior doctor colleagues reveals increasing frustration with "management", scant willingness or capacity to advocate for improvement, and a steely determination to endure these early years and move to slightly greener hierarchical pastures.

I want to be able to reassure my medical student that when she tremulously signs her first prescription, each task of her house officer role will be valuable, or at the very least explicable.

I want her to be appropriately nervous about being a doctor, but excited about the ideas and innovations she can bring to her new role.

I don't want her to feel employed as a Friday-night hospital secretarial support.

DHB: We're listening

• Dr Rosemary Wyber did her medical degree at Otago. A Fulbright Fellow, she holds a Masters degree in public health from Harvard. She has practised as a junior doctor in the Pacific and New Zealand, and last week finished at Wellington Hospital to work in Australia on global rheumatic heart disease control.

• Capital & Coast District Health Board chief medical officer Dr Geoffrey Robinson says the Medical Council reviewed the quarterly rotation of resident doctors, and feedback indicated it should continue.

"Because house officers are at an early stage of their career, they need to experience a number of different rotations to develop skills and to determine their future career choices."

Robinson says the DHB has made considerable efforts to listen to the concerns of resident medical officers (RMOs), including holding patient safety forums and meetings with hospital management. A staff and patient safety survey is scheduled for August which will measure how well managers and doctors engage with each other.

"Clinical administrative tasks, such as attending to charts and completing discharges, do not end when an RMO finishes their training. Senior medical staff and GPs perform many administrative duties," Robinson says.

"The board believes it goes to considerable lengths to ensure RMOs are made to feel welcome and that their opinions are valued during their time here."