President of the Association of Government Medical Consultants (AGMC), Dr Konrad Lawson has presented a broader analysis of challenges within the public health system following a number of issues raised by junior doctors last week in the Jamaica Observer.

Among the problems highlighted by junior doctors were long, tiresome hours without adequate pay, abuse, and the absence of supervision by senior doctors. However, in an interview with the Jamaica Observer Press Club last Wednesday, Dr Lawson, without debunking the complaints of long hours, denied the charge that consultants have been neglecting their duties.

“Nothing could be further from the truth. The doctors are working long hours, but the consultants are doing what they are supposed to do although they are not always there. The doctors who are always there are the interns who are pre-registered [doctors] and resident doctors who have to be resident at the hospital [so that] if anything arises, they must be within walking distance. As you go further up the line the day-to-day, hands-on responsibility becomes less and less, but you have other added responsibilities put on,” said Dr Lawson.

He insisted that the majority of consultants do what they are supposed to do, admitting that some might flout their additional responsibilities.

“The many consultants who do what they are supposed to do should not be blamed en bloc for the actions of some who do not do what it is that is required of them. I get the impression that what is happening is that all consultants are being targeted as objects of not pulling their weight — not doing anything —because they are not as visible in the institutions.

“The problem is that some consultants may not know all of their duties and responsibilities, and for those who know, they may not accept or do all of them the way they ought to. At the very least, the clinical management of the patients under their care must be done.

“There are problems in the system [and] we all have to work together to solve those problems. But pitting one against the other and trying to move attention off of one thing and focus onto another is inappropriate as it is inaccurate,” said the senior doctor.

Dr Lawson, a senior orthopaedic surgeon at the Kingston Public Hospital with over 22 years service as a consultant, said that the delivery of health care is done in teams with several layers of different functions. The ultimate responsibility, he said, rests with the consultant who guides and directs everything regardless of their absence or presence.

He explained that there is a continuum of doctors operating at eight levels. The first four levels are for doctors whose primary function is the delivery of health care. Doctors at levels five to eight carry out administrative functions.

“Every consultant starts at level four. One, two and three are the ranks for the junior doctors. Level three in the junior doctor system is somebody who is classified as a specialist trained doctor. Essentially, the doctors who work in the hospitals are grades one and two. When you become a specialist, you can occupy a grade three post, and as a specialist you are eligible to be appointed a consultant,” said Dr Lawson.

He said, however, that sometimes a level three junior doctor, who is also a specialist, will make decisions without the oversight of a consultant.

“They [junior doctors] may be required in some of the larger institutions to make snap decisions in emergency situations without the advice of their consultant. But they will have other senior colleagues who they would be able to get advice from. So that is an unusual thing for junior doctors to be making decisions on their own, unless it is an emergency and they had to make a decision right there and then. But usually, the consultant is a phone call away. And in the public hospital setting, if you (a junior doctor) can’t get through to the consultant who is directly responsible you, the protocol is to call the SMO (senior medical officer).”

“If it is run-of-the mill routine, it doesn’t necessarily have to get to the attention of the consultant due to the level of the senior most junior doctor, who typically should be somebody well advanced in their training as a specialist or a trained specialist in their own right.

“What ought to happen is that the consultant ought to now review and see each new patient that comes in within 24 hours of the admission. The consultants ought to be conducting regular ward rounds, usually on a daily basis and whatever decision is needed to be made by them, they make it, or the decisions that have been made are reviewed.”

Dr Lawson also pointed to the fact that consultants are on call 24 hours of the day, seven days per week.

“A consultant is a special position. You not only lead a team, but you have administrative responsibilities as well. You are responsible for the care of that patient 24 hours a day. Every patient gets admitted under the name of a consultant. That person has ultimate responsibility, and you also have administrative responsibilities. Some consultants will be the senior medical officer for the entire hospital. Some will be heads of departments in the bigger type A hospitals. You are also patient advocate; you advocate to the administration on things that are happening with the patients, and you advocate to the Ministry of Health on behalf of your patients.”

He continued: “Any hospital that has consultants who have junior staff, the responsibility of that consultant is not only to look after the patients, but to teach, educate, and train all of those junior doctors working with them. When you are a consultant you take on all these additional roles; not only clinical management of the patient but multiple other things is your responsibility as a consultant.

“When you are at home in the evenings and you are called about a patient that has just come in, and we spend the next half an hour going through what the initial management ought to be — you are on the job 24 hours a day, seven days a week. That is a part of our job as the consultant. And that is difficult for them to see because we are seen as just the highest paid junior doctors,” said Dr Lawson.

By right, Dr Lawson said that only consultants should lead a medical team for the delivery of health care. However, he said that the current system does not always work the way it should.

“Unfortunately, our system doesn’t work by virtue of not having all the ideal things. You have some grade three doctors who are specialists who have been asked to lead a team like in the rural Type C hospitals, but they are not consultants.

“Things have happened in the past where SMOs at some of the smaller hospitals haven’t even reached a grade three; some of them have been grade twos and given administrative responsibilities. That is something that we hope we will never see again. No doctor should be appointed to the position of senior medical officer of any hospital without having specialist qualification and being in a grade four position,” said Dr Lawson.

Another sore point for junior doctors was the lack of resources and equipment in the hospitals. On this matter, Dr Lawson agreed with his subordinates.

“Very often what happens is the staff is not able to do what they are trained to do because they don’t have the equipment to do it properly, [and] they don’t have sufficient access to the operating theatre.

“Do you know how frustrating it is for a trained specialist to know what to do for a patient and they are unable to effectively do it because of shortages of everything in the system? It is frustrating and demoralising. And this is what is happening to a number of consultants in the system,” said the senior doctor.

On top of that, Dr Lawson said an inordinate amount of time is spent by consultants, primarily those in the executive of the AGMC, negotiating for better wages with the Government.

“It is unfortunate where a lot of our effort is spent in negotiations with the Government for salaries and fringe benefits. It takes up an inordinate amount of our time, coupled with our responsibilities with our patients. We seldom have time to fight for advocacy on behalf of the patient and what we see happening — the staff shortages, the equipment shortages. Our juniors have a little bit more time and are more vocal about it. From time to time we will come out and say that we have them (problems) and agree with what they are saying. We might not be in the forefront of the fight, but we talk to them, we guide and direct, and give council. They don’t always have to follow it, but more often than not, they listen to what we have to say because ultimately they are all aiming for our positions once there is a vacancy,” said Dr Lawson.