Why the OMA dispute and the UK Junior Doctors Contract Dispute are the same but different.

Yet another person has commented on the fact that they believe the labour disputes in Ontario and the UK between the governments and physicians in the respective jurisdictions are similar situations. They are actually more different than they are similar.
Firstly to acknowledge there are some commonalities. Bargaining talks over pay issues broke down between the government and the doctors in both situations. In the OMA’s case, the Ontario government has chosen unilateral action, meaning it has decreased the amount paid to doctors (practising physicians, NOT trainees) without a PSA (physician services agreement) in place- in other words, the Ontario docs didn’t agree to the pay cut. In January of 2015 2.65 % was cut across the board for all physician services by the Ontario government, and another 1.3 % in October of 2015 for fee for service payments. There may be more cuts on the horizon in Ontario, we just don’t know. In the junior doctors UK (JDUK) case, the British government has threatened to roll back paid overtime for after hours and weekend work, and also wants to legislate lightening up on the surveillance of the hours that junior doctors work.This has also been done without the agreement of the organization representing the junior doctors. The hospitals in the UK are financially penalized if trainees work over a certain number of hours a week, and a softening of these rules has been proposed, meaning trainees will likely have to work longer hours without the hospitals being punished.
Now I was not paid a penny of overtime for either after hours or weekend work when I did surgical residency in Canada, and it is the same in the US. Trainees in North America currently receive the same salary based on their year of training, regardless of the number of hours they work. I can guess what probably happened here. There was some sort of international conference on medical training, and program directors or some sort of health administrators from the UK and North America started comparing notes over tea on trainee compensation- “What do you mean you pay for overtime, weekend, and night work for trainees?” says the guy from North America- “Ridiculous, we don’t pay any overtime, that would get expensive!” A light bulb went off in somebody’s English head, this revelation trickled up, and ultimately the information ended up on Jeremy Hunt’s desk.
I worked in the UK for a year in a medical research lab, and while I was not doing any clinical work at the time, I interacted with a lot of physicians, including a lot of people who were either training or had recently completed training to be doctors. I then went on to work in Australia, which has a very similar system to the UK, for four years. The system in the UK and Australia for trainees is a lot nicer than it is in Canada. Paid overtime, enforced limits on work hours- these are things physician trainees in Canada and the US can only dream of. And just to be clear, I absolutely think trainees should be paid for overtime and have limits put on their working hours. The system as it exists now in North America is completely in the hospital’s favour to allow the abuse of residents. And I think we should all be advocating for improved working conditions for residents- including and especially those of us who have finished our training. So if you want to support the junior doctors in the UK in their fight for continuing to be paid overtime and restricted working hours, maybe we should be advocating for the same benefits for our trainees closer to home?
There are huge differences between being a trainee and being a consultant physician with your own practice. Firstly, consultants get paid a lot more than trainees- right? Or do they? As a junior consultant in Australia, I was paid a flat salary (kind of like a Canadian trainee is). It did not matter how many hours I worked, the pay was the same. As a new consultant in Australia I was on the lowest rung of the pay scale at the hospital. This meant some of the senior registrars I worked with- who were at the top of their pay scale and paid for overtime- were making more money than I was at the end of the year, even though I carried more responsibility than they did for the care of the patients. How do I know? Because firstly, I also worked in Australia as a senior registrar for a year, where I did get paid for my overtime and secondly, I can count. So I think we have to ask ourselves if it is a fair system when the senior doctor supervising the care of the patient given by the trainee is being paid less than the junior trainee doing the care? Of course the vast majority of trainees are paid significantly less than their supervisors, but it is an interesting quirk of the system of physician remumeration when you salary physicians but pay overtime to trainees. It is the opposite in Canada, with trainees on flat salaries and a lot of consultant doctors paid via fee for service.

Another big issue of course is that after a very long road of medical training, employment in medicine post training is no longer guaranteed. This has been a problem for decades in the UK, which trains far too many doctors for its needs and exports many of them, and is sadly a now established problem in Canada, where we have legions of un and underemployed physicians churned out by training programs who need them to fill call schedules as trainees, but not to employ as consultants. England currently has over 53 000 junior doctors, a far higher number of trainees per capita than Canada. The NHS hospital system has allowed itself to become almost completely dependent on these trainees, where they perform a lot of functions that overlap or replace nursing care (blood draws and IV starts as two quick examples) as well as looking after patients.But I digress.
Well over 90% of Britons support the JDUK in their job action according to polls. The UK is a country where people turned up at Margaret Thatcher’s funeral just to be able to turn their backs on her casket because of well remembered decades old grievances with her actions toward unions. The people in the UK are also extremely proud of the NHS, a national system of socialized health care. I think on some level, most people understand that being a medical trainee involves a lot of long hours and poor pay, which then morphs into still long hours but better pay when you practice independently.  I also think most people understand that up the food chain from that trainee is a consultant physician, who will step in to fill the void if these junior doctors do go on strike. While I’m not going to get into the somewhat sticky ethical world of who is responsible for what in the apprenticeship which is medical training, striking trainee doctors are not the same as striking consultants and I think the public is smart enough to know this. And since the Ontario healthcare system runs largely on community based doctors outside of large teaching hospitals where trainees work, the public sentiment toward physician job action in Ontario would not be nearly so kind as it is in the UK.
While I wish the JDUK all the best in their efforts for a fair resolution, I don’t see these two situations as being all that similar. The exception being both have dragged on for far too long without a satisfactory solution for anybody, not least of which includes the patients.

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