SAMJ 7165

RWOPS abuse ‘eroding ethical standards of juniors’

The impact of Remunerated Work Outside the Public Service (RWOPS) abuse on the ethical understanding of young doctors is ‘deva­stating’ while patient care is ‘doubly disadvantaged,’ through a dearth of teaching and lack of actual physical care.

This is how a respected Stellenbosch University medical and legal ethicist and a cutting edge community and primary health care innovator at the University of Pretoria (UP) see the fast-evolving RWOPS abuse saga which took centre stage in public health over the last 3 months.

Professor Jannie Hugo is a family physician in the Department of Family Medicine at UP, who is helping reshape the country’s primary and rural healthcare system. While RWOPS consultants say that they are overworked, he finds an innate contradiction in this claim: ‘How then do they still find time to do RWOPS?’ he asked. To Hugo, it’s a straight-up ethical issue of the consultant ‘rather spending time in a situation with people who can pay me more money than those who pay me less’.

‘When I was a medical student, I learned most of my medicine between 5 pm and 8 pm when I was on call, and there was always a consultant. Nowadays, if a consultant is doing RWOPS you’d be very happy to see anything of him after 2 pm. If you look at the practice of young doctors in the state, they’re following suit. The impact of that on their ethical understanding is devastating.’

Hugo said the overall tertiary healthcare public debate is taking the focus off the challenge of making primary care in South Africa universally functional. ‘If you get five babies dying in a big hospital it’s a big story. But the slew of babies dying in communities is hardly reported. So the amount of attention given to tertiary issues, even around RWOPS, doesn’t do justice to what’s happening in communities. If this is the way for the state to rid itself of the ills of RWOPS, I’d support it.’ Hugo said he is detecting ‘unhealthy competition’ between the public and private sector in preparation for universal health coverage: ‘The public sector wants to build itself so it doesn’t look so bad against the private sector.’ For him, the controversy raises a fundamental question: ‘Where’s the clinical governance? It’s also a bit like telling your wife, “I’ve got this mistress but it’s OK, I’m only spending two hours a month with her,” – for me it’s an ethical issue’.

Professor Jannie Hugo, of the University of Pretoria’s Family Medicine Department.

Public’s macroview skewed by media coverage

Professor Keymanthri Moodley, Head of the Centre for Medical Ethics and Law in the Department of Medicine at Stellenbosch University, said two key virtues of what is commonly known as ‘the good doctor,’ are honesty and integrity. ‘It’s very clear that doctors are not in the public sector when they’re supposed to be. Patient care is doubly disadvantaged. Juniors and students are left on their own to work, often outside their scope of practice, and they lack the supervision they need to properly care for patients.’

Moodley said that there is no countrywide fixed standard for working hours and productivity, and RWOPS abuse exacerbates this problem. RWOPS doctors ‘need to be held accountable. Medical professionals are expected to have a personal work ethic. They shouldn’t have to be policed and should be able to regulate themselves in terms of their commitment to patients and providing healthcare. Yes, you can find fault with management, but is that what’s expected? Do you have to follow the rules of a profession only because someone is watching you?’ She said it’s ‘extremely embarrassing’ for a facility manager to have to police doctors, and that this erodes respect and trust, two cornerstones of the profession. ‘This is a matter of doctors starting to reflect on their own behaviour and realise how they are eroding these values. They are setting a dismal example for their juniors, registrars and medical students – just look at KwaZulu-Natal.’ (See main story: ‘RWOPS abuse could cost, or even ruin, offenders’)

Stellenbosch University medical ethicist Professor Kaymanthri Moodley.

Moodley said unprofessional behaviour nullifies the effects of the best medical teaching, but cautioned against disciplining doctors without taking into account several factors impacting on their morale. Examples she gave included the failure of Home Affairs to control illegal immigration (which sends patient loads soaring), failing equipment, lack of maintenance and dysfunctional management. ‘What’s clearly not happening is [doctors] understanding and balancing their primary employment commitment with their private work,’ she concluded.

Chris Bateman

S Afr Med J 2013;103(8):505-506. DOI:10.7196/SAMJ.7165

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