KEY POINTS:
In May 2006, a nurse at Wanganui Hospital fired off an email to her manager. "Dr Hasil is still a worry," she wrote. "I have given up reporting his ridiculous actions and recording of the same. Nothing is done. He will make a grave mistake."
As we now know, not much was done. Czechoslovakian-born and trained Dr Roman Hasil has been revealed to have botched sterilisation operations and sometimes stank of alcohol.
Health and Disability Commissioner Ron Paterson's report on the saga is sobering reading. At one level, wrote Paterson, what happened was simple.
Dr Hasil had not placed the clips correctly on the fallopian tubes of eight women. But the story of why he made such basic mistakes was far more complicated.
While Paterson's report pulls no punches about the behaviour of Hasil and the failures of both the Whanganui District Health Board and the Medical Council, running through is another theme: desperation.
Attracting New Zealand doctors and specialists to our smaller cities and rural areas has been problematic for a long, long time.
When news broke of Hasil's stuff-ups, around 80 per cent of Wanganui Hospital's doctors were overseas trained. People didn't like it. The Dominion Post reported racist slurs against foreign doctors.
People contacted the hospital demanding to know where doctors were born, and some people cancelled operations if the surgeon was foreign.
But if you don't like the fact you might get an overseas-trained doctor, get over it.
Forty two per cent of the country's 9000 doctors, from surgeons to general practitioners, are overseas trained. That's 3780 people.
Without them, the health system would fall apart. New Zealand simply does not train enough doctors to be self-sufficient.
The Medical Council points out that of those overseas doctors, half will leave the country within a year. Some are graduates from the UK who come for a year as a registrar, but others are locums who come for a short time and need to be under intense supervision. This ties up a lot of staff time, and then they leave.
The higher the turnover coming in and out, the more potential for someone substandard slipping through.
Professor Iain Martin, dean of the Auckland Medical School, would like a lot more New Zealand-trained graduates in the system but says any backlash against overseas doctors because of Dr Hasil's actions is simply not fair.
"The vast, vast, vast majority are dedicated individuals. The system at the moment would not survive without their professional service."
The bottom line, he says, is that even if New Zealand kept every last graduate produced from the country's two medical schools each year, we still would not have enough.
And, even if a "bold move" was made to ensure New Zealand was self-sufficient for doctors, that would still take at least 10 years to achieve.
But achieve it we should, thinks Professor Martin.
The pressure this country faces for qualified medical professionals is faced all over the world. The opportunity to recruit from overseas is not going to get any easier.
There are other compelling reasons to want more home-grown doctors. A system so reliant on overseas staff makes forward planning for an integrated training system at home exceedingly difficult.
Then there is a moral, philosophical component. Is it right, asks Professor Martin, for a relatively affluent, developed country like New Zealand to not ensure it produces enough medical practitioners to meet its own needs?
"Because you have to remember that doctors that come here are from countries that can afford to have gaps to an extent even less than we can."
The medical school is trying to help attract New Zealand graduates to smaller centres and this year sent a group of students for a fifth year of training in Whangarei.
The idea is to introduce them to the concept of working in a smaller city - they will do stints in Kaitaia or Dargaville hospitals - so they can see there is a life out there in the regions.
The scheme has only been running two weeks and if successful won't help areas such as Wanganui - still struggling to fill obstetrician and gynaecology vacancies - for some time.
Paterson's report says that in Wanganui, Hasil worked in a "grossly understaffed department".
Wanganui Hospital had tried hard to find consultant obstetricians and gynaecologists. In six years there was not a single expression of interest from within New Zealand. Weekend duty for Hasil was supposed to be one in four but increased to one in two as the number of consultants in the department decreased.
By September 2005, Hasil was operating without direct supervision. He told the commissioner he was working 90 to 130 hours a week. He told how, unlike most New Zealand candidates, he had been looking for a "quiet hospital" because he wanted to prepare for the Royal Australian and New Zealand College of Obstetricians and Gynaecologists examination which he had already failed several times.
He told how he had thought that as a medical officer he would be supported by a number of consultants and he would have time to study.
Hasil was never hired as a specialist obstetrician gynaecologist but the shortage of senior medical officers meant that before long he was "forced" into the role of a specialist.
When a consultant left, his on-call roster became a ratio of 1 in 2 which, according to international standards, is "demanding and unsustainable."
The ratio is considered so unsafe it is regarded as unreasonable to allow it to continue: "It burns out and exhausts staff, thus increasing risks to patient safety," wrote Paterson.
Paterson told Weekend Review that desperation was the right word to use when it came to Wanganui Hospital's search for staff. The obstetrics and gynaecology department wasn't just understaffed but "grossly" so.
Funding was there for 3.4 full time specialist equivalents. The reality was only one specialist and Hasil.
Paterson believes when faced with this situation it may be better to close down the service. No one is suggesting the hospital itself close, he says, but when you need specialists you cannot get for a particular service the clear message from the Wanganui case is a need to move to regional services.
This already happens with Southland and Otago's cardiology and opthalmology services which proved too difficult to run separately.
Paterson says there is no need to be alarmed about the numbers of overseas doctors working here. After the issue was raised last year, his office analysed the figures and found complaints against overseas doctors for 2000 to 2007 were slightly under-represented compared to New Zealand-trained doctors.
Just last week he put out a report about a West Coast New Zealand-trained specialist orthopaedic surgeon who took on a knee replacement which was too ambitious and the patient ended up losing her leg.
And New Zealand is not the only country to have screwed up in the hiring of both overseas and home-grown doctors. Staggeringly, the Medical Board of Queensland suspended the registration of Hasil only last week after Paterson's report.
Hasil had worked for Queensland Health last year even though he had been stood down by Wanganui.
Says Paterson: "It beggars belief, where we have a market of doctors moving between Australia and New Zealand, that information cannot be freely shared between registration authorities. That needs to change."
We don't need to panic, says the commissioner. But we do need to be vigilant.
DODGY OPERATORS
ROMAN HASIL
Hasil, a Czechoslovakian-trained doctor with a jail record for domestic violence, was employed at Wanganui Hospital in 2005, the same year he was dismissed from a hospital in Australia for drinking on the job. He is accused of botching the sterilisations of 11 women in both New Zealand and Australia, including removing the ovaries of a New Zealand woman without her knowledge.
Whanganui District Health Board now faces a lawsuit from affected women.
GRAEME REEVES
This disgraced former Australian doctor operated in the town of Bega, New South Wales. Despite being banned from obstetrics and ordered to seek psychiatric counselling, Reeves found employment and attended to patients at two hospitals. He got away with this because Bega was desperate for staff and did not fully check his credentials and record. Reeves is accused of mutilating the genitals of possibly hundreds of women.
JAYANT PATEL
The Indian-trained surgeon Jayant Patel falsified his application for registration in Queensland, failing to mention he had been found guilty of gross negligence in the US. Patel was reportedly interested in a job at Kaitaia Hospital but had thought the position too junior. Instead, he was hired as director of surgery by Bundaberg Base Hospital after medical authorities failed to check his record. Patel is implicated in 17 deaths.
