Issue 14 / 18 April 2011

AUSTRALIA has one of the best health care systems in the world, particularly from the perspective of quality of care and access to services. It is, however, under increasing stress to cope with the ageing population, chronic disease and unrealistic demands.

Predictions are that the health budget will consume nearly 20% of gross domestic product by 2025. Health is the largest sector of the Australian workforce, with about 1.4 million workers in health and social services.

Given the human resource-intensive nature of this sector, we will probably need to recruit about half a million workers into health and social welfare in the next decade if we are to maintain the existing standard of community services.

So, it is against this background that we need to ask the question: are we training too many doctors? And, can we afford them?

You have to take into account that we have an interesting way of paying doctors in this country — an uncapped (no limit) fee-for-service system that rewards doing things (a procedure) rather than making a diagnosis (taking a history and performing what is still one of the best “investigations” in medicine, a full physical examination). This tends to reward the specialists.

  • To properly answer the question on doctor numbers we first need to know:
    What health services we want to provide in 2020
    Who might deliver those services
    Where they will be delivered
    How to ensure adequate training of those delivering these services
    Who is going to pay for them

These issues raise the further question of whether other health professionals (nurses, carers, pharmacists, physiotherapists, physician assistants) could be trained to do some of the tasks currently carried out by doctors.

Certainly, any role expansion by these health workers must not compromise patient care but this sort of activity already occurs in many other countries. For example, nurse endoscopists and nurse anaesthetists work closely with the relevant specialists in the United Kingdom and United States to expand the services that can be provided for patients without changing patient outcomes.

Team care is what the future of health care is all about — learning to work in teams with shared responsibilities, good coordination and excellent communication across those teams.

No one in health care can really claim to work as an independent practitioner in 2011; we work as teams.

The use of technology (mobile devices, teleconferencing) will allow these teams to communicate distantly with each other and with patients, and thus provide access to health services that are currently only available in major centres across this broad wide land .

Telemedicine rebates are due to be initiated in July at last, and this could influence our requirements for doctors significantly.

A recent book, 2030 — The future of medicine, presents compelling arguments for engaging the community in their health care using new communication platforms and ensuring that doctors and health professionals in general keep patients out of hospital.

“Head in the clouds,” you say?

Yes, that is exactly where we must be — in the information “cloud”. If we increased the average health literacy of Australians by 20%, imagine what that might mean to health worker predictions, including the number of doctors needed,  and the health of the community.

A community that takes responsibility for its health? Don’t dream; help to make it happen.

Professor Peter Brooks is the director of the Australian Health Workforce Institute at the University of Melbourne.

Professor Brooks will be one of the speakers at a seminar titled “Are we training too many doctors?” in Sydney on 3 May as part of the University of Sydney Controversies and Leadership in Health Seminars.

Posted 18 April 2011

8 thoughts on “Peter Brooks: Are we training too many doctors?

  1. Rick says:

    When I graduated, 30 years ago, it was predicted that there would be an oversupply of doctors, and I’ve not seen any improvement in the accuracy of workforce predictions since then. Now we’re trying to predict what medicine as a whole will look like in 2025 to 2030 – purely speculative, and likely to be wrong, I think.
    I strongly agree that a skilled history and physical examination and personal interaction are and will be crucial to quality care (but what is the evidence for this?). However, few clinicians are any good at these nowadays or take the time; as a basic example there seems to be an almost universal failure to get an accurate medication list from patients whether they are in hospital or in an outpatient setting.
    I’m not disturbed by the notion that 20% of GDP might be spent on health services – these are services that have value, and the money spent recirculates in the economy; I would be more disturbed if it were spent on something like the “military-industrial” complex. What is clear, however, is that if public money is spent, value-for-money is needs to be obtained. Better rewarding spending time with patients (doing things like taking a good history and doing a proper examination), might be a step in the right direction – we probably need evidence for this, though.

  2. Jim Yong says:

    Before I make a short statement may I say that those who are not prepared to identify themselves when they make comments should not be allowed to do so. Medicos are generally honorable and those who bother to comment usually do so because they are passionate about the issues. The shortage of doctors has been apparent for the last 10 years. About 20 years ago medical student intake in universities was cut drastically because of the perception that too many doctors were being trained. The population growth in Australia and especially in Sydney was at a standstill. The population has increased and we are now short of doctors. To address this shortage of doctors many medical schools have sprung up in the last 5 years. Some of the medical curriculum leaves a lot to be desired. Many doctors are now about to graduate rom the new medical schools. I predict that in the next few years there will be a glut of doctors. Those that are in control are also actively recruiting overseas doctors to make up the shortfall. So we will go through boom and bust cycles. What really concerns me is that the educational standards are changed and dare I say the bar is lowered to make sure we graduate or recruit doctors. In my own specialty of anatomical pathology there was even discussion of upskilling laboratory scientists to make histological diagnoses to address the shortage of anatomical pathologists. There was also talk about telepathology and sending the virtual images of cases off shore for diagnosis. This senario is no different when you talk about telemedicine, allowing health professional to do the doctors work. I am not that conceited to think that other well-trained health professionals cannot do doctors work but I would argue to let the doctors do the doctors work and that the other health professionals do the work they are trained for. Let us not train too many doctors but let us train good doctors to maintain the quality of health care that we enjoy and take for granted in this country.

  3. woolly says:

    You gotta be kidding me. I have worked in many emergency departments the past 20 years and the consistent problem is how overworked and overstretched the staff are, and the use of locums to try to fill in gaps. And we still have surgical registrars who are on duty for 24 hours. To suggest there are too many doctors or that we can effectively be replaced by other health professionals or by teleconferencing shows the author of this article has not worked at the coalface and is totally out of touch with the real world.

  4. Rob Loblay says:

    This represents the triumph of hope over experience.
    Despite all the well meaning arm waving, it’s clear that teams of allied health practitioners are not going to reduce the need for doctors. I have been working with a team of nurses & dietitians for over 25 years. By having them carry out defined procedures and provide detailed management advice they have certainly relieved me of the burden of doing these things myself, but the consequence has been to free me up so I can see more patients and spend more time with those who need it. Better service, but greater cost.
    New communication platforms? We have been using email for patient communication for many years, and more recently SMS. This is efficient, and prevents the need for many face-to-face follow-up consultations, but once again, it just frees us up to see more patients. Better service, but greater cost.
    Outside the public service, it would be hard to find a better example of Parkinson’s law: ‘Work expands to fill the available time…’
    And what about health literacy and the ‘information cloud’? While better access to health information via the web has empowered many patients, a little knowledge is not always a good thing. Helping patients to separate good from bad information and to navigate their way through the maze of misconceptions and alternative health belief systems that infest the ‘information cloud’ generates more unnecessary work, not less, and hence drives costs up, not down.
    Previous attempts to restrain costs by restricting the number of doctors, based on economic rationalist arguments, have been a dismal failure. In the face of unlimited demand from an ageing population, any savings from increased efficiency or spreading the load will be offset by greater demand for doctors’ services.
    More like ‘cloud cuckoo land’ IMO.

  5. John Stokes says:

    I like the concept of teams in medicine and being more collegial with other health professionals but I intensely dislike the way these good ideas are hijacked by controlling administrators who often reduce it all to the lowest common denominator. A good example in Peter’s article is the way a seemingly good incentive ruins good clinical medicine. It would seem logical to reward medical procedures but it has done so at the expense of history taking, examination and consultation. Our best cardiologists are technicians now more interested in procedures than consulting, the same with our gastroenterologists who now find any orifice to look into. The Item number book has vastly changed medical behaviors moving our focus more towards procedures rather than to care. If we reduce medicine to procedures then technicians may as well replace us. Similarly, telemedicine might be a good idea, but if it is used to replace doctors seeing patients and being available in remote and regional Australia then it will be a retrograde step and centralise control in the hands of the proceduralists. We must not let our health administrators think that good care can be replaced by communication technology that allows our workforce to cluster only in metropolitan Australia. Telemedcine will have niche success only. If we don’t give all the community access to us in person and provide good care where they live then they will get it by different means. What really frightens me is the concept that health care will consume 20% of GDP. At that level we won’t be able to afford mortgages, educate our children or enjoy other vital public services. Keep thinking Peter, we all need to have open minds. I would add don’t dream, make good and worthwhile things happen.

  6. Frank Johnson says:

    Currently,the Australian Health Practitioner Regulation Agency and Medical Board of Australia are wasting potential expert skilled contributions to the medical work force by making the requirements to stay qualified for registration (CPD, etc) an all or none option. Senior active doctors have either to keep up the same standard of CPD as a fully active doctor or be deregistered and unable to practise any medicine at all, even writing repeat prescriptions. The option for graded registration as suggested by the Australian Doctors Fund and set out on its website would allow senior active doctors to contribute significantly to medical services.

  7. Anonymous says:

    The suggestion that we might be training too many doctors concerns me. Advice from “workforce experts” over the past 20 years has excluded large numbers of wonderful young Australians from medical schools while we have imported a legion of poorly-trained overseas doctors to work in our hospitals. We don’t need nurse practitioners or overseas-trained doctors. We need adequate university places to allow young Australians to become doctors.

  8. roland owen says:

    Interesting topic. Didn’t really seem to answer the question though. Huge subject – how will the next generation of Gen Y doctors translate into full-time equivalents in the workforce? Will they replace 1 for 1 & work full time- or, as seems to be happening, work/life balance means more part timers. So we need more doctors to MAINTAIN the workforce.
    (I not a cynical baby boomer about to retire either!)
    Another question I have is where are we going to train all these new graduates, esp where I work in Qld?
    There is going to be more graduates than training posts in Qld over the next few years. My GP practice group is involved in interns working in general practice & have already had a couple hrough – but there hasn’t been much state or national discussion or co-ordination about all this. Just money going to ever-increasing med schools & then pop, out they come with qualifications but nowhere to go??
    Will we have a point soon when we have unemployed doctors?

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