David Tiller: Education overkill

UNTIL the 1970s many young doctors — who were overwhelmingly male — after a couple of years of internship or residency spent some time overseas expanding their education and observing how patient care and research were managed in another country.

This excellent process has now almost ceased because of the time it takes to complete Australian medical training. It is one of the many poor outcomes of the move to excessively long training.

My experience was common: graduated in 1964, completed 2 years as an intern and resident medical officer, then, during my third year as a registrar, successfully completed my exams for the Royal Australasian College of Physicians.

If I had not spent 3 years in the US, I could have been in a consulting physician practice at age 26 — 9 years after entering medical school. If I had started my career as a GP I could have been in practice after 7 years.

Back then, that seemed like a long training time compared with other professions. For those doing dentistry, engineering and architecture the time to starting in practice was 4 years; for veterinary science, 5 years. The law was also 4 years with a year of “articles”.

There has been little change in training time for these five professional groups. However, in medicine the length of training now seems to be out of control.

At the Sydney Medical School students now must have completed a graduate course of 3–5 years before they can “do medicine”, which is a 4-year program. This is followed by internship and at least year as a resident medical officer, then 3–5 years of “advanced training”, whether for general practice or neurosurgery.

So, leaving school at 17, completing a 3-year bachelor degree, then 4 years of medicine, then two of hospital residency then three of advanced training —  it is 12 years after leaving school, at age 29, that you can begin to practise independently in your chosen field.

And this is an absolute minimum.

If you change direction, complete an honours year with your first degree, spend 3 years in hospital residency, or wait for a training position to become available, you will be at least 31 years old before you are able to practise your craft.

With 50% of students now women, if you pause to have a family you have to add another 3–5 years to this equation.

Why has this occurred?

Universities insist that the explosion in medical knowledge requires 4 years of education and training as a minimum. For most it is 6–7 years at least.

Health departments have realised that they pay resident medical staff and quite correctly demand appropriate service in return, mandating that the first years after graduation cannot be a part of advanced training. So, add 2 years, sometimes with a flexible second year where some advanced training can commence.

Advanced training usually starts in the third year and extends for 3–4 years or longer. It is in the hands of the colleges and their special groups, which have grown in number and size in the past 40 years.

When I graduated there were three colleges — the Royal Australasian College of Surgeons, the Royal Australasian College of Physicians and the Royal Australian College of General Practitioners. Now there are probably 20, although it is easy to lose track with the number of subspecialties.

All these bodies demand that in addition to a medical degree and a period of supervised hospital or community training, applicants must pass a written exam and a clinical exam.

Is all this necessary? Are our medical practitioners better equipped to deliver excellent patient care than they were with shorter training times?

There are no clear answers, so what should be done?

It’s time for a national forum to deal with this issue or we risk wasting opportunities for many very clever young men and women who will eventually become our future medical practitioners.

Professor David Tiller is professor of medicine and associate dean of planning and development at the School of Rural Health, University of Sydney.

Posted 7 May 2012

Does it take too long to become a doctor? In a two-part series, the MJA tries to find the answer.

[poll id="181"]