Issue 2 / 23 January 2012

NOT a day goes by without a general practice patient bemoaning the inability to see a specialist in a timely fashion.

When I work in the city, patients complain that they cannot get in to see a specialist soon enough. In my main practice in the bush, particular specialities often don’t exist at all within hundreds of kilometres of the town.

So is the problem that we do not have enough specialists?

In fact, in most specialties the opposite applies. It is the poor distribution of specialists and sub-specialisation that is the problem.

Australia has never had more doctors. And we have the tsunami of graduates coming through our universities. Yet when you look at the number of medical graduates and the number of GP training positions, it becomes apparent that only about one in four young doctors choose to become GPs. The rest become specialists.

As knowledge expands, trainees are becoming less inclined to be generalists. And government policies don’t help. Lower rebates and increasing red tape (eg, accreditation, practice incentive programs, care plans) mean general practice is less attractive than specialty practice.

However, it seems the days of general specialists are also numbered. There is already a trend for orthopaedic surgeons to restrict practice to one or two joints; and for the “general” surgeon to do bowel cancer but not gallstones, even when a tumour may be just 2 cm away from the gallbladder.

If governments created and funded more public hospital training jobs and graduates were given Medicare provider numbers (which have not been automatically issued since 1996), it would be possible for colleges to train more specialists, particularly as most specialties still involve a significant amount of hospital work.

An imbalance now exists between graduate numbers and training positions, which is emerging as a real problem.

An added problem for current specialist registrars is budgetary constraint in the public hospital system making it harder for registrars to get enough experience to satisfactorily complete training to the high levels that medical colleges expect.

In recent decades, our burgeoning health bureaucracy has decided on two major strategies to control hospital medical costs.

The first is to place more hospital specialists on salaries rather than fee-for-service.

The second tactic has been to reduce the number of public outpatient clinics where registrars and consultants see numerous patients free of charge. Those of us that have been around for a while remember when there was an outpatient clinic for almost every problem, from inguinal herniae to complex brain tumours.

Now, for many health problems, we have no choice but to refer to private rooms or the emergency department. This has diminished access for the disadvantaged and taken away excellent training opportunities for junior doctors.

What is the point of spending about $200 000 each on 3000 graduates per year, only to have them unemployed or underutilised?

Sweeping reforms introduced by previous Health Minister Nicola Roxon may see further impacts on specialist recognition and training. While provider numbers are being given to nurses, midwives and others, some young doctors are missing out. What all this will mean for standards and public access to health care is anyone’s guess.

The bottom line is that in all the cost shifting that is going on between state and federal governments, registrars are being denied the opportunity to access comprehensive training. And that cannot be good for the health of the nation.

Dr Aniello Iannuzzi is a GP practising in Coonabarabran, NSW.

Posted 23 January 2012

2 thoughts on “Aniello Iannuzzi: Desperately seeking specialists

  1. Dr Amanda says:

    An insightful discussion from Aniello and flowing on. We need to debate the outcome of increased training of doctors and they are desperate to know that their ongoing education and training will not be affected. Hospitals have had a lot of time to prepare for this. It is of concern that another medical school is to open in Western Australia.
    It is interesting we do not hear from the medical administrators??

  2. Sue Ieraci says:

    Aniello – I see this specialist “distribution” problem as having various different aspects. Firstly, there is geographical maldistribution, which disadvantages outer metro areas as well as rural. Then, there is maldistribution BETWEEN specialties, with areas like aged care and emergency medicine (specialties mostly confined to public hospital practice) being under-represented – based on a combination of lifestyle and income. Further, there is a maldistribution between community needs and specialists’ preferences – for example, public vs private psychiatrists, interventional vs non-interventional cardiologists.
    Lastly, I see increasing risk aversion and greater expectations as a reason for super-specialisation, where clinicians are reluctant to take responsibility outside their narrow area of specialisation, and patients want the super-specialist to advise on their particular condition. This leaves rural or isolated GPs – one of the few community practitioners who are adept at most things – being held to the requirements for referral of their inner city colleagues, but without the specialty base to refer to. An invidious position for some of our most capable and skilled clinicians.

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