IN 2020, I will be one of more than 3500 Australian medical graduates starting their internships.

It is likely that not everyone who studied in Australia for the past 4–6 years with me will be able to do so – the internship shortfall is constantly increasing. But while this is a well known issue, a second bottleneck for junior doctors is also narrowing at later stages of medical training.

It is predicted that there will be a shortfall of 1000 specialty training places by 2030. By the time a doctor in training reaches this point, the government has already invested a great deal of money into their training. So it is not just an issue for the students reaching this bottleneck, but also of wasted investment in our workforce. As doctors complete their training at a later age, they will also have less years working independently as a qualified specialist.

Australia can do little now to reduce the growing oversupply of medical students compared with internships and training places. There are no easy solutions to the complexities of workforce planning. However, in order to address areas of need, medical schools are a key part of influencing the careers that students choose to pursue.

Australia has 3.6 doctors per 1000 population, higher than the OECD average (3.2), the UK (2.8) and the US (2.5), but only 33% of our doctors are GPs. From 2008 to 2012, there was a 67% increase in specialists, but only a 33% increase in GPs. As the population ages, we will need more high quality community care from GPs, most especially those with skills in care of patients with multiple conditions. Where Australia will need more doctors, there aren’t enough.

Despite the increasing bottleneck of training places for Australian junior doctors, not every training place is being filled. In 2019, while there were 2015 applications for 1500 GP training program places, only 1437 were filled. This suggests that a proportion of those applying do not actually want to become a GP – perhaps using it as a “back-up plan”.

Obviously, we want to attract passionate and high quality applicants to produce excellent GPs, but the system isn’t working.

It is hard for many students and junior doctors not to have reservations about a career in general practice. While benefits such as long term patient care, ability to specialise in areas of interest, and flexible (or at least lower) working hours are all seen when we are on placement, general practice is clearly facing challenges. The public, the media, and often other doctors seem to be gradually devaluing the role of the GP in an efficient and effective health care system (here, here and here). The Medicare freeze contributes to the difficulty of running a profitable business as an independent GP. GPs are restricted in what investigations they can order and referrals they can make.

The increasing opportunities for rural placements and new rural training pathways is promising. Medical school is a key influence on student career choice. Currently, you may have an excellent rural GP placement as a student, only to go back into training in a hospital for your first few years as a junior doctor. For many people, when the option for extensive rural training becomes available again, they have already put down roots in a city – a partner, family, a house.

The appeal of many rural placements as a student is that they are typically less crowded and have more opportunity for practical skills development. As a junior doctor, these placements can be seen as limiting career opportunities. Specialty applications require references, and many rural placements have rotating specialists and, therefore, decreased time spent with the trainee. There may be less case breadth, as rarer and complex cases are sent to larger centres. For a junior doctor applying to competitive training programs, these are not ideal features. And when I graduate, every training program will be competitive.

Completing medical school and applying for training programs is expensive. After a 6-year undergraduate medical degree, a student’s HECS debt will be at least $60 000, with many having additional cost burdens of research degrees, overseas placements and training courses. It is difficult to find a part-time job that fits around long placement and study hours. An application to a training program will then cost hundreds to thousands of dollars. As costs increase, this will inevitably affect which career pathways students choose.

What sort of doctors are we trying to train?

For me, one of the most concerning parts of the increasing competitiveness throughout the pipeline is the change to medical school culture. Of course medical students and junior doctors should be held to high standards – we have chosen a career where lives are at stake. But are we wasting recent gains in the other aspects of becoming a doctor?

As I’ve progressed through medical school, the focus has been on much more than pure medical knowledge. Medicine is a team sport, and we need to learn from the start how to work in a team. From the competitive final year of high school, we started a degree with self-guided learning, small group classes and non-graded pass marks. This seemed to indicate the focus was on becoming a professional and collegiate doctor.

We’re told now that our mental health is important as we go through medical school, but once transitioned into working, many options for seeking help disappear. Applying for training programs is becoming more time consuming, expensive and competitive. This will inevitably contribute to fatigue, stress and burnout. In beyondblue’s national survey of medical students and doctors, the most common source of work stress was work–life balance, reported by 27% of doctors, along with too much to do at work (25%).

Work–life balance

As I have gone through medical school, there has been increasing focus on our mental health, giving rise to a variety of impressive initiatives by medical students. There is little anyone can do about too much to do at university or work, but in work–life balance I see many of my peers excel. Many students participate in co-curricular activities with enormous time commitments – the orchestra, the annual musical, competitive sport. But will all this fall by the wayside as career progression becomes more difficult? More students are undertaking research early, often seemingly with a focus on CV quantity rather than research quality and critical thinking skills. I worry when looking at the looming training bottleneck that the qualities of well-rounded doctors that I see in my peers – teamwork, peer mentoring, creativity, work–life balance – will be gradually phased out.

Too much to do at work

As a student on placement, we often have the opportunity to spend more time with patients than the treating doctors. Patients, of course, appreciate feeling heard, whether it’s explaining an upcoming investigation or surgery, or simply listening to a story. As a student, being thanked for doing so is also one of the most rewarding parts of a placement. But for most junior doctors facing these situations, there simply isn’t time. As an intern, you may be told that extensive unrostered and unclaimed overtime is necessary because you simply need to learn to be faster. You may then be told that it’s your fault you’re overworked by a senior doctor who has a direct influence on your likelihood of you entering a training program. We cannot be surprised that in this work climate these issues remain unreported and unresolved.

In the US and other countries, medical training is more specialised from the end of medical school, with immediate entry to a specialty internship and residency. The appeal of the Australian system, by comparison, has been the use of post-graduate training years to “try out” a variety of specialties, and increase general medical knowledge before specialisation.

However, the training crisis is constantly reducing junior doctors’ ability to take years to do so. It seems a risky choice to do more post-graduate general years – or take time off to start a family – when every year the number of junior doctors competing for each place in your desired training program will increase.

So, as a student close to graduating, I worry that all our gains as students will be wasted once we transition to working. There is simply not room in most hospital environments for some of the highlights of medical school – collegiality, work–life balance, the opportunity to spend time connecting with patients. Just creating more training positions is obviously not easy, and unlikely to change rapidly. Everyone wants these positions to be of high quality, to allow for adequate learning, and to be in areas of need. Training positions need teachers, and appropriate caseload and exposure.

But everyone can work to reduce the factors related to distress and burnout present in the current system. When the reporting system for workplace issues requires you to report to people with an influence on your career, change needs to come from the top down. We are currently wasting everything taught to medical students about work–life balance and mental health.

Rebekah Clark is a final-year medical student at the University of Adelaide. She is the president of the Adelaide University Paediatrics Society, and outside medicine enjoys writing, baking and sewing.

 

 

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.

8 thoughts on “A student’s eye view of the training crisis

  1. Ian Hargreaves says:

    I treat many patients who are professional athletes or musicians.

    They also work in areas with team work is of vital importance, but where competition for a place on the team is decided on a weekly basis. If you cannot be there performing at 100% on this Saturday, you will be replaced, and you will only get your job back if you can demonstrate that you are better than the person who replaced you.

    Despite this, they understand the ephemeral nature of their job security, and their work life balance if the orchestra is doing a tour of China or the team is playing in Auckland – there is no question of child care or whether you can cope with the additional pressure – you perform at full speed, or you do not.

    But these people are some of the most collegial of all occupations, and it is possible to reconcile the collegiality and competition. As a specialist, I am aware that every patient and every GP has a choice to refer to me or to one of my colleagues – all I can do is to do my best. The pressure to achieve perfection does certainly not stop after training.

    And although we always think we have it bad, spare a thought for Israel Folau, who quoted on social media (clumsily and out of context) the holy scriptures of his devout religious belief, and was instantly sacked from his day job. AHPRA seems benign by comparison.

  2. Anonymous says:

    As a female GP, I totally agree with everything in this very thorough article from a very intelligent and informed Medical Student. The demand on GP’s is always increasing with poor work-life balance despite our struggles to maintain this. The statistics showing the poor rise in GP positions is frightening, when considering the amount of the general work load that is left up to the GP to undertake, especially with the aging population that we are facing. For a medical student to look in from the outside, General Practice is unrewarding and poorly remunerated. Thus it is understandable why potential trainees do not undertake General Practice Training. It must be up to the Government to invest in General Practice, the baseline of all medicine in Australia, to improve medicare rebates and provide improved remuneration for all activities undertaken by the GP. To allow us the time to put into our patient care without the heavy burden of time management pushing us to rush through our daily lives.
    If all of this could change, General Practice may then be seen as the rewarding experience it is with the opportunities to make continued differences in our patient’s lives, without the problems of stress, burn-out and mental health issues that are currently facing our Specialty. Remember General Practice is a specialty, but one that has a wide span of knowledge and experience across every other specialty and maintains the general underlying medical system here in Australia. Get to know us and come and be one of us, the rewards are there if you look for them and change will always give us hope for the better medical management of the Australia population.
    In the meantime, good luck with your internship.

  3. Dr Joihn Crimmins says:

    One area we must address as a profession is an unreal expectation of a return in working as a Doctor in Australia.

    Many of your school mates now do a tertiary degress or TAFE qualification but Drs starting and yaerly lifetime pay is at the top end of all professions-on a standard 37.5 hour week.

    Many of your schoolmates do two degrees, will work many unpaid hours and have responsibility loads commensurate to their professional experience no different to being a doctor.

    Why should a surgeon at 35 years earn $300 plus an hour (yearly income >$250K) or a GP at 35 earing a wage of about $180K which puts both at the top few percent of highest professions wages. To incraese places for incoming Drs a revision of how much Drs are costing the community is a great start. And why is there a differentiual between the specialties (remembering a GP is a specialist as well). As a procedural GP working in a remote town I would be paid 20% of a O&Gs delivery fee for a NVD-and my insuarnce was initially 80% of what they paid??? yes not a joke.

    Lets look in our own backyards as well when looking to find a better path for those that follow.

    Bit like the housing cost debate-I feel the baby boomers have alot to answer for.

  4. Peter Shanahan says:

    An excellent and thoughtful article identifying an issue of strategic importance for everyone in Australia. Well done on bringing this to our attention – it indeed needs wider circulation.

  5. Pacho Pepe says:

    My view is that there is a lot Australia can do. Most registrars in training work long hours, some are stretched to their limits (“long hours makes you tough”), some work until they are mentally and physically exhausted. Unpaid overtime is a reality. The high numbers of suicide of doctors in training, the substantial problem of substance and alcohol abuse in this profession reflects part of the problem. Higher numbers of trainees (job sharing) would improve the situation for doctors in training. Safe working hours, less on call and more time for your patients….and also for your family and yourself, everyone would benefit. But it costs money.

    Australia needs to get training reformed, training should be adapted to acceptable working hours allowing time for reading and review, but also for family and private life. Read the newspaper! Australia’s doctors in training have big issues! And while training posts are limited and a logistic funnel is created by making training in tertiary centres compulsory the hospitals in rural areas struggle to find enough trainees as well as specialists. As long as there is a lack of doctors in rural areas the Colleges should not be allowed to limit training positions. Doctors should have the possibility to go through the full training program in rural training settings.
    This is should be possible for many of the subspecialties.

    Another problem contributing to young doctors not wanting to go into GP training is the fact that GPs today have been downgraded to “specialists for referrals”. We need to show more respect for GP job, allow them to participate a bit more with treatment and decision making by creating a system that supports and creating a system that trains and respects GP’s with a “subspecialty”.

    The GP job has been driven into a “10 minute medicine”. This does not only make the job less attractive, it leads to early burn out of doctors. Try to consult 8 hours every day for 5 days a week and see 4- 6 patients every hour. That is the pace your practice manager will ask you to keep in a bulk billing business if you want to make a decent living in order to pay the debts that you have accumulated during your career as a medical student.

    Last not least : the Australian system has another problem: AMC, AHPRA, the Colleges and the medical education network as well as the Department of Health are institutions that lack communication, they do not talk to each other They have different goals, their approach is an individual approach rather than looking at the big picture.

    Australia can do a lot. The ones responsible should look at the big picture.

    Being a doctor can be very rewarding…but you need to be careful that you find the right balance. The system that is in place to train doctors in Australia (and in many other countries) does not really support you to help find this balance.

  6. Lana Tran says:

    What a great article! As a colleague also in my final year of medical training at university, I completely concur with Rebekah and feel that she has captured the student voice – our aspirations and concerns – very well.

  7. Anonymous says:

    I am so glad the RACGP are taking over GP training from the RTOs. Not a moment too soon. Registrars always complain about exams, but what makes GP training most unappealing in addition to concerns raised in the article, is the lack of a formal training or feedback process in relation to the assessment. The RTO are not in charge of the exam, and the RACGP do not give any formal feedback when one is unsuccessful and fails their KFP and or AKT. No wonder application rates for training have plummeted when there is a high fail rate for exams, a college who are not giving feedback to unsuccessful candidates and an overall sense of pessimism prevails for trainees unless they pass first time. I wouldn’t apply if I had my time again. In this profession I’m not interested in what makes me the most money, after ten years of working in medicine there are easier ways for me to make a dollar than being a lowly paid GP reg. I’m working out in a rural area and have been for three years now, with the aim to qualify as a GP so I can continue to help people improve their health. The standards are so high, registrars aren’t trained any more to compensate for their lack of services living in a rural area, in fact the access to training is much much worse (I even live an hour away from a capital city now and I still can’t get to any of the RACGP run in-person pre-exam teaching as they are on weeknights, and not put on the internet) It’s far from ideal and there are easy and cheap ways to improve it if only they would listen.

  8. Matthew Hird says:

    Australia must lower its own standards for students to study medicine. Or we will continue to have to gamble on the standards that we import from foreign medical schools.
    There is no point holding our own students to such high medicine entry level standards while importing the standards of other countries.
    We can monitor the education of our students and produce better general practitioners for ourselves. This would not only provide more opportunity for slightly lower achieving students. It would also help Australia’s disadvantaged communities to access local linguistically compatible doctors through the already overburdened Medicare bulk billing system.

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