A student’s eye view of the training crisis

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.