LAST week, in response to Dr Yumiko Kadota’s blog, I wrote an article calling for the abolition of unaccredited registrar positions. Throughout the week, a string of articles emerged in the media – for example, here – reporting doctors working in horrific conditions but too afraid to speak out publicly for fear of jeopardising their chances of getting a training position.

I was delighted by the overall response to my article, and at the time of writing this article, around 80% of the 408 voters in the poll agreed or strongly agreed that these positions should be a thing of the past.

I was also contacted by a large number of people seeking clarification as to what an unaccredited registrar does and why I, along with others, have continually labelled the current situation facing junior doctors a training crisis. This is hardly surprising as the training environment has changed so rapidly and affected different specialties at different times depending on where the training bottleneck tends to occur.

The number of doctors graduating each year was fairly stable up until 2006, before exploding. By 2013, the number had doubled and continues to rise at an unsustainable rate. Predictably, the number of doctors graduating far outstripped training places and thus a training crisis emerged. This means that doctors who applied for training posts in 2008 faced a radically different process to aspiring trainees of today. I graduated in 2010, and due to differing lag times, my surgical colleagues, who are almost all unaccredited trainees or very junior accredited registrars, have had an entirely different experience to my physician or anaesthetist friends who are almost universally first-year consultants in their subspecialty of choice.

Considering this mosaic, it is understandable that, in my experience at least, even the youngest of consultants often find it hard to relate.

Although when discussing the training crisis I often refer to surgical training numbers, it is important to clarify that this situation is by no means limited to surgery. The main reason that I can refer to surgical training numbers is because of the Royal Australasian College of Surgeons’ admirable transparency when it comes to trainee selection — a standard that I believe all Colleges should be held to.

Yet, even in the absence of published data from some Colleges, it is clear that aspiring applicants to nearly (if not) all specialties, from general practice to radiology, face a torrid time. Indeed, whereas my physician friends had fairly linear training paths, today’s aspiring physicians face many of the same bottlenecks as surgical trainees, albeit at a slightly different stage of their training.

So why does this all matter?

In contrast to the North American system, the Australian training model has traditionally promoted an exploratory approach to finding a specialty. Until very recently, junior doctors were generally encouraged to try a few things, take their time and then decide on an area of interest. With barriers to training usually low and a supply and demand ratio favouring doctors, specialisation was generally guaranteed for those seeking it and willing to work hard enough to pass exams. Even this week, the few people who have come out in favour of unaccredited positions have lauded them as opportunities to “try out a speciality”.

But times have changed.

The oversupply of medical graduates has dramatically shifted this paradigm, with applicants for specialty training far outstripping the number of training positions available. With few, if any, programs undersubscribed, this mismatch will worsen in coming years, with potentially serious individual and cultural consequences.

Take for example an aspiring surgeon. Many surgical specialties now require applicants to be a minimum of post-graduate year (PGY) 4 by the time of application. Further prerequisites often include the completion of the General Surgical Sciences Exam and specific resident rotations, such as emergency and intensive care. In addition, evidence- and skills-based curricula vitae mandate the completion of certain clinical milestones (such as a first operator appendicectomy). These requirements are subject to frequent change and are often restricted by recency limitations. For example, from 2022 completion of a clinical exam will also be a prerequisite to apply to some surgical specialities.

Yet even if this exhaustive checklist is completed, depending on the year and specialty, an applicant has a less than two in 10 chance of getting a training position. Traditionally, unsuccessful candidates would face a simple decision: try again or switch specialties. Increasingly, neither of these options are available. Again, this scenario is not limited to surgery.

The tsunami of medical graduates means that there is an unprecedented supply of junior doctors merging with a compounding group of those waiting to access training. Yet, it is clear that doctors cannot be held in a holding pattern forever.

The enterprise bargaining agreements (EBA) in each state and territory vary, although there is significant overlap. If the Victorian EBA is used as an example, it is evident that for much of the first decade of their career, a doctor’s pay increases year on year, independent of expertise. Indeed, in Victoria, there is an arbitrary change of classification from hospital medical officer to medical officer (or registrar) after 3 years of practice. This is unavoidable and cannot be renegotiated on a case-by-case basis. Regulations around individual flexibility arrangements specifically prohibit such undercutting.

When supply failed to meet demand, the hospitals had little choice but to pay these rates – and doctors benefited. Not anymore.

Why would a Victorian hospital pay a PGY6 (MO3 — $2264.90 per week) to do the same resident job that, on paper at least, a PGY2 can do (HMO2 — $1521.50 per week)? During a time of severe budget cuts, this is one area where it is easy to make savings. Experience-based discrimination follows. In turn, it is extremely difficult for juniors to explore various options or change their minds once committed to a path. They are simply priced out of the market. This is a very realistic proposition for a whole range of doctors but I will give the example of a “failed” surgical trainee wishing to complete the prerequisite prevocational experience required to apply for general practice.

The ramifications of this cut-throat application process are beginning to emerge.

First, it has created a qualifications arms race whereby juniors often spend all their time away from the hospital, as well as all their discretionary income, on skills courses, exams, or graduate level study. This raises the selection stakes even further, promoting an all or nothing culture. It remains questionable whether any post-graduate study leads to better clinicians.

Second, it has made junior positions a veritable battleground. Prerequisite rotations are not rationalised across Colleges. Therefore, there is often far more demand for rotations mandatory for multiple specialties than there are jobs available. Human resources departments, previously desperate to fill positions, are now simply overwhelmed with applications.

Take, for example, figures published in the Postgraduate Medical Council of Victoria (PMCV) 2010 and 2014 annual reports. Among other things, the PMCV runs a computer match, facilitating the placement of interns and hospital medical officers along with basic physician, radiology, nuclear medicine and radiation medicine trainees.

Analysis of the figures tells a frightening story. In 2010, with intern and nurse numbers excluded, 236 of 1318 (17.9%) of applicants missed out on positions. This shortage was partly mitigated by 81 unmatched hospital places that these unemployed junior doctors could theoretically take. Four years on, in 2014, as the training crisis started to emerge, the number of doctors missing out on places rose to 571 of 1918 (29.8%). This represents a 142% increase in the absolute number of junior doctors missing out of placements. A figure for unmatched hospital positions is conspicuously absent from the 2014 report.

It should be noted that these figures are limited to Victoria and do not represent job uptake.

Some doctors may have accepted other roles or decided on a year out of clinical medicine, thereby freeing up positions for unemployed doctors. But many such doctors would be included in the 410 and 417 doctors who withdrew from the match in 2010 and 2014, respectively. A paucity of data combined with the lack of a nationalised system for the recruitment of pre-vocational doctors makes further analysis difficult.

Worryingly, the PMCV figures do not take into account many doctors trapped between their third year of practice and a formal training position. Numerical data quantifying this group are sorely lacking, but applications to specialty Colleges provide a surrogate marker. Again, this makes for troubling reading, with 1600 surgical and GP applicants alone missing out on training positions in 2014. It is highly likely that since 2014, the crisis has expanded its base and worsened in severity.

Anecdotal evidence is beginning to mount that insufficient workforce planning is leading to a generation of unemployed and unemployable doctors. A new paradigm is emerging: fail to get a training place (and a very significant number do fail) and the odds of finding a suitable position are worsening by the year. Failure to find a suitable position means juniors run a real risk of falling into a vicious cycle whereby recency limitations mean that past experience is no longer recognised. With locum positions at this level severely limited and the odds of getting back into the system deteriorating with unemployment, a career cliff looms.

Just what junior doctors should do when faced with such an inflection point is difficult to say. There are some who would argue that medicine is finally being subjected to the same supply and demand dilemma that other professions such as law and engineering have faced for years. Proponents of this line would likely argue that market forces will result in a new equilibrium with the cream rising to the top. However, economic theory dictates that such an equilibration only occurs in a truly free market. Medicine is anything but.

Indeed, even in the case of GP trainees, an area of readily identifiable need, hundreds of applicants are rejected each year. The limitation of training places, whatever the rationale, in effect creates a restraint of trade.

Juniors could move overseas but this is a costly and uncertain move laced with red tape and further examinations. Australian doctors are further disadvantaged by the absence of memberships (as opposed to Fellowships) awarded to doctors in training who have successfully completed their first part examinations, as they are in the UK. As a result, those who are unsuccessful in gaining a training place will leave the specialty without any formal recognition of the exams they have passed or time they have served. Therefore, any transfer overseas likely represents starting again at the bottom. Then, should that doctor wish to return home, they would face a challenging qualification recognition process that is marred in uncertainty and subject to change at any time and with no regard to precedent.

Invariably, some will choose to work as career medical officers or go into medically allied industries, such as research. Yet, for a great number, the stark reality is there will be little option other than a complete career change. Not only is this a great waste of resources and investment, but it will likely be an immense personal challenge to those who have devoted 15 years or more to pursuing an undergraduate degree, a medical degree and several years as a junior doctor.

I understand that the same could be said for fully trained specialists unable to find work due to a drastic increase in the number of trainees entering their field. This is a legitimate and understandable concern. So too are concerns around training quality and ensuring that standards of care for patients are maintained at all times. But in my opinion, a fully qualified specialist is empowered and has options to use their qualifications in a variety of ways. Perhaps most ideally for our patients, they could move to areas of unmet need and provide much needed services that improve health equity. Alternatively, they could leverage their qualifications into a career change as an expert in their field, should they so choose.

Again, I am sympathetic to, and do not want to dismiss these concerns. However, I still see all of these options as better than continuing to treat our unaccredited registrars as they currently so often are. It is worth remembering that many of these doctors will have completed just as many exams and years of work as consultants of the past, and possibly far more skills courses and other postgraduate study. On balance, my personal view is that expanding training numbers is the utilitarian way forward.

Undoubtedly, this is a complex and challenging issue. The correct solution is probably to go back in time and prevent the reckless and irresponsible increase in medical school places. Obviously, that is impossible. It is time that we work frankly, collaboratively, compassionately and quickly to address this issue because to those out of work, or stuck in training limbo, one thing is crystal clear: training reform is urgently needed.

Dr Tim Lindsay is an Australian doctor and PhD student in the MRC Epidemiology Unit, at the University of Cambridge, UK, supported by the Cambridge Commonwealth Trust.

 

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 that is so stated.


Poll

If a hospital has a need that can be filled by an unaccredited registrar, then a training position should be created instead, to fill that need
  • Strongly agree (62%, 495 Votes)
  • Agree (17%, 136 Votes)
  • Disagree (9%, 74 Votes)
  • Strongly disagree (8%, 60 Votes)
  • Neutral (4%, 35 Votes)

Total Voters: 800

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36 thoughts on “Career cliff: an end to the Australian training model?

  1. Anonymous says:

    Really well written article – thanks.

    As a physician we are interested in similar issues. In the UK where there has been an oversupply of applicants, a research degree is perhaps the medical equivalent of an unaccredited position. To a certain extent, again a type of cannon fodder. But it also means that their graduates are excellent by the time they are finished, whereas in my field, neurology, there are some people now coming through with pretty limited training, little or no research experience and therefore no ability to interpret research, and limited interest in learning more as far as I can see, which is a problem given the depth and complexity of our field.

    I’m not sure that just because the position is exploitative, perhaps a dead end etc means that all unaccredited positions should go – as I can’t see any current alternative. But good on you for writing about it. And there is no doubt that the expansion of graduates without downstream changes has shown the workforce planning aspects to be a fail – unless the idea is a marked laissez faire…which with medicine / peoples’ lives may be not so wise

  2. Anonymous says:

    This excellent summary of current circumstances makes sober reading. In the dim dark past, any registered doctor could receive a provider number. As a young doctor I moonlighted for after-hours locum and home visit services as well as doing weekend locums at rural ED. This type of work suited a young (and then single) graduate who was willing (and able) to work additional hours at unsociable times. Perhaps one possible solution to the disaster that is unemployed doctors, would be to introduce regional provider numbers for non trainee graduates. This would allow them to provide needed services in regional areas, support isolated doctors, gain experience and study while working towards a training program. Reducing the number of medical graduates is the long term solution, but there is a pressing need for some short term interventions.

  3. Anonymous says:

    While I don’t support unaccredited training positions I don’t believe the situation is a dire as portrayed in this article. There are still trainee registrar vacancies in psychiatry and in rural training positions. When I last looked Australian Graduates did not face the enormous hurdles described to obtain training positions next door in New Zealand.

    As A Director of Training in NSW what I am hearing about is medical graduates who only want to work in their desired specialty in the select group of hospitals that they deem suitable. Maybe they could be encouraged to think more broadly both as to where they will work and in what area they will train.

  4. Anonymous says:

    Dr Lindsay has simply and succintly produced a ‘business case’ review of the appalling action of government and their advisory bureaucracies over the last decade or so wrt medical training and IMG importation practices in this country. I have always thought that the ludicrous blow-out in medical school numbers (most of dubious calibre) and IMG import numbers undertaken by governments of both persuasion (but mainly by Labor) was nothing more than an crude and obvious attempt to drive down the earning capacity of future medical practitioners by manipulating the labour market supply and demand balance without any consideration for the training position numbers available down the track for this avalanche. If you remember (perhaps you don’t) that it was the ‘wise’ Labor bureaucrats who decided in the early nineties (during Hawke and Keating’s time in government) that the best way to control Medicare payments was by reducing university training places.Of course that caused a dearth of Specialists in training ten years later. The last fifteen years has been nothing but a knee-jerk response (of dual purpose) to deal with that government induced fiasco. What you are seeing unfold unfortunately is exactly the outcome that you get with Socialist command economies. Clearly the current Medicare Review process is just the next step in tightening the Medicare budget.
    Pardon my cynicism, but perhaps all these under-employed and potentially unemployable young medical graduates should consider a career change and become Psychologists so as to join the latest 2 billion dollar blow-out gravy train again created by bureaucrats on the altar of dumb government policy decisions.

  5. Anonymous says:

    It will be good and fair to everyone in the general medicare/medical policy decisions to be discussed, opinions made by appropriate stakeholders and the approval of the new policy changes in the government health issues, to involve a representative in each qualified leader of the specialist, medical trainees, medical students, IMG, and maybe a public community member interested in urban and rural health needs to be sorted out, in the best interest of the Australian people.

  6. Patrick says:

    reply to anonymous 4 – are the notorious socialists who run the surgical subspecialty boards also in on the conspiracy? They certainly benefit from exploiting unaccredited training positions.

    Back in the real world, both political parties enthusiastically increased the number of medical students in the 90s and early 200s, see for example Howard’s introduction of the bonded medical places scheme and accompanying 25% increase in student numbers. The recent attempts to establish new medical schools have also been led by liberal governments.

    Poor planning by nearly all of the responsible parties has created this problem – to my mind, a bit more of the centralised planning you’re complaining about might have improved the situation.

  7. Anonymous says:

    Anonomyous comment # 4 is clearly angry to the point of being a conspiracy theorist about it, but why should medical graduates be guaranteed anything? If I do an engineering degree or a law degree what I have at the end of it is a degree, not a guaranteed job for life as an engineer or lawyer. Our profession is a bit precious to think only we are entitled to have all our graduates employed in the careers of their choosing.

  8. Prof. Berni Einoder says:

    Keating in the 1980’s first restricted medical intake assuming that it would reduce costs that made things worse, many jobs were filled by Overseas trained Doctors some took ages to become useful
    Keating then opened the gates by increasing medical student positions and imports and also allowed advertising by the medical profession in the vain hope that competition would force down prices. This increased the numbers as well as the costs
    Keating then lost the election and no Government since has had the courage to fix the system.
    Most country hospitals still have difficulty filling all medical positions including Consultants, hence there has been no reduction in OMGs.
    There is no one solution to this problem but a good start would be;
    1, to fill all posts with Australian Graduates first and make it mandatory to do two years of internship before full registration.
    2. Rotate these second year interns to the peripheral hospitals that have difficulty recruiting their own staff
    3..make it a prerequisite to have worked at least one year in a peripheral hospital prior to allowing them to enter a tertiary training position.
    4. Make it obligatory to do at least one year in a peripheral hospital during your training to become a consultant.
    5, Increase the remuneration of Doctors working in the country town where they see less patients per day but are on call most days and nights
    2, increases the number of career positions in all hospital to replace the unaccredited posts where people linger in purgatory and then get thrown to the wolfes
    he

  9. Anonymous says:

    No ones forcing them to do these unaccredited jobs.

  10. Greg the Physician says:

    In reply to Prof Einoder, the problem with forcing young inexperienced doctors into country rotations is that they are frequently inadequately trained for the work they have to do in these regional hospitals. Therefore they have an unsatisfying and stressed professional experience and so never want to work in a regional centre again. I went from two months into my PGY2 year (JHO) to Relieving Medical Superintendent at a hospital in inland Central Qld. I had asked for experience in obstetrics and resuscitation (especially intubation) prior to departing Brisbane and was laughed at by the Deputy Medical Superintendent for making such a request. My time on country relieving duties was repeatedly extended and I was transferred to another country hospital in a one doctor town. Eventually I had to threaten to resign in order to return to Brisbane in time for my own wedding. And yes, I needed obstetric and resuscitation skills during this time, and experience in other areas, including managing unconscious head injuries, bilateral traumatic haemothoraces, and a miner who lost his leg in an underground accident. I never had an uninterrupted night’s sleep the whole time I was there and was continuously on call every night and weekend.
    If you think junior doctors in non-accredited city positions are exploited, you should take a long hard look at those who are forced to do rural and regional relieving rotations as the price of being re-employed in a city hospital’

  11. Ian Hargreaves says:

    A friend’s son trained in diagnostic nuclear medicine about 7 years ago at the time when MRIs were supplanting many nuclear medicine techniques. After graduating, only 2 of 60 trainees got jobs (not good jobs, advanced jobs – just jobs. 58/60 unemployed in their field. He worked as a croupier at the casino to pay the bills.) My friend wrote to the NSW State health minister about how this situation could be allowed to happen – she replied that universities were federal, and the state government had never promised anyone any jobs.

    My primary school teacher daughter was informed by the New South Wales Teachers’ Federation a couple of years ago that there are 44,000 teachers in the state like her, who do not have tenured jobs, only casual work. If “this makes for troubling reading, with 1600 surgical and GP applicants alone missing out on training positions in 2014” that small number of doctors may not get much sympathy if they complain at a parent-teacher night. Although they won’t meet my other high school teacher daughter, who after having a baby didn’t get the generous maternity leave that tenured teachers get, and then discovered her casual contract was not renewed. Yes, the government can do that. Nor should a doctor expect much sympathy when buying shoes from my youngest daughter, whose qualifications are in musical theatre. According to Actors’ Equity, only 3% of its members are in a job at any given moment. By contrast, my son (anaesthetic registrar) has never been unemployed in his chosen profession – he doesn’t have to sell shoes to earn a living.

    Whenever anyone becomes a medical politician such as a college president, they seem to lose their ability to be honest, as with other politicians. I wonder whether they tell their patients “your cancer is all gone and everything is fine” rather than saying “I am sorry, your cancer is not curable”. The end result is the same, but I suspect most of us would prefer honesty upfront.

    In the case of unaccredited surgical registrar positions, what leaders of the profession cannot admit is the need for human cannon fodder, to maintain 24hr rosters. If the Hospital has 3 plastic surgeons and 2 trainees working a brutal 1/2 roster, there is a reasonable prospect of each getting a consultant job (assuming a 30-yr career, there will be one consultant vacancy every 10 years). However, if safe working hours are implemented by having 5 or 6 accredited trainees, that is too many for them to have a reasonable chance of a senior position. And even with 6 trainees, each will be on call one night a week and back the next day, or will do rotating night shifts, to provide 24 hr cover. In the UK where Dr Lindsay works, this is achieved by having overseas-trained doctors including many Australians in ‘service’ jobs, with no prospect of a consultant position. When I did a fellowship in the UK in 1990, my registrar colleagues were an Indian, 2 Irishmen, a Pole and only one Englishman. Only the Englishman remains as a consultant in the NHS.

    Having junior registrars who fail to get a training position, means that those people are put out of their misery earlier, rather than having them go through training positions and paying their training fees ($6,370.92 per annum for an advanced RACS plastic trainee, plus fees for compulsory courses), without any realistic prospect of getting a job at the end of their training.

    I suspect the College would be enthused by Dr Lindsay’s suggestion of making all training positions advanced, thereby requiring all trainees to pay the Generic Surgical Science Examination Fee ($4090), the Clinical Examination Fee ($3100), leading up to the Fellowship Examination Fee ($8495 with around 70% pass rate, no discount for repeat exams), and for those who pass the examination, the Fellowship Entry Fee ($5550) – a quaint term for what the real estate agents call ‘Key Money’. Then the Annual Subscription ($3155) in perpetuity, if they want to stay registered as a specialist.

    Training risks becoming an unsustainable pyramid scheme if the arithmetic is ignored. If training takes 10 years, and a specialist career is 30 years, a trainee/surgeon ratio of 1/3 pretty much guarantees a job, 1/1 gives a 1/3 chance, and 2/1 gives only a 1/6 chance of a specialist job. Population growth or expanding the range of surgical procedures may drive some greater demand, but not the vast increases required to accommodate an ever growing population of trainees and well-qualified OTDs.

    These back of envelope calculations are conservative, if trainees start as advanced trainees and take say, 6 years, any ratio over 1/5 expands the specialist pool. Although Dr Lindsay feels: “in my opinion, a fully qualified specialist is empowered and has options to use their qualifications in a variety of ways” this is not the case for surgeons, who need a hospital operating theatre and anaesthetist to do their work. The sort of bush operating that Fred Hollows did a generation ago would now be in breach of infection control guidelines.

    Perhaps the question that needs to be asked of (particularly surgical) trainees is: “Would you prefer to work a 100 hour week while training, then a 35 hour week as a specialist, or a 35 hour week while training, and a 12 hour week as a specialist?” Alternatively, the trainees can be offered specialist employment based on their training hours–if you work an average 100 hours a week during training (i.e., 2 of you working your tails off, 1/1 rosters when the other is on holidays), you have 100% chance of a consultant job , but if you work a 35 hour week during training (i.e. 6 of you working rotating shifts), you have a 35% chance of a consultant job.

    One of my regular surgical assistants pointed out that in Taiwan where she trained, there were people with PhDs staffing retail outlets, because of the number of people who valued and pursued higher education. If unemployed or underemployed doctors need work, my daughter is acting manager at the shoe shop, and is always after staff with good people skills, a sharp intellect, high ethical standards, and trainability.

  12. Anonymous says:

    In response to 7, medical education is very different from law and engineering, which teach highly transferable skills. Medical graduates can be good for research positions. But is there anything else that is offered in med school? We do not learn business, entrepreneurship, finance, law, or management skills. Even my previous science degree prepared me into a wider career options. Unless medical schools run education like science and engineering, then it will be pretty harsh for medical graduates to pick up any other jobs.

  13. Elizabeth Sigston says:

    I disagree with your poll. Based on my 9 years on the training board for ASOHNS the situation arises where posts do not meet the minimum requirements for a training post. These include a minimum of 2 FRACS in the service, 3 supervised operating sessions per week, 1 supervised outpatient session per week, microscope in outpatients, no more than 1 in 3 on call ect.

    The problem is whilst the training boards can set criteria for accredited trainees, unaccredited trainees have no representative or oversight body. The way forward would be to have an ‘unaccredited training Board’ at RACS that could set conditions on these posts. Good unaccredited positions are very valuable for trainees.

    Having worked overseas and supervised many overseas fellows, I can say that Australian trained doctors are at the top of the pile, primarily because of the broad scope we start with. Choosing which speciality you wish to do as a medical undergraduate is a bit akin as choosing which University course to select in high school- most will have no idea.

    The second part is that all governments have become reliant on medical staff of all levels working unpaid hours to the point where this has become not only the accepted practice, but the expected practice. This is the true crux of the matter. When you do not pay people hours worked, you say that you don’t value them. The medical profession has been undervalued by administrators and governments for way too long. Pay the experts in healthcare what they are worth, and watch our healthcare system flourish. And I would predict very little true increase in cost.

  14. Anonymous says:

    As a member of the “tsunami” of medical graduates, a lot of this resonates. Having spent tens of thousands of dollars on expensive conferences, courses, and application fees, I would be extremely jaded if it was all for nothing.

    But ultimately while junior doctors will suffer and be jaded and have high rates of suicide, the Australian public will probably benefit. In my short career I have seen plenty of colleagues give up on their surgical dreams and move into GP or Psychiatry. A lot of new Emergency Consultants (where private practice is very limited, and where there are few unaccredited registrar positions and thus plenty of newly graduating consultants) are working peripherally or regionally, or doing fly in/fly out work. Other specialties will eventually follow. It is probably better for rural towns to have unhappy doctors working there, rather than no doctors at all. The career cliff for doctors is a danger for city slickers but still some time away for those willing to work regional and rural.

    Of course there could have been better ways to encourage doctors to work regional and rural. James Cook University has to be really commended for prioritising Australia’s future rural medical workforce and implementing that in their selection criteria.

  15. Anonymous 4 says:

    I am neither angry nor a conspiracy theorist, just trying to add historical perspective on we where find ourselves wrt to medical education. Prof Einoder is correct in asserting that it was the Hawke Keating Government that created the initial error by freezing medical training posts in the late 80s early 90s (transferring positions from Adelaide to Townsville instead of adding numbers to match overall demography). The logic of the times was that doctors generate Medicare costs so that restricting numbers would logistically put a break on them. The beauracrat who championed this action actually admitted the error in the Australian a couple of years ago. The Howard government was culpable in failing to respond earlier to correct the looming specialist and junior doctor shortages this created and under extreme pressure from the states belatedly opened the flood gates to undergraduate training positions and IMG visas in an uncontrolled and currently uncontrollable fashion. Ironically it was in fact a remote Labor party beaucracy that created the problem by initially allowing Reaganomics to drive Healthcare here. Everything ‘Ian’ asserts is true. I have two medical graduate children, both now well advanced in their careers and both were fully aware of the issues ahead for the younger people following them. I have no idea what answers can be found to now adjust medical training to meet demographic needs but I do know something urgently is required to prevent the massive waste at both a personal and government level that is occurring as we debate here. Our brightest and best have been dreadfully let down by successive governments so in that respect I do plead guilty to a charge of anger.

  16. Anonymous says:

    O&G can’t get rid of unaccredited registrars unless CMO roles (with ongoing training) are created. To supply a 24hr on-site service in regional and rural areas requires many more doctors than training places – without the scope for training for them all. I’d hate to have to water down the surgical experience of the few trainees in my centre just to cover the on-call.

    I’d like my College to take on CMO support. This could also be an escape option for the many trainees that “never quite get through exams” despite being great team members. I’d also like to stop more IMGs arriving, while they have been an asset in the past (and no-one would suggest sending those already in our system away) going forward we should look after our own first

  17. Jon Smit says:

    Anonymous 3 – to hear a self-proclaimed Director of Training speak so ignorantly of the problem is the most concerning part of this article.

    Dr Lindsay has presented empirical evidence of a rapidly worsening training crisis and your response is – I’ve heard of one or two places out bush. Do you also dismiss meta-analyses in favour of your own anecdotal experience?

    You do realise that juniors go to places with a track record of getting people onto training programs, don’t you? This is often impossible in the country. For example, I worked in Geelong for a while (as well as Warrnambool and Hamilton). They are brilliant hospitals with supportive consultants, but they have an abysmal track record of getting people onto training programs – so many doctors leave.

    Some of the other responses ranging from advice to go and sell shoes, to victim blaming, to complete denial of the problem demonstrate remarkable levels of arrogance and a concerning lack of empathy.

    As a junior doctor currently severely depressed as a result of the predicament I am in, it is heartbreaking to see such callous responses.

    Those currently sitting on medical thrones would be wise to show a little more compassion. Disruptive technologies are emerging by the day and people have long memories. I doubt aggrieved former doctors will show one ounce of mercy when their start-ups systematically make doctors obsolete. One speciality at a time. After all, the majority of senior consultants have shown them none.

  18. Anonymous says:

    Anonymous 16 – why can’t everyone working within the unit be a trainee? Australia is one of the very, very few places in the world where unaccredited registrars exist.

    It is also one of the very few places in the world where training is so service driven, as opposed to properly developed and structured as in the US.

    The underlying cause is a mystery…..

    Actually, oh that’s right – Australian doctors need to protect their private incomes first and foremost.
    Where is Australian medicine’s version of Bernie Sanders when you need him.

  19. G.Wong says:

    The shortage of training spots exists because these particular specialties are anti-competitive. How else do you earn $600k/year? They don’t want to dilute that.

  20. Anonymous says:

    Why can’t we cut back medical school places which is the root cause of the problem?

  21. Marcus says:

    Because, #18, a training post needs a threshold quantity of ‘material’ and cases to learn on and supervisors to oversee the training. Work that needs doing for the unit – which may be menial or service tasks by an unaccredited registrar – may not equate to quality training exposure.
    The US may be well-structured, but the surgical case load for a US trainee in my specialty is about 1/4 – 1/3 what we would expect for an Australian trainee at the completion of our program. A similar dilution is what one would get here if all posts were made into training positions and the cases had to be shared around.

  22. Anonymous says:

    Hi Anonymous 18 from Anonymous 4. All training is also Pro Bono here and in the UK. Don’t see lawyers or anyone else doing this do you..
    In the USA, gross over-servicing and over-reporting of a level not known anywhere else in the world also exists as a consequence of that structure. Careful what you wish for.

  23. Anonymous says:

    A very succinct article that is relevant to the current situation for junior doctors.

    However, one thing that I think has been entirely overlooked is the fact that graduates are now 60% female and many of whom are looking for part time work and training options and will need to have maternity leave during training. Perhaps addressing training options for the new demographic of doctors also needs to be considered?

  24. Louise says:

    As Anonymous 16 says – colleges offering CMO/PHO support, or a separate entity that supports CMOs, locums in the middle of or not in training, and other doctors who aren’t recognised fully or partially by a college, would be welcomed.

    Something State and Territory-agnostic, as so many of us these days are relocating interstate for at least a year, if not 10, to work in Accredited or other more recognised positions to enhance our chances of furthering our trainee journeys. (I have worked more than half of my career now while an Interrupted trainee and none of this work counts towards any training with any College despite locuming for Accredited college trainees in nearly 30 of these jobs.)

    Also agree with Anonymous 23. And it’s not just impending mothers who are keen for part-time. The degree and speed of information we are swamped with in the digital age, let alone unjust hours, relentless bullying and other unnecessary pressures, make us more prone to burnout. As doctors, we see patients whose lives end or are severely crippled by their late 20s, 30s, 40s – many through “lifestyle diseases”- we know we should practice what we preach, and how can “doctor, heal thyself” if colleges and hospitals penalise us through joblessness for wanting to work parttime to retain one’s mental wellbeing?

  25. Louise says:

    Thank you Tim for another great article.

  26. Anonymous says:

    Try a College like Dermatology for example who charge $ 1600 for an application for a training position and at the time of applying they can’t even tell you if they will have any positions in that state !!! And if that is not bad enough the fee is not refundable if no training positions become available (WA and SA regularly have nil or 0.5 FTE positions only) .
    Totally unfair, incompetent system. No other industry would get away with such silly systems

  27. Pacho Pepe says:

    Having young doctors work in unaccredited training positions is nothing else but a modern / hidden slavery model.
    The Colleges have too much power, young professionals who have performed all their life to become a doctor have their careers delayed or shattered, their dreams destroyed, their self esteem and confidence is crushed. Is anyone surprised about the high number of suicidal doctors? I do not have the impression. Does anyone really care?
    The Colleges hold the power in order to protect ….what really? The income of the fellows? Shame. High standards? Nonsense. The restrictive attitude is certainly not in the best interest of young doctors, future quality improvement or in the best interest of the Australian population or the patients. If you work in a training institution and your work is comparable to the work of a candidate working in an accredited position the time a doctor spends at work should be accredited. Until all empty positions are filled in the acute hospitals nobody’s work should be unaccredited (= not acknowledged). It is an ethical question.
    The Colleges have created a two class system: the accredited ones (winners) and the unaccredited ones (losers).
    This is not only unfair, it is against Australian principles.
    Advance Australia fair!

  28. Anonymous says:

    i have to say that unaccredited posts used to be called RMO years, they let us choose what we really wish to do for the rest of our lives without the need for study for exams, and the feeling ‘we failed’. in the old days that was compulsory and as such doctors gained extra experience. we now have a rush to commence and complete training, yet each position is costly to both the doctor and the employer.
    however, we have BPT training positions available in regional SA, which are not filled as well as physician positions covered by locums as no Australian trained doctor thinks it is a good idea to work in a regional hospital. so, if you think you wish to train, come on down and get employed. if you think that regional hospitals do not offer what you are looking for, then perhaps you do need to think about what it is you wish in life. I have found it a pleasure to work in such areas, with patients who are much nicer and more common sense in their approach to life.

  29. Marcus says:

    Yes Pacho Pepe (27)!
    “High standards? Nonsense.”
    Agree: make all the posts accredited, even if it means spreading the training material more thinly.
    And let’s not just restrict it to medical specialists: what about the closed shop for airline pilots???
    Like you, I would be entirely happy flying in an A380 with a pilot who has done only 1/3 the number of flying hours compared to what was as was traditionally required.
    How hard can it be?!

  30. Anonymous says:

    The answer, of course, is to reduce medical school places.
    There is NOT a need for many more non-GP specialty consultants.
    There IS a need to keep up a minimum case load for those that are working.

    Healthcare costs money.

    I’m assuming #29 is being sarcastic…
    Oh, and it’s worth noting you do get paid to be a registrar, even unaccredited.

    It’s a tough gig we’ve chosen. But lives are at risk.

  31. Anonymous says:

    I agree that abuse of ‘unaccredited trainees’ shouldn’t be tolerated and hopefully shedding a light on recent examples of this helps to end some of the exploitation that clearly still exists.

    I disagree, however, with the proposed solution of giving out additional accredited training positions. The two additional points that I don’t think have been made in the comments above are:

    1. The risks of increased over-servicing with larger numbers of private practise – If there were even just twice as many surgeons and no additional public positions, what will happen to all of the extra consultants? There will be a huge surplus of surgeons in an already small market. Is it not inconceivable that this would lead to further over-servicing in both the public the private sector at a massive cost to consumers and tax payers? Just so that everyone that wants to be a surgeon gets to be one? I don’t think so.

    2. Do people in other careers just get to become a manager because the want to be? No, they have to work for it and be better than their peers vying for the same position. Lawyers don’t just get to be a QC because they want to be one. Builders don’t just get to own a successful business because they want to. Politicians don’t just get to be a minister because they’d ‘always dreamed of being a minister’. They have to work hard and be the best they can to get there. And even then, they still might not. So they have to move on and try something else. Surgeons are managers, and take responsibility not only for their patients, but often also of the staff they work with or employ in private practice. These skills take time to develop and doctors should’t just expect that because they’re doctors and that they’ve always got what they wanted that this will continue indefinitely.

  32. Anonymous says:

    Although the work is there, the training capability and support is not. We need to enhance the CMO or PHO models otherwise we will end up with too many consultants who haven’t experienced enough cases within their own specialties. We cannot just turn all unaccredited positions into training posts because there is already not enough support to ensure we are churning out quality physicians, surgeons or whomever.

    However I agree we do need more quality trainee doctors in regional areas. This is not a one size fits all solution, but I disagree that turning unaccredited positions into accredited positions are going to solve this. I also echo that we have too many medical student places, and not enough training places. There are some specialties now that have seen an over supply and people become indefinite “Fellows” or have very small fractions in public hospitals and work in other non-related fields – Radiation Oncology, Nuclear Medicine Physicians, Cardiothoracics. This problem will only deepen as the new wave of medical students hit, and creating more accredited positions without fixing this problem is not the answer.

  33. Pacho Pepe says:

    Anonymous: out yourself! Who’s interests are you representing??
    Certainly not the ones of doctors trying to get their work accredited.
    The answer is not simple and there is no ideal model.
    However: as long as hospitals struggle to recruit for registrar positions (and this is the case in metropolitan as well as rural areas) doctors applying for these positions and filling empty registrar positions should be accredited for the work they do. Everything else is abuse and hidden slavery.

  34. Mike says:

    Many interesting points made about this important topic.

    A couple of points I would highlight are:

    1) Medical students are trained by universities. I don’t confess to know the specifics of federal funding for medical student places at universities, but based on my experience and observation it seems to me that universities will train as many medical students as they can because they benefit financially. And we all conveniently ignore the fact (as someone else mentioned) that no other degree comes with a guarantee of employment, so why are we (doctors) any different? Ultimately the world is a competitive place – especially the employment market – and those who can do the job better will generally be rewarded with a job over someone judged to be not quite as good. That’s real life! I appreciate that governments may be able to influence the overall numbers of medical students, but they don’t do it for teachers or scientists or lawyers, etc, etc, so why are doctors any different? That is a genuine question – why?!

    2) There are many other professions where people ‘slave away’ trying to get to the top but never quite get what they wanted. Just look at professional sport for the most obvious examples! There are literally thousands of really good and highly-talented people who ‘nobody has ever heard of’ because they just aren’t as good as the top-level professionals like Roger Federer, or Serena Williams, or Phil Mickelson, or Cathy Freeman….you get the idea. These people chase a dream for years and put it all on the line only to ‘never quite make it’. It happens to actors, and I suspect in every single profession – teachers, ‘tradies’, small business owners, etc. I’m not saying we should all be cut-throat and mercenary about it, but the sad reality is that (as someone already said) not everyone can end up doing exactly what they want. If you work hard and end up being better than most of ‘the others’ you will likely get to the top (i.e. get on your chosen training program and become a qualified specialist in your chosen specialty). It is unrealistic to think that junior doctors can choose a specialty and virtually be guaranteed of reaching the end goal.

    It is sad when people have a dream and work hard and ultimately don’t make it, but perhaps we need to focus on the alternatives, and particularly on support for those who are unsuccessful. Maybe there could be more training places – especially in rural areas – but training needs both quality AND quantity. Any rural training place needs to be a quality experience with enough quantity to not just maintain knowledge and skills, but more importantly to develop and expand the knowledge and skills of the trainee. It’s not just about service provision, although that is something to consider. The other vital ingredient is appropriate consultant supervision, and for many reasons this can be suboptimal in both rural and metropolitan areas. Due to reduced specialist numbers and high workloads in rural areas this may be a particular training issue in rural areas.

    The arguments about ‘volume of practice’ can not be ignored – for trainees or specialists – regardless of location! Dismissing these concerns would be naive and lead to an erosion in standards. For most medical specialties I think Australians are admired around the world and considered to be at the ‘top’ with regards to quality and standards of practice. It would be a shame to see that change, and to dilute training experiences significantly would be a major retrograde step.

    This is a complex issue with many factors to consider, but ultimately unaccredited positions have pros and cons from both sides. I think the bigger issue is appropriate career support and mentoring from the hospitals, with reality checks for aspiring trainees. Attention to “safe working hours” is something that needs more attention and governance in most hospitals, and clearly there is room for change/improvement across the board generally. This could and should be a focus into the future, because nobody should be ‘abused’ in any role – either accredited or unaccredited.

    In any profession/specialty there will always be casualties….those who ‘have a crack’ and don’t make it. We need to make sure that regardless of the stage of training junior doctors are supported during the whole process, and can transition to other pathways if the need arises. Sadly the same applies to medical students who may find themselves without a job.

    This is the new reality!

  35. Anonymous says:

    It’s a social issue to have many qualified people unable to find employment in their field. And yes, this is so for lawyers, teachers, engineers, etc. It’s a massive social drain to have people waste 5+ years of their life training for a job that doesn’t exist, then heading back to uni for another 2-5 years to re-train in another career. Medical training, unlike e.g. legal training, doesn’t prepare one for many other jobs – maybe research? maybe teaching in a medical school? Some might go into government and health policy roles, but their experience as clinicians is of limited value in comparison to their colleagues with higher degrees by research qualifications in public health. Even with the current number of legal graduates in major metropolitan cities, a good graduate from a good law school won’t struggle to secure their career; an average student from an average student may have to set their sights a little lower, but they, too, are likely to be able to establish themselves. That is not the case in medicine, where there are examples of many excellent doctors struggling to secure training.

    It’s also a pretty poor argument to suggest that just because other professions are facing similar issues that there is no need or scope for reform in medicine. There are huge reasons to be concerned about the state of the teaching profession. The levels of casualisation and lack of tenure is enormously stressful and we see talented teachers exiting the profession after only a few years (no doubt there are many contributing factor – burn out and a lack of support from those more senior than them being one of them).

    Some of the above comments discuss ‘training dilution’ and suggest that a slip in standards would result from reform. The cynic in me suspects that the colleges are less concerned with such an outcome, and more concerned with the dilution of specialist salaries… which, I should add – is not a necessary outcome, particularly if the pesky issue of geographic distribution of specialists could be addressed.

    We need an imaginative and brave (and centralised) response to the situation. Unfortunately, I don’t think we’ll be getting one.

  36. Albi says:

    history repeats itself!
    in 1994 when I started medical school there were too many doctors being produced so the government capped the number of medical schools in the country to 10 and the number of graduates to 1000 per year. Along with restricting provider numbers for no VR doctors.
    This went on for 10 years to create an “undersupply” and then the number of medical schools and graduates exploded and the door opened to IMG’s.
    Now they will go back to cutting the supply again. Might clean up dodgy medical schools.

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