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.