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FOR me, the recent comments in InSight+ about the experiences of junior doctors with the current structures for training (here and here) highlight our failure to develop a cohesive long term plan to proactively adapt the medical workforce to meet contemporary expectations for work/life balance and the nature of medical practice in the 21st century.
The current state has arisen from the compounding consequences of responses to parochial short-term issues on a background of many decades of failure to look at the big picture. The fault lies with all of us: governments, universities, health service managers and our profession.
The creation of doctors is an expensive business largely funded, directly and indirectly, by government (the taxpayer) as an investment for the future of the health system, which is itself predominantly funded by government. While some may tout the benefits of natural selection in an open marketplace, it seems wasteful of both money and human capital, unethical and thoughtlessly cruel to knowingly encourage some of the brightest of hopeful young minds to embark on a journey that leaves so many demoralised and will be, for some, a dead-end road.
The growth in the demand for junior doctors has been driven in part by the shift to more reasonable working hours. I will not go on about working horrendous hours in the 1970s and 1980s and the number of times that I fell asleep over dinner. Paradoxically, however, that intensity of work provided clinical experience that is hard to achieve in a 37-hour week, and poses a challenge for the design of training programs.
Simultaneously, the growth in the quantity and complexity of knowledge about diseases and their treatment has dramatically increased the number of subspecialties while decreasing the range of the illnesses that individual doctors manage. Many patients now have several specialists involved in their care and every public hospital specialist requires an intern and/or resident to undertake the practical work, along with registrars to oversee them.
Unfortunately, in the absence of an overarching plan that considers broad-scale and long-term consequences, the edifice of public hospital specialist practice is now supported by a vast base of junior doctors employed to cover the shifts required for the hospital system’s mandated standard working week, and who allow us to continue to work in the manner to which we have become accustomed. However, these numbers have not been matched by sufficient specialty training positions nor, in turn, by the prospect of subsequent specialist jobs for all medical graduates.
In my field of palliative medicine there are about 130 advanced trainees (3 years’ full-time equivalent [FTE] advanced training). While a number of us are retiring every year, I find it hard to believe that state governments will fund an ongoing annual growth of perhaps 30 FTE consultant positions. I understand that we are not alone and that the marketplace of available jobs is becoming saturated for a number of other specialties, particularly in large cities.
So, how can we address this problem?
The first step is to consider the goals of a plan for a sustainable medical workforce. The outcome must provide for a reasonable working week, deliver high quality training and career opportunities for all medical graduates and, in the face of rapidly changing technologies, meet the needs of a community that expects round-the-clock, high quality, whole-person care.
In a steady state, and very crudely, if on average a doctor qualified at age 25, trained for 7 years to attain specialty status (GP or other) and subsequently worked for another 35 years (at say 0.8 FTE), then the ratio of total number of junior doctors to the total of those who are working and have completed their training would be a bit above 1:5. The number of doctors completing training would match the number of trained specialists (by definition including GPs) leaving the profession each year.
Of course, we do not live in a steady state. Sustaining an effective workforce structure would require active management of a complex dynamic balance between the number of doctors in training and the evolution of their career opportunities driven by science and technology. The problem is a bit like a complex multidimensional version of one of those high school maths exam questions that have two trains approaching each other at different speeds.
On the one hand, the intake of medical students, and consequently the number of doctors in training, should anticipate current and future workforce requirements. It should not be driven by the need to fill rosters for a 37-hour week.
On the other, in addition to meeting the current and future healthcare needs of the community, the number of specialists (particularly those working in public hospitals) must be adapted to the consequences for service delivery of a changed proportion of junior doctors. Included in this calculation is the significant amount of time necessary to educate the evolving numbers of medical students and doctors in training.
Variables include the variety of roles of all specialists, natural attrition rates, part-time work, parental leave, illness, career change, the needs of different communities, demographic change and changes in disease prevalence, task transfer to other health professionals and, not least, the evolution of medical practice and technology.
I cannot see any solution to this test of our ability to collaborate in solving complex problems that does not re-balance the structure of the medical workforce, including the roles and responsibilities of all doctors.
The first consequence would be an increase in the number of specialty training positions and a concurrent phased reduction in the number of medical students. The quality of training for junior doctors would also be enhanced by a greater emphasis on education and experience, and a reduced role in some aspects of service delivery.
The progressive reduction in the numbers of junior doctors would require the employment of higher numbers of specialists who would provide a higher proportion of direct patient care, including 24/7 rosters (just as many do now in private practice and in public hospital acute care; eg, emergency departments and intensive care units). The more intensive training needs of increased numbers of advanced trainees would also be met by the larger numbers of specialists. While raising challenges in terms of continuity of patient care and maintenance of skills, the numbers of specialists would have to match contemporary expectations for work/life balance.
Over time, the excess supply of junior doctors would be mopped up while patients should achieve better health outcomes (and experience lower risk) from having an increased proportion of their care being delivered by doctors who had completed their specialist training.
Managing such a transition would be a huge challenge. Governments, universities, medical colleges, health care employers and, most of all, doctors would have to accept that change was necessary and embrace a huge shift in their understanding of their roles and responsibilities. It would require leadership and a willingness to address the huge range of vested interests that benefit from the status quo of particular niches in our unsustainable medical workforce ecosystem.
This discussion may seem to have moved a long way from the distress voiced by individual young doctors. However, while the goshawks in the tree below my veranda may live by a strategy that is successful when one or two of their three hatchlings reach maturity, I am sure that is a high attrition rate is not acceptable for the training of doctors. Most of the selection of the fitter candidates occurs before admission to medical school.
Clearly, this article is deliberately provocative designed to stimulate discussion. I don’t think we can choose not to act.
Dr Will Cairns is a palliative medicine specialist based in Townsville and an Adjunct Associate Professor at James Cook University.
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.
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The issue is not new and won’t go away.
In 2012, I touched on some of these issues:
https://insightplus.mja.com.au/2012/2/aniello-iannuzzi-desperately-seeking-specialists/
Specialty training is way too long – we should consider restructuring and look at Memberships and Fellowships – Members could get specialist rebates and fill many suburban, regional and rural positions. Those who want to train longer – nowadays meaning subspecialising if we’re to be honest with ourselves – could fill the teaching hospital positions that require subspecialists.
We have dropped the ball on generalism, which has made worse all the issues Dr Cairns analyses.
One way of increasing Australian medical graduates to encourage them to work in the rural and remote health community, after doing internship they can apply in any rural health as GP trainee their interest for at least 8yrs under the specific rural training program of the RACGP, ACCRM or RDAA and they will get 50% reduction of their medical education debt plus no need to take the fellowship exams.
Same thing to IMG’s, will sign a contract to work in the rural work force shortage for 10 yrs or more if given the opportunity, under the training program of the same organisation mentioned, or even work permanently in the needed rural communities as long the community needed/ happy with the IMG.
Maybe these options can be a thought over for the Dept of Health.
I agree with Dr Ian Hargreaves. Career medical officers provide opportunity for those who don’t want to go through the expense and slog of specialising yet are still interested in an area. They provide stability for the unit as well as experience thus reducing the need for as many ‘training jobs’ as the current model requires. The career medical officer has job security while the government will likely save money in the cost of training.
Very interesting discussion piece and commentary.
Unfortunately the problem is that ‘A grade’ medical schools continue to churn out large numbers of very bright young things who prefer to specialise and sub-specialise. Very few, if any, actually choose to become GP’s because of the low income, the frequent uncertainty in managing undifferentiated presentations, and the need for careful management of continuous, complex and chronic care of patients in the community.
A serious discussion about medical workforce needs to actually address the elephant in the room: Medical graduates do not want to become GP’s, and who could blame them? Pharmacists, nurse practitioners, alternative health providers, even rugby league players wives all want a slice of the action, whilst GP’s continue to slide down a slippery slope of devaluation by politicians, general community and their specialist peers.
will
many thanks for your well considered article. medical school places are no longer set by the commonwealth nor by the states, so it is unclear to me whether a reasonable solution’s is going to be possible.
In the interim, my approach, and that of an organisation that I lead, is to do everything that we can to focus on the safety of patients and the welfare of the unaccredited registrar DiTs. they are political orphans, and only an industrial approach is likely to work
neither side of politics, as of today, appear interested in NSW to taking such an approach, even though the awards in WA and Victoria mandate rostering no worse than 1 in 3, effectively forcing an equitable rostering of unaccredited versus accredited registrars.
this is very disappointing.
Tony
Will, I always enjoy reading your deliberately provocative articles, and as so many satirists would agree, it often takes a little provocation to expose peoples’ attitudes. It amuses me that doctors who would think nothing of buying shoes from an unemployed university-trained actress, would consider it demeaning for an unemployed doctor to work in a shoe shop.
When I started at Sydney University in 1977, we were told there were over 3,000 applicants for the 250 places. Many of my school friends were heart-broken at age 17, to miss out on their dream, but went on to have happy careers as dentists, stockbrokers etc.
Unfortunately, the universities worked out how to monetise that demand, by creating an increased number of medical school places, increased “pre-med” courses like medical science, and upgrading their entry level medical degree to a post-graduate doctorate rather than a bachelor degree, as doctorates get more government funding.
Perhaps fortuitously, the tsunami of medical graduates was largely absorbed into a gulf of safe working hours, so the shift I used to do from 7 AM Saturday to 9 PM Monday became the work of 3-5 people.
The politicians were not overly fussed about the expansion of numbers, because some of them got to open medical schools in their electorates, and the overall cost to the government of employing 2 people to do a 40 hour week each, was less than employing 1 person to do 40 hours of over time. However, there was no consideration of workforce issues, as noted by my patient who is a senior police officer, who pointed out that the universities train 200 forensic science graduates per year, while the police need 2 new graduates per year. “CSI Centrelink” may not rate well.
When pressed (and journalists have been exquisitely gentle in terms of pressure) university administrators say that their role is not vocational training, but allowing people to pursue their aims of higher education for its own sake. I suspect they may change that tune if threatened with the loss of their vocational courses like medicine.
The idea of having more specialists with fewer trainees is reasonable, and certainly sounds very workable in medical specialties. Phoning the physician rather than the registrar to ask about an antihypertensive dose is not particularly complex. However, I have my doubts about its long-term viability in surgery.
Changing a unit from 3 specialists with 3 trainees, all on a notional 1 in 3 roster, to a unit of 5 specialist surgeons with one diurnal trainee (thereby achieving a steady state, and a viable career path for trainees), would greatly increase the cost of the work in the public sector, because it would be a specialist call back rather than a trainee call back for every minor emergency case. For major surgical cases, which require an assistant, presumably one of the other specialists would have to be second on-call. Assuming all are staff specialists, the hospital has to provide 200 hours of surgical work per week for the 5 specialists, rather than 120 hours per week for 3 specialists, and every operation costs money. (I did try telling my public hospital administrators that operating on poor people was our core business, but they kept on insisting that I was operating on too many public patients, which was costing the hospital money.) The same issue of surgical assisting applies to elective cases, where the cost of paying a specialist to assist a colleague is more expensive than paying a trainee. That may upset the pollies who would rather spend money on a new shiny football stadium, a coal mine, or a freeway.
In the UK, the solution to stable numbers has largely been to use overseas trained doctors as juniors, with no prospect of promotion. In Australia, we tend to give more permanent registration and residency to our overseas trained doctors, so this model is probably not viable.
The other option is a Career Surgical Officer / permanent Hospitalist position. In a surgical unit, this person can deal with the patient’s medical illnesses better than a specialist surgeon could, could assist in theatre during the day, and could be rostered on duty for evenings/nights for minor procedural things like putting in a catheter, suturing a minor wound in ED, emergency assisting etc. A doctor in this role would get the benefits of award provisions like safe working hours, parental leave, etc, without the exorbitant costs of College membership, and fulfil the hospital’s need for 24 hr service provision. Having a tenured CSO position would be cheaper for the hospital in not having to interview prospective unaccredited registrars every year, while an experienced CSO who wanted to change to a rural GP career would have plenty of minor surgical skills.
Although I agree emotionally with the statement that “I don’t think we can choose not to act” I note that most politicians are law graduates, and despite that, they have allowed untrammelled expansion of law schools to the point where there are now unemployed law graduates. I won’t hold my breath for a pollie to announce on the electioneering hustings that they will close or downgrade the medical school in their electorate.
And for those currently looking for work, only last week the president of the Tasmanian Rural Doctors’ Association was writing in the Hobart Mercury about their severe shortage of doctors.
Your article addressed a lot of the current issues. I would like to add population growth as a consideration for specialist growth as well as expansion of hospital infrastructure. Without expanding the hospital infrastructure, it’s not possible to hire specialists nor have speciality training positions, let alone junior doctors. Without expanding hospitals, the health system cannot cope with increasing pressure of patient demand nor doctors can expect a work-life balance. The longterm plan should include and start with brick and motor.
As you say Dr Cairns your article is designed to start discussion on a major issue that has been long (25 odd years) in the making. How on earth anyone is going to mobilise all the listed vested silos that you identified to voluntarily forego their income sfreams (B grade university medical schools especially) when COAG and the federal government can’t even agree on seating arrangements for their meetings in most instances? As I said in earlier comment, the dislocation of medical school numbers from the actualpopulation demographic and from the availability of viable later stage medical specialty training post numbers occurred firstly by a deliberate restraing policy on medical school numbers by the Hawke/Keating government in the early 90s (in the belief it would rein in Medicare costs) and then as a delayed over-reaction to the consequential looming shortfall in active specialist numbers by the Howard/Costello crew. The initial shortfall in doctor numbers at the time was exacerbated by the concomminat uncontrolled explosion in population (that is still occurring). The dumb political answer at the time (early 2000s) was more medical schools with no thought or planning whatsoever for further specialist training posts or the life-style changes that you have correctly noted. I agree entirely with you that the human cost of our best and brightest and the financial waste for taxpayers is just appalling. Unfortunately I have little faith that any of the multitude of financial players in this slow moving train wreck will have either the wit, the understanding or even the desire to meaningfully address this extremely complex issue along the lines you have reasonably suggested. A very scrambled egg indeed!
Or, instead of doing all the absurd bureaucratic and social re-engineering things in this article, we could simply address the author’s one objection to market forces: that we are “knowingly encouraging” our best and brightest minds into medicine. The much more achievable and inexpensive solution, therefore, is open disclosure to medical students that embarking on a degree no longer guarantees them a lifetime job in their chosen career – and they make an informed decision and take their chances like prospective undergraduates in every degree do.
While I do not disagree with Dr Cairns, I think it is unlikely that the degree of organisation required to meet his goals is probably beyond the capacity of health departments and the Colleges.
One of the root causes of the current situation is the industrialisation of hospital care, both in the public and to some extent in the private sector. There are a number of reasons for this, including the increasingly technological nature of medicine, an expectation of certainty in diagnosis, leading to unnecessary over-investigation and the mechanistic management style of the bureaucracies that manage health systems and hospitals, and which treat people as numbers, staff and patients alike. Much of this can be traced back to the initial establishment of Medibank (remember that?), in which public hospitals were made the health factories and excellence, such as it was, was traded for the activity created by government discouragement of private medical practice, which is, or should be a more humane way if providing what is essentially a very personal service, ill suited to monolithic institutions.
I’m elderly. Once worked for FMP [remember it ?] and participated in training at Newcastle University. One or two of the earliest lecturers there may remember me; regrettably not all are still alive. Have an MHPEd [UNSW] and other degrees including MBBS. I enjoyed teaching young doctors, medical students, nurses and other ancillary health personnel, and researching methods of assessment. It’s time I did something useful if I can be used. Lifelong experience of GPs and the occasional specialist have not changed an earlier view that medical education is incomplete in that it fails to develop the humane, caring, and perhaps the moral potential.