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With the guarantee of a training position and a pathway to consultancy, Australian medical trainees might have greater capacity to focus on clinical excellence and patient care, rather than competing in a qualifications arms race.
I read with interest Dr Witter and Dr Hodge’s essay on the need for reform in vocational training and agree with their well argued contention that structural change is necessary to improve trainee wellbeing.
One solution is a “match” system at the end of medical school, which allocates trainees to their specialty of interest and region. While a matching process is currently used only for internship positions in Australia, several countries, including the United States, Canada and France, have been successfully allocating medical students to vocational training programs for decades (here). Although disruptive, this might produce benefits for patients, trainees and colleges and might help fix the broken vocational training system, addressing many of the concerns raised by Dr Witter and Dr Hodge.
First, trainees would be guaranteed a vocational training position throughout the entirety of the program, foregoing the incessant uncertainty of one-year employment contracts. In contrast to most other industries, junior doctors, at least throughout Victoria, are employed on 12-month contracts (here). There is no guarantee of continuing vocational training, and even when a trainee gains an accredited position, the location of training is often not predetermined. Applying for jobs every year, in some cases to dozens of health networks, creates unwarranted stress and uncertainty. Fixed, several-year contracts within or between health networks could provide some respite to burnt-out trainees.
Second, a formalised residency match would mean the federal and state governments have no excuse to not coordinate workforce planning to ensure the needs of our demographic change are being met. Currently, the number of non-general practitioner specialists in training, physicians for example, is outstripping our much-needed generalists (here). As of 2022, in Victoria alone, we have 4759 specialists-in-training despite only having 8255 GPs (here). The Australian Medical Association predicts a shortfall of more than 10 000 GPs by 2031–2032 (here). Likewise, patients in rural and regional settings remain consistently underserved, in large part due to lack of medical trainees and specialists (here). Matching the number and specialty of trainees at the end of medical school to our projected population needs is our best chance of ensuring Australians receive the care they deserve.
Third, providing every vocational trainee with an accredited position, supported by their respective College, might lead to a reduction in the exploitation of trainees. Unaccredited trainees provide an invaluable service to health care networks across Australia. One does not have to look far or wide to see how the lack of protection from colleges leaves unaccredited trainees ripe for abuse (here). Unaccredited registrars are routinely subjected to unreasonable work hours and breaches of the doctors-in-training enterprise agreement and feel unable to speak out about dangerous working conditions, largely due to career uncertainty. If these trainees were matched, and guaranteed vocational training, it is possible trainees could feel better empowered to challenge their work conditions, ultimately leading to better trainee wellbeing and patient care.
Lastly, with the guarantee of a training position and a pathway to consultancy, trainees might have greater capacity to focus on clinical excellence and creating impactful change on patient care, rather than competing in a qualifications arms race. Given unaccredited training can take more than a decade, there is an expectation of higher degrees, diplomas, certifications and further extra-curricular activities from trainees. This may not actually improve clinical acumen (there are no data on this) and, regardless, is expensive, time-consuming and stressful. Moving the selection process back to the completion of medical school would eliminate the time and resources spent on competing with other trainees for accredited posts, rather than perfecting their craft. Importantly, selection at the end of medical school would not usurp trainees’ ability to pick a vocation but rather expedite an inevitable decision.
Some may argue against a proposed match system. Questions about the challenges of implementing a match are moot, as Victoria already uses an internship match without reports of significant technical issues. The matching costs for trainees applying locally and nationally would be equivalent to what trainees already incur applying for specialty programs.
Another concern is that residency matching prevents trainees from exploring specialties in their prevocational years. I agree with this sentiment but believe the years of toil and hardship endured by unaccredited trainees with no promise of an accredited position far outweighs the loss of early career exploration.
A radical reform such as this would not be easy but offers the best hope for resolving the structural challenges we face, ultimately ensuring we look after our trainees, workforce and patients.
Dr Manu Juneja is a haematology registrar at the Royal Melbourne Hospital and the Peter MacCallum Cancer Centre.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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Thanks, Manu,
I’d certainly agree that the qualifications arms race is harmful to both trainees and patient, with little value added.
From a rural doc point of view, I think the main issue here, as others have argued, is the underlying industrial landscape.
If the terms and conditions across different specialities were more level, e.g. with EBAs that support non procedural medical work in less advantaged communities, much of the problem would disappear.
Really appreciated reading your article, Dr. Juneja, and the insightful comments. It’s a topic that’s deeply personal for me. After six years in the medical field in Australia, I’ve seen and felt the struggle and uncertainty firsthand.
The idea of a “match” system is definitely thought-provoking. It could offer a clearer, more straightforward path for trainees. But, echoing some comments, such a system isn’t without its flaws. Take the USMLE in the States, for instance, where one exam can make or break a doctor’s career. It’s a stark reminder that no system is perfect.
In my own journey, I’ve seen how our merit-based system doesn’t quite measure up in recognising true clinician skills. We award points for exams, research papers, and such, but how do we gauge a doctor’s humanity, their bedside manner, their ability to alleviate suffering? We don’t really have a metric for that. It’s led to doctors becoming multi-hat-wearing scientists just to get into training programs. Yet, isn’t being a doctor about the skillful application of science to alleviate suffering?
This disconnect weighed heavily on me, to the point where I didn’t choose GP or any other pathway. I’m now exploring alternative careers, seeking a path where I can find clarity and purpose.
While a match system might simplify things, we also need to think about how we can improve roles like GP and change specialty selection criteria to better reflect what being a doctor is really about. Every idea and perspective adds to the solution.
It’s a complex issue, but it’s encouraging to see it being discussed openly. I’m looking forward to seeing how this conversation shapes the future of medical training in Australia.
Points made by Manu – We need matching system to help correct imbalance of Non-GPs to GPs – yet Manu himself is a Non-GP (haematology trainee); the reason there is a CV arms race/exploitation of non-accredited registrars/higher degree’s is because there is low interest in persuing a career in GP – why doesn’t Manu take the first step and swap to GP training to prove this point?
Maybe instead of bringing in a Match system (which will only push CV arms races further into medical school) we make GP a more attractive speciality by giving it the respect it deserves and as a medical community push for greater work conditions (ie. salary and organisation) – maybe then the balance can be fixed rather than forcing medical students into careers they might not want through a forced ‘match’ system.
Another option would be to recognise that GP’s are the backbone of our healthcare system but not appropriately recognised or remunerated for this work within the current medicare system. I know many peers and juniors interested in GP but concerned about current uncertainty in work structures and also fearful of entering training and junior consultancy at a time in regional Aus when many seniors are looking at retirement. I think a solution that involves improved collegiality and respect comes from leadership from colleges and government funders who are ultimately responsible for ensuring sustainability in the medical system. Written as a regional public subspecialist whose practice and patient care ultimately depends on GP early recognition, diagnosis, referral, and follow-up.
I am an Australian who has done the US steps, match process, and indeed 2/3 of EM training in the USA. I returned to Australia to complete vocational training in radiology.
I can assure you that the US system and the match are not stress-free endeavours. It is complex, multifaceted and simply shifts much of the angst you describe to the medical school years. Such a system (probably quite rightly) demands some objective method of ranking candidates. In the USA this falls, somewhat arbitrarily, to the USMLE step 1 basic science scores and creates extraordinary emphasis on this curriculum within medical schools (somewhat to the benefit of medical specialties, and possibly the detriment of surgical specialties).
It is an error to assume the a matched residency/vocational training will mitigate workplace abuses. It certainly did not in my experience, not least because under this system there is virtually no ‘horizontal movement’ ie. you are locked effectively to a hospital network and it is nearly impossible to change as everyone has their places ‘locked and loaded’; if you are suffering abusive practices you cannot ‘vote with your feet’ as it were. There is no ‘unaccredited role’ to turn to. On the up side this means that programs are ‘stuck’ with you and thus assume a substantial portion of the risk of ‘not passing’ specialist exams (they get into trouble if this happens and can lose substantial funding). And there is substantial benefit from having ‘1 set of hoops’ that all must jump through, rather than the Kafka-esque hoops and shifting goal posts that many Australian colleges throw up; these are a tremendous waste of human capital it seems.
My main point is that each system simply shifts the uncertainty and issues to a different time and place. There’s no ‘free lunch’. The match system does get people ‘fully cooked’ much faster though.
I agree with the point that many medical students are not sure of what specialty they wish to do when they graduate. Additionally, having a match process will just move the extracurricular arms race earlier into medical school (as is the case in America). Also, what happens to the medical students who studied 6+ years and get matched into a specialty they hate? I can’t imagine their wellbeing will be very good. There are other ways to improve wellbeing, e.g. better hours for unaccredited registrar jobs, and removing points for unnecessary extra-curriculars. Additionally, forcing people into less popular specialties will just worsen the reputation and desirability of those specialties further – the goal should be to improve the perks of these specialties so people want to work in these roles (e.g. look at the difference in applicant numbers for RACGP vs ACRRM)
I completely agree. Our Non-accredited surgical registrars are “in limbo”, and if they are not selected after a few years, they have no career path to follow.
The selection for specialist training cannot be made from medical school. This is utterly ridiculous. Most interns have no idea what speciality they are cut out for.
Secondly the criteria or selection into trainee posts needs radical overhaul. Surgical candidates need to be assessed primarily on surgical/technical skills not PhD completion in an obscure field.
Thirdly the default for most interns is to pursue specialist practice or hospital medicine. Why? Because GP is seen to ge undervalued. We must reduce the financial /income discrepancy to allow more people to choose GP. In fact every Dr should do two years in
a GP as an RMO level before qualifying for specialist training
In other words, can we have a British ‘national training number’ and programme to match that existed for decades introduced to Australia state by state.
An alternative is to develop a points system for specialist entry and provide preferential selection points for 2 years in primary care before applying to do specialist training. This is similar to University ATAR. Many of my consultant teachers in the 1980’s had worked in primary care before commencing specialist training. They were appreciative of the difficulties of primary care and not disparaging of GPs .
Completely agree.
I would go as far as to suggest we adopt a National Exam and rigorous logbook competencies for internship before this “match” takes place allowing for some flexibility in career path decision after completion of medical school. This could then be used by the colleges as separate tools in addition to their assessments for selection.
I think in Australia we would be better served by a Match that is not immediate training but rather a structured approach depending on speciality match. For example if one desires a career in neurosurgery, they would match after internship and do two years of residency with a mix of rotations in surgical specialties including ICU/ED/Neurology/Nsx followed by a five year training program + optional 1-2year research/academic pursuit. In other words you would be “matched” post internship for a 7-8 year program which would be state-based.
most medical students would not have any idea of which specialty they wish to pursue at the end of their basic training. This decision is often only made after 1-2 years as intern or further experience. I would agree the selection criteria used for specialisation requiring extra degrees, publications etc are not necessary to ensue the appropriate candidates are picked. I agree too many specialists in training and not enough gp trainees.