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LAST week the ominous situation facing medical graduates in South Australia was exposed with an estimated 22 domestic graduates projected to miss out on internships in 2017, and up to 39 to miss out in 2018.
Unfortunately, this training gap only represents the tip of the iceberg, with a national workforce report predicting that more than 1000 junior doctors will miss out on an advanced training place by 2030.
The recent approval of a new medical school in Western Australia shows that the tsunami of medical graduates is unlikely to abate, so is it time to rethink medical education?
This year, an estimated 3736 Australian medical students are expected to graduate, an increase of almost 280% from the 1347 who graduated in 2001. Despite this massive increase in graduates, there has been a comparatively small increase in the number of training places available to junior doctors. This leaves many graduates facing a grim training outlook.
The latest Royal Australasian College of Surgeons Activities Report indicates that in 2014 more than 800 applicants to surgical education and training (SET) were unsuccessful. There are reports of similar results for training places in other specialities, including general practice.
Few, if any, training programs across the medical landscape have been under subscribed, with the net result being an unprecedented training backlog with little relief in sight.
When this mass of prevocational junior doctors is added to the still growing tidal wave of graduates year on year, the stark reality is self-evident — not all of us can be clinicians.
Unfortunately, there is no easy solution.
Junior doctors could move offshore, but increasing regulatory barriers mean that the days when young doctors could simply move to the UK or the US and expect to work are gone, let alone come home and have qualifications recognised.
Medical training in Australia could be completely overhauled to more closely resemble US-style training. This would mean service registrar positions, the utility of which has long been questioned, would be abolished and training streamlined.
However, reform would take years and would likely face tenacious opposition.
Another option is to reduce student numbers, but for various reasons this has proven untenable. One reason may be the high cost of establishing and managing medical schools, so reducing numbers is unlikely and potentially short-sighted.
Nonetheless, with an oversaturated market, should these new schools have a moral imperative to ensure that their graduates are employable?
Australian medical education is, by tradition, clinically focused. Variation from this invariably includes teaching, research and, more recently, public health.
The shortening of contemporary medical courses as postgraduate degrees has resulted in an even greater prioritisation of clinical skills, possibly to the detriment of skill diversity. Graduate medics may benefit from exposure to varied subject matter in their undergraduate degrees, but these too are becoming increasingly prescribed and narrow in focus.
The result? Junior doctors often graduate with few transferable skills, making the ramifications on their career prospects even more dire.
The trend towards focused clinical education in Australia actually goes against what is happening in other countries, particularly in the US and UK. In those countries, programs combining degrees such as a Master of Business Administration, Master of Public Health, Juris Doctor or Doctor of Philosophy degree with medicine are booming in popularity and some Australian institutions have been quick to follow this trend.
However, for debt-laden graduates, further studies cannot be the sole answer. Industry placements, non-clinical electives, innovation training and mentorship and coaching programs should all be considered as ways to better equip medical students for modern career challenges.
Producing competent clinicians should always be the main priority of any medical school, but the time has come to ensure that medical schools also prepare graduates for careers outside of practice.
After all, for those trapped in the midst of the graduate tsunami, one thing is crystal clear — we cannot all be clinicians.
Dr Tim Lindsay is an Australian junior doctor and PhD student in the department of surgery, University of Cambridge, UK, supported by the Cambridge Commonwealth Trust. Dr Harris Eyre a psychiatry registrar and is undertaking a PhD through the University of Adelaide.
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The reasons for the medical student ‘ tsunami’ are related to a projected doctor shortage. In turn this was due to the modern trend for doctors to work shorter hours, and the fact that women now constitute over 50% of medical students in many schools. Women doctors will generally work about 0.6 compared to male doctors, due to pregnancies etc and will often end up working part time. This is not sexist but is a fact. I recognise it is politically incorrect to make this point. Fifty years ago doctors were predominantly male and worked 60+ hours per week, in some cases many more hours. So the whole landscape has changed with feminisation of the profession and emphasis on lifestyle over work. To train students and then have no career pathway for them is shameful and another example of poor planning by Governments and Universities.
While there is clearly a need for medical graduates to participate in non-clinical roles, I would strongly oppose a reduction in clinical skills training. This is one of the strengths of the Australian system
You only have to work in north america to realise how shorter training programs focussing on non-clinical aspects leads to excessive referral and over servicing. This in turn increases costs, but the “workload” justifies everyone’s job.
Expensive university degrees are the real problem here. Debt-encumbered graduates want shorter training programs, rather than spending time gaining experience, either clinically or in other realms like research or public health
We have consistently provided supply-side solutions to demand-side problems with medical education. They have not helped much. I have always thought of the medical training system as “cannon-fodder medicine”. We have traditionally needed junior doctors to keep hospitals working, so we have made a Faustian bargain: you work horrendous hours and under poor conditions to keep the system going, and we might give you a chance to become a specialist in the future. Traditionally, medical graduates have been willing to submit to this. In my own field, I would argue strongly against adding a Master of Public Health to a medical degree for 2 reasons. Firstly, having a clinical background, even if slim, is an enormous help to public health decision making; and second, the job market for medical public health is very small. If we train more, we will just replicate the problem. I think the solution is on the demand side: we need to be clearer about the kind of workforce we need, and then train to that.
Social engineering.
Puts the government in a strong position for price negotiation, drops excessive income, and potentially improved coverage of poorly staffed areas. If the government were willing to increase job opportunities, and the AMA willing to negotiate lower salary packages, the country could be the winner.
The so-called major medical shortage in WA to open a new course at Curtin Uni is a fallacy generated by self-interested academics and using a naive consultants report as justification. The GPs on the ground in Perth tell me they have plenty of appointment capability but of course these charge a fee. The same applies to rural practice with 457s used as cheap labour because of the ridiculous Medicare rates for after hours (who wants to be 24/7 on call to get up to a 4-victim smash for less then a daytime plumber callout rate). After the moratorium the 457s all head into town, understandably. Almost 4000 graduates this year!! Wage control mechanism by the government and their self-interested academic flunkies.
The current medical courses are being stripped back with less and less time spent on basic clinical skills, something which shows up in post-graduate years. If anything, more time needs to be spent on core competencies. As a clinican and researcher with a strong teaching component to my practice, I struggle to understand why such skills are being devalued.
There is (or at least was) a Batchelors’ Degree in Medicial Science, which was an Honours Degree, offered at the completion of pre-clinical training which offered an insight into non-clinical research etc. That seems to have fallen by the wayside, possibly because it added an extra year to what was already a six year degree.
We’ve offered non-clinical electives in laboratory medicine and research in my unit, with few candidates coming forwards. Those that have done so have generally found it to be a rewarding and positive experience, but there are many that don’t choose such an option.
Masters’ degree are post-graduate degrees by definition, and will add one to two years to the basic degree, along with expense. My Masters’ degree cost over $30,000 a dozen years ago. Who will pick up the tab for that?
It almost beggars belief that we should further reduce the clinical component in this situation. Some additional education in non-clinical fields is essential, but not at the expense of the basics.
But we’ve been through this many times before. Perhaps we simply reduce the number of medical students graduating until there are enough jobs to go around? Or don’t the economic principles of supply and demand apply to medicine?