Hospital scandals are big news. The multiple deaths associated with Bundaberg Base Hospital surgeon Dr Jayant Patel, known around Australia as Dr Death, have turned the spotlight on Australia’s growing reliance on overseas- trained doctors. Only last year, whistleblowers in Campbelltown and Camden exposed a major crisis in the quality of care at these outer Sydney metropolitan hospitals. The ensuing investigation revealed the core problem was closely related to a shortage of quality doctors. While the health sector is particularly prone to high-profile media attention due to its emotional charge, these disasters are symptomatic of widespread problems in meeting our medical workforce needs.
Recent governments, ALP and Coalition, must accept a significant share of the blame for too few quality medical staff being available. The Health Department believes that doctors create their own demand, and so strain the health budget. Both political parties supported measures in the 1990s to ration the supply of doctors and the provision of services. Medical student places, specialist training places, and Medicare provider numbers were all restricted.
However the government and its advisers in the Australian Medical Workforce Advisory Committee got their numbers badly wrong. They underestimated demand for medical services and overestimated the number of hours doctors were prepared to work, with more doctors retiring early or working part-time. Though the government has belatedly recognised its earlier mistakes, commissioning a landmark study by the Productivity Commission and expanding the number of medical student places, it has been forced to rely on overseas-trained doctors to fill the gaps. Their numbers entering Australia have more than doubled since the late 1990s.
A demoralised medical workforce
These policies contribute to a growing demoralisation of significant sections of medical practitioners. Though, as we will argue, the current system of training doctors, especially at the postgraduate level—which is effectively all specialist training—is a major issue, these difficulties are occurring at a time when there is a considerable shift in the role and status of the doctor. This is taking place both in the health setting and in wider society. Nurse practitioners, midwife-run birth units and alternative medicine have all chipped away at the authority of the modern doctor. Even health-related advertisements end now with “If symptoms persist, please see your health professional”. The doctor is now but just one of many healers in a crowded landscape.
What presents to the doctor has shifted dramatically in recent decades. In fact, the triumphs of medical science means much of what is taught in medical schools shows up less and less to the general practitioner. It is estimated by the Royal Australian College of General Practitioners that up to half of what the modern GP sees is related to psycho-social problems. This translates to the layman as a combination of the “worried well” to those suffering from serious depression.
Perhaps there is no other field where expectations are so mismatched, both at a consumer and practitioner level. Consumers will often believe that all problems, death included, can be postponed by all-conquering medical science. This is often encouraged by the plethora of hospital programs depicting the job as exactly that, a perfect combination of Einstein and Mother Teresa. Likewise for new arrivals to the profession, having been trained in pathophysiology, diagnosis, and treatment, they find themselves spending more time thinking about issues like management, ethics and communication.
Doctors have suffered a relative decline in financial status in the past two decades. While globalisation and deregulation have driven incomes in fields like finance, IT and advertising into the stratosphere, the same period has seen greater regulation of health, an exponential rise in legal claims and longer training programs to become specialists. On top of all this, Medicare repayments have not kept up with inflation. According to Health Insurance Commission figures, Medicare repayments have increased by about 60% in 20 years. By contrast, consumer prices have increased by about 120% in the same period.
Doctors, especially those in the public sector, are among the last few that remain in the socialist section of the market economy. They are now more part of a caring complex, with teachers and nurses, than powerful elite professionals. For training doctors, there is a realisation that they are effectively trapped for long periods in the public sector. But while doctors’ groups will cry for more pay, doctors’ role is changing so much that their contribution needs to be reassessed. Even more importantly, the way we produce them needs an overhaul.
Junior doctors
Recognition of the need for change is reflected somewhat in the growth in graduate medical schools, instead of entry straight from school. Five graduate schools have opened up in the past decade and more are being proposed currently in Victoria and Queensland. But while this pre-vocational aspect of medical training is experiencing a shift, the more arduous training that takes place after graduation has changed little.
The postgraduate path of a young doctor is a minefield of regulation. The mandatory intern year is followed by several years of ‘service’ residency, time used to decide which specialty training program to enter. Upon effecting that decision, the young doctor must then pass a series of exams to be allowed entry into a specialty ‘college’, and possibly a further set of sub-specialty exams in the future.
This group of training doctors is arguably the most important segment delivering health-care in our public hospitals. They do the grunt work and much of the high-level work while many specialists are attending to their private practices. This process is arduous, poorly remunerated, and so family unfriendly as to put unacceptable pressures on many older, postgraduate students who are now entering the profession.
But jumping through hoops as a junior is a part of any career, so why is medicine any different? The problem is that a number of interests outside a junior doctor’s control affect his or her career progression. The training of a junior doctor is manipulated by both the government, whose aim is to fill workforce shortages, and the ‘learned colleges’, whose interest is to regulate the number of new members entering specialties.
One of the main issues is the conflict between ‘training’ and ‘service provision’. Medicine is the ultimate form of ‘on the job’ training. Training doctors learn their trade whilst providing an essential service to the community. The best training occurs in large, central teaching hospitals located in the Australian capitals where access to experienced clinical teachers is high. But the interest of the state governments (and therefore local health bureaucracies) is to have smaller, district hospitals staffed at all times. Consumers expect 24-hour access to healthcare at a reasonable distance from home. The public uproar that greets plans to close or merge hospitals is indicative of the public’s ‘drive-through’ mentality to modern health care. The political equation is simple—no doctors, no service, no votes.
Unfortunately, these district hospitals are bottom-heavy, with very poor support from senior staff. The Macarthur health inquiry found that this was not only a poor training environment, but dangerous to the health care consumer. The incidents involving the hospitals at Camden and Campbelltown highlighted gross gaps in service provision, both in the number of junior doctors available to fill positions, but more importantly in the access to quality training and advice from senior staff. At the end of the day, it is the junior doctor who carries the can for a government’s lack of political will.
A recent Australian Medical Workforce Advisory Committee report published in the Medical Journal of Australia reflects bureaucratic attitudes toward junior doctors. It concludes that ‘interventions to influence doctors’ choice of specialty need to target the (early postgraduate years)’ when career choices are made. The language reflects the culture of manipulation that limits junior doctors’ freedom of choice, even in choosing their own career paths
Rural doctors
Coercion is perhaps best shown in State and Federal Government efforts to solve the rural doctor shortage. There is nothing wrong with rural service terms as a junior. The government has a responsibility to its citizens, and rural terms have been shown to increase the chance of a doctor practising in a rural area. The problem is that the extent of compulsory service is reaching unreasonable levels. It has gradually extended far beyond 3 or 6 months in the first two years of doctoring. Most specialty training now includes rural service, meaning that junior doctors are uprooted every year for up to 5 years after graduating. If you want a shot at being a specialist, you must give rural service. This is nothing short of blackmail. It shows what happens when the provider of health services is also the trainer of junior doctors. Service provision always wins, the freedom and independence of junior doctors loses.
Regional provider numbers are the ultimate form of compulsory service, whereby the number of GPs who can bulk-bill in an area is regulated. Should current trends continue it is foreseeable that the Federal Government will introduce such legislation. City provider numbers will be jealously guarded, and GPs will lose all control over where they can construct a career.
It is argued that the government invests so much money in training a junior doctor that there exists a notional right to dictate the course of the doctor’s career. Of course, nobody seems to use this argument in the training of engineers or lawyers. Only junior doctors face a form of geographic conscription to fill vacancies in particular areas.
The coercion and perverse incentives used by health bureaucracies are responsible for dissatisfaction within the junior echelons of the medical profession. They are leading to unacceptable stress on doctors and their families. As regulation reaches past the junior years into specialist training and beyond, there can only be one outcome. The steady drain of locally trained doctors who are retiring early, moving overseas or simply leaving the profession will continue and workforce crises will be perpetuated.
Colleges
The ‘learned colleges’ are an integral part of the training process, and admission as a fellow of a college is the final step in becoming a specialist. They set curricula, exams and most importantly, the length of training and number of training positions. Colleges have come under fire in recent years from health bureaucracies and the Australian Competition and Consumer Commission for over-regulating the number of juniors in specialty training. Whilst the Australian Medical Workforce Advisory Committee makes suggestions regarding medical workforce composition, the Colleges ultimately decide the number of training positions available.
The government has a vested interest in producing far more junior trainees, particularly in surgery. This will create a critical mass of young surgeons to cope with the increased demand for surgical services. The catch comes later. Whilst the government wants Colleges to allow more doctors to enter into training programs, it refuses to increase the number of ‘advanced’ training positions. Put more simply, the government wants to create a bottleneck at the point of becoming a specialist. The Royal Australasian College of Surgeons argues that 100 junior surgeons are already waiting to progress through their training but cannot do so because of too few advanced positions.
This is the holy grail for the state health ministers. They imagine a system run by junior doctors who cost far less to employ than specialists, but who arguably do the same work. NSW Health Minister John Hatzistergos has sharply criticised the Royal Australian College of Surgeons for not increasing the intake of surgical trainees in 2005. He has called upon the ACCC to investigate the College on the grounds that its policy is anti-competitive. But the RACS is absolutely correct to resist. It is not reasonable to allow junior doctors to enter a training program at the same time as limiting their ability to exit training and become a specialist.
The principle advocated by Hatzistergos echoes that of the United Kingdom. The NHS has a capped number of ‘funded’ training positions which are quickly filled, leaving a significant number of junior doctors to fill ‘service’ roles which offer no prospect for career advancement and lack important entitlements like research and study funding. Amongst other effects, the two-tier system has led to local graduates leaving the system and overseas-trained doctors occupying the service jobs. In the wake of the Patel case, Peter Beattie and company would do well to consider the effects of such a plan.
The changing demands of medical education
While they can protect the interests of junior doctors, some colleges have come under fire from within the profession for not keeping up with the demands of modern medical education. The Royal Australian College of General Practitioners is the stand-out performer, offering a high degree of flexibility in training including the ability to job share. By contrast, the College of Surgeons does not do as well. The process to enter surgery, known as Basic Surgical Training (BST) costs a second year doctor in excess of $10,000. A doctor who fails must invest a further few thousand dollars to sit again. Failing the exam in two consecutive years means the junior doctor needs to restart the whole process, for a similar financial loss. Once in the program, very few trainee surgeons have the opportunity to job share, a process actively discouraged by the college.
For a number of years, the College of Physicians has been criticised for its outdated curriculum. There is very little focus on the issues that are important to patients today such as complementary medicine, communication skills or holistic medicine.
Today’s junior doctors find themselves in an era of ever-increasing patient expectations without having the appropriate training to deal with them. The College of Physicians examination process has far more to do with culling the appropriate number of trainees from the system than in training quality physicians who can respond to the demands of today’s patients. The process of reform is long overdue.
The College of Dermatologists has recently increased the length of its training program from four to five years. This arbitrary increase was needed to increase ‘private practice’ training time, even though it is accepted that the best training occurs within the public system. All the College has done is force trainees to spend more frustrating and fruitless time before advancing their career.
The dermatologists, physicians and surgeons show the disparity and lack of co-ordination in junior doctor training. Whilst their senior colleagues dream of the next arbitrary training requirement in high-backed leather seats paid for by College fees, the trainees themselves find themselves in lengthy training programs that fail to meet their needs as future specialists.
Medical Schools
A common answer to the shortfall in doctors is to train more of them. This can be seen in the current approach of funding a range of new medical schools. It is odd that the Productivity Commission’s inquiry comes well after these schools received their go-ahead.
Three new medical schools, at Notre Dame's Fremantle campus and at Griffith and Bond Universities in Queensland, opened this year. Queensland now has four schools.
The Prime Minister has announced a new private medical school in the centre of Sydney, the Catholic, Western Australian-based University of Notre Dame. This followed earlier announcements by the government that the Universities of Western Sydney and Wollongong will each have their own medical school. This is part of a wider misguided campaign to fund several new medical schools when extra places in established faculties would be far cheaper and produce the same outcome.
Professor Adrian Bower, the Dean of Notre Dame’s medical school, was quoted after the Prime Minister’s announcement saying “What this has shown is that a small place like Notre Dame can actually dream of having a medical school”. No mention of plugging doctor shortages, just a reflection on his university’s standing. The fact is that there are few things more prestigious to a university than a plush new medical school. It offers the promise of the brightest students in the land strutting the lawns and lecture halls of its campus. There is the prospect of research grants—the highest academic status symbol. For new universities trying to gain a name, or those struggling to improve their image, it’s gold.
Prior to his current appointment, Professor Bower was Dean of James Cook University’s medical school. James Cook is the newest medical school in the country, based primarily in Townsville. It remains to be seen whether it can play a role in plugging doctor shortages, but when it opened in the 2000, it was the subject of widespread criticism. James Cook was accused of taking student places from the established universities in Queensland. Some of those schools already had regional programs running in Northern Queensland that were damaged by the new body.
Furthermore, there are no guarantees that a student who goes to a medical school in a regional area will continue to practise in that area. The main reason that students from regional or rural areas are poorly represented among medical students is that they struggle to gain the entrance marks required. Education Minister Dr Brendan Nelson has complained that medical schools need to be populated by students other than those from the North Shore or the Eastern Suburbs. But how can a medical school change the geography of its intake? Assuming selection remains based on merit and an interview, geography is not a factor that can be weighed.
A study published in the Medical Journal of Australia this year gave three major factors most likely to contribute to a doctor practising in a rural area. They were that the doctor came from a rural area, had a spouse from a rural area or had postgraduate experience working in a rural hospital. The location of the medical school was not a factor.
The future
Even with the significant increase in future undergraduates, the impasse in specialist training is effectively unchanged. Interns find themselves not in a free market where they compete with their colleagues for the best opportunities, but in a highly regulated system where the best of the best may just as easily end up in the least desirable positions.
This effectively limits choices available to young doctors and contributes to dissatisfaction. A study by the NSW Branch of the Australian Medical Association found junior doctors were at their lowest level of morale ever recorded. Whilst the findings were based on feedback from anonymous members, it was a clear indication that this group bears the brunt of the stress on the hospital system. There is no doubt that this is a clear reason for the declining workforce participation rates amongst new doctors.
A look at this declining participation reveals that of the first intake of graduates from the new graduate entry course at the University of Sydney, approximately 7% returned to their previous occupations, be it accountants, scientists or vets. This represents a significant waste of taxpayer dollars.
At the same time, females make up 50% of new graduates and this is expected to increase in coming years. This has a lot to do with females performing better in their high school examinations. Whilst there are more than a few women taking on the most demanding jobs in fields like surgery, they are more likely to work part-time at some stage in their careers.
Whilst this trend is related to a growing desire on the part of workers to have balanced lives, it is also a reflection of the declining attraction of medicine as an appropriately rewarding career for many males. This is consistent with an earlier point that medicine is increasingly part of the essential caring complex these days, rather than the realm of the powerful elite professional.
In summary, the debate on the shortage in the medical workforce needs to be more nuanced than simply suggesting the need to train more doctors. The complexity of postgraduate training needs to be reassessed for a new age, as it has been for undergraduate training. Its inflexibility, unnecessary length and one-size-fits-all approach are contributing to a growing demoralisation within some our nation’s best and brightest young people. It is also leading to a significant loss of taxpayer money as training doctors choose part-time work or leave the profession altogether.
Dr Tanveer Ahmed is a psychiatry registrar. Dr Nick Coatsworth is a medical registrar. Both work in Sydney hospitals.
