Issue 7 / 27 February 2012

REMEMBER when you could buy a Paddle Pop for 20 cents? My mum tells me she could buy one for 5 cents. Now you pay at least $1.20 — that’s money inflation.

Remember when a medical degree gave you enough qualifications to open a practice? Not only that, but to also enough income to buy a house, a car and send your kids to private schools?

To do that now you need to be a procedural specialist. Or own a chain of medical centres.

Or perhaps you remember when a medical degree allowed you to simply choose what specialty you wanted to do, and then do it?

Now you need to have a Masters, a PhD, publications, and to have waited for half your life just to get an accredited training spot. And if you want to do dermatology or ear-nose-and-throat surgery, just be prepared to wait three-quarters of your life and have a university medal too!

Remember when finishing specialty training meant you’d get a job at the hospital where you trained?

Now you need to have an overseas fellowship year, a PhD, have published widely and have impressed everyone from the cleaner to the health minister.

And remember when you just needed a good high school pass to enter medical school?

Now most entrants need prior degrees, Hollywood-quality acting skills for interviews and Mensa memberships to pass the IQ puzzles that make up the screening exams. To cover their bases, many candidates have done extensive community service, higher degrees and plenty of work experience. Before long, a PhD may be required to enter medical school.

Is this really what we want for our profession?

These four points demonstrate academic inflation — degrees and diplomas just lack the punch they used to have. To make matters worse, many specialty training schemes have blown out and can now take up to 6 years to complete.

In the past when I spoke to registrars and young Fellows, most felt they had mastered the general aspects of their specialty by the third or fourth year of training, with the final 2‒3 training years spent acquiring subspecialty skills and other CV-liners to assist in finding a job.

This sentiment is verified by GP training and GP special skills training. Both the GP colleges produce competent generalists in 3 years. GPs can then extend their training to become competent in general obstetrics, anaesthetics or emergency medicine after a 12-month special skills post.

Many country towns and regional centres boast GP generalists who perform as well as specialists. Older readers may remember GPs with appointments at city hospitals pulling out babies, appendices and tonsils.

Given the dearth of specialists in many areas, insufficient training posts for graduates and lack of specialist posts in larger centres for new Fellows, it may be time to assess whether academic inflation needs to be reined in.

Not all new specialists need to be in teaching hospitals. It may reasonable to want some of the specialists in the teaching hospitals to have PhDs and to know every footnote in Harrison’s, but is it necessary for all to be like that?

Reducing specialist training to 3–4 years would allow colleges to reintroduce the membership award, which would allow members to practise in suburban and regional centres. Many registrars would be grateful to finally alight from years of school, university and postgraduate study to start earning an honest living.

This would free up training posts for others, fill vacancies in the outer suburbs and the bush and reduce reliance on patient transfers to big hospitals.

Medicare could be modified for the changes and it would reinvigorate hospitals and medical services in areas that have languished for years.

Registrars who aspire to higher levels of specialisation could press on for another 1–2 years, achieve a full Fellowship and compete for the teaching hospital posts.

Back to the future!

Dr Aniello Iannuzzi is a GP practising in Coonabarabran, NSW.

Posted 27 February 2012

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14 thoughts on “Aniello Iannuzzi: The cost of academic inflation

  1. Tom Ruut says:

    I have to agree with the article. It is crazy to expect a cardiology [or other] reg to get a PhD just to enter a training scheme:a waste of time and manpower! A different story if you want to be a scientist!

  2. OS says:

    As a RMO who is facing the prospect of being stuck in the training bottleneck for a long and indeterminate amount of time, I highly commend the author for highlighting this important issue.

    I suppose what really frustrates me is that everyone is now expected to play the ludicrous charade of adding more letters to their name, more research, more publications in the goal of getting onto a coveted training program.

    However, ultimately, how much do these activities add to better day to day clinical practice and do they actually make better clinicians?

  3. ST says:

    Agree with this article. The length of training becomes even more ludicrous when compared with other advanced systems, e.g. the US, where graduates complete a 3-year (or 4-year max) residency after medical school and then become fully qualified as specialists. In Australia it takes 7-10 years…

  4. Zonk says:

    Fully agree with this article. The increasing costs of being in training and the prolonged duration makes one wonder the worth of the additional suffix. The cost of RACP training has increased >100% from last year. Has the renumeration of trainees kept pace anywhere near?

  5. Tom Ruut says:

    30 years ago we used to say that it was a year in the wilderness cutting up dead rats!

  6. JD says:

    This “academic inflation” is driven by the academics who are giving themselves a reason to exist: juniors to train, plus do their work and do their research for them.
    I used to say come the revolution they should be “put up against the wall”, until someone pointed out that’s what usually happens, and may not be so enlightened.
    But seriously, in some other countries, a more realistic view of “training” is taken in that it is always ongoing: you will be a better specialist in the years to come than when you just qualify – to me this makes more sense.

  7. Aniello Iannuzzi says:

    Someone told me another example today. What about our titles, like Doctor, Professor, etc.?! Do they pack the punch they once used to?

  8. Tony Chung says:

    Specialties that demand PhDs etc are extremely competitive and can name their requirements. Provided these requirements are justifiable, transparent and subject to scrutiny and the selection process similarly so, I see nothing wrong with that. The current clinical training period in Australia is barely sufficient especially in the procedural specialties due to short work hours. Talking to trainees who think they mastered the skills in shorter periods maybe fanciful as they all have a vested interest to qualify as quickly as possible. The judges most likely to be able to give a considered view are people who have worked in the specialty for many years and who have a better grasp of what competence means, having had their own tested over a long period of time. These are basically the colleges. GP training is different and I agree 3 years of all round exposure and 1 year extra should be sufficient. But can you imagine a doctor being a competent general surgeon or an obstetrician gynaecologist with 4 years training at 50 hours a week work experience?

  9. CJ says:

    Once competency-based assessments replace arbitrary training times it will prove very hard to justify current training times and processes. This will be especially so when more specific credentialling for clinical work is required. No point spending a year learning to do something exotic when you will never be allowed to do it at Bundaberg hospital anyway!

  10. Sue Ieraci says:

    My view of competency-based training is that it over-values procedural skills and under-values cognitive skills and decision-making. In generations past, specialisation may have been less academic but it was much more experiential and involved a lot of apprenticeship-type training. Many current senior surgeons did some general practice before they specialised – doing that now would virtually block you from a training position. I regret the focus on procedural skills over human and cognitive ones – good doctors are distinguished by the way they manage risk, make decisions and communicate with patients – not just technical skills.

  11. Dr J says:

    I totally agree. Local councils require surgeries to have wheelchair access. I didn’t realize this was mostly for the doctors’ benefit. By the time they get their degree, they have only a few years left. I wonder whether the Productivity Commission should look into it.

  12. Michael Bennett says:

    Tony Chung and Sue Ieraci make valid points and perhaps time in training should depend upon the quality of training. There is no doubt that today’s newly qualified specialist is much less competent than his/her teachers were at the same stage. The problem is that they receive less training because they spend much less time ‘on the job’. If they did the hours and received the training that their US counterparts do, they too would be much better prepared to function as specialists than is currently the case.
    In addition, the educationalists in our colleges have the view that nobody is untrainable yet senior teachers with decades of experience will confirm that not every trainee in a surgical post will make a competent proceduralist and should be advised to change courses.

  13. ex doctor says:

    I am a retired and therefore un-registered ex doctor so must be circumspect in comments made about “professional” matters. The extent to which the education industry has captured the whole of medicine in the name of “quality” and “maintenance of high standards” is truly frightening. Specialty training is just a small part of this political con job inflicted on the whole of the health system with little evidence of benefit let alone cost benefit. They deserve a swift kick in the credentials.

  14. Wrong wrong wrong.... says:

    Couldn’t disagree more with this article. What it is proposing is the death of generalism. Yes, you can become a procedural luminologist (gastro, bronch resp/cardiol) in a short period of time (nurse practitioners will be doing that), but it is the cognitive specialities that need the time. You need time to recognise patterns of illness. We have already cut down med school training to 4 years, and with lower hospital stay times there is less clinical contact. There is therefore less training going on. I want a neurologist, endocrinologist who has seen the tricky patient before, not just read a book on it. I say, get rid of postgrad med schools, return to 6 years, straight out of high school and a minimum of 6 years advanced training. PS, Im not over 40 so its not just a yearning for the past.

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