Issue 17 / 7 May 2012

UNTIL the 1970s many young doctors — who were overwhelmingly male — after a couple of years of internship or residency spent some time overseas expanding their education and observing how patient care and research were managed in another country.

This excellent process has now almost ceased because of the time it takes to complete Australian medical training. It is one of the many poor outcomes of the move to excessively long training.

My experience was common: graduated in 1964, completed 2 years as an intern and resident medical officer, then, during my third year as a registrar, successfully completed my exams for the Royal Australasian College of Physicians.

If I had not spent 3 years in the US, I could have been in a consulting physician practice at age 26 — 9 years after entering medical school. If I had started my career as a GP I could have been in practice after 7 years.

Back then, that seemed like a long training time compared with other professions. For those doing dentistry, engineering and architecture the time to starting in practice was 4 years; for veterinary science, 5 years. The law was also 4 years with a year of “articles”.

There has been little change in training time for these five professional groups. However, in medicine the length of training now seems to be out of control.

At the Sydney Medical School students now must have completed a graduate course of 3–5 years before they can “do medicine”, which is a 4-year program. This is followed by internship and at least year as a resident medical officer, then 3–5 years of “advanced training”, whether for general practice or neurosurgery.

So, leaving school at 17, completing a 3-year bachelor degree, then 4 years of medicine, then two of hospital residency then three of advanced training —  it is 12 years after leaving school, at age 29, that you can begin to practise independently in your chosen field.

And this is an absolute minimum.

If you change direction, complete an honours year with your first degree, spend 3 years in hospital residency, or wait for a training position to become available, you will be at least 31 years old before you are able to practise your craft.

With 50% of students now women, if you pause to have a family you have to add another 3–5 years to this equation.

Why has this occurred?

Universities insist that the explosion in medical knowledge requires 4 years of education and training as a minimum. For most it is 6–7 years at least.

Health departments have realised that they pay resident medical staff and quite correctly demand appropriate service in return, mandating that the first years after graduation cannot be a part of advanced training. So, add 2 years, sometimes with a flexible second year where some advanced training can commence.

Advanced training usually starts in the third year and extends for 3–4 years or longer. It is in the hands of the colleges and their special groups, which have grown in number and size in the past 40 years.

When I graduated there were three colleges — the Royal Australasian College of Surgeons, the Royal Australasian College of Physicians and the Royal Australian College of General Practitioners. Now there are probably 20, although it is easy to lose track with the number of subspecialties.

All these bodies demand that in addition to a medical degree and a period of supervised hospital or community training, applicants must pass a written exam and a clinical exam.

Is all this necessary? Are our medical practitioners better equipped to deliver excellent patient care than they were with shorter training times?

There are no clear answers, so what should be done?

It’s time for a national forum to deal with this issue or we risk wasting opportunities for many very clever young men and women who will eventually become our future medical practitioners.

Professor David Tiller is professor of medicine and associate dean of planning and development at the School of Rural Health, University of Sydney.

Posted 7 May 2012

Does it take too long to become a doctor? In a two-part series, the MJA tries to find the answer.

Sorry, there are no polls available at the moment.

14 thoughts on “David Tiller: Education overkill

  1. Aniello Iannuzzi says:

    As I said in a recent comment article (…), we need to go back to the future and re-introduce memberships of the colleges, and reserve Fellowships for the teaching hospitals.

  2. Tom Ruut says:

    It is crazy when you even need a Ph.D to be a nonacademic cardiologist
    Overqualification is a waste of doctors!

  3. Jules Black says:

    I am an alumnus of David’s, and I still do specialist locums in 4 states. I have as a result worked in well over 30 rural Australian hospitals, many of which have registrars, residents and some even have students. Since I believe in a patient being a whole person, I weave in as much general medicine, pathology, pharmacology, microbiology etc as I can when doing rounds and interacting with these doctors. I can still run rings around them at all levels. I have these daily reminders when on the job as to how well-trained we were back then compared with the young doctors I have come across these past 15 years or so.

  4. ST says:

    Thank you to Dr Tiller for raising this very timely issue. As a current registrar (4th year post graduation) who has many friends and colleagues in training programs, I can testify that in reality training is even longer than stated in the article. Dr Tiller states that ‘advanced training usually starts in the third year’. I wonder if he means ‘basic training’. Basic physician trainees start studying for exams in post graduate year (PGY) 3, sit in PGY4 and commence advanced training in PGY5. ED training has provisional training in PGY3 and advanced training from PGY4. ICU college starts advanced training at PGY5. Anaesthetics has basic training PGY3 at the earliest (although most people only get in PGY5 or up). There are colleagues I know in their mid-thirties who are still registrars. Apart from the practical effects this has on trainees, I wonder if anyone has studied the effects of such long training on doctors’ social and psychological development – to be still training and not settled into a position, well into the 30s…

  5. Michael Tam says:

    As a relatively recently Fellow of the RACGP, I sympathise with walking the long road of training. However, we should reflect that the explosion of medical knowledge and technology is real. Furthermore, there has been a substantial change in the expectations of quality of care. Taken together, ill people are more likely to survive – the acuity of care has increased – and greater importance has been placed on patient safety and the assurance of quality.

    These are good things.

    I don’t doubt that there are process reasons leading to the lengthening of training as well, but fundamentally the practice of medicine requires greater technical skills and knowledge.

  6. SL says:

    Perhaps if we better focussed training time we could not only save time but make graduates more skilled at what they need to do the job.

    – train medical students to be interns
    – train interns to be registrars
    – train registrars in their chosen specialty

    This would require real teaching during HMO years and not just reliance on experiential learning. With hospital struggling to find ways to accommodate 50% more graduates, a bit more non-clinical time spent learning might be of benefit to the hospital and doctor.

    We need broad exposure early on, both for a complete education but also to give students a chance to experience a variety of specialties before making up their mind. Specialising too early in a training program (ie. as a medical student) seems fraught with more new problems than it is likely to resolve.

    One benefit of the graduate programs has been getting more doctors with other life experiences. If it becomes a de-facto 7 year degree (B. Med Sci + graduate medicine) then we risk losing some of this perspective. I applaud anyone that can find a way to make having a young family (whether mother or father) more compatible with post-graduate studying!!

  7. AB says:

    In some areas of medicine, the registrars are essentially the workhorses of the hospital, and without the public services would be on the verge of collapse. Many fellowships appear to be time based rather than competency, but from a cost perspective, it makes a lot of sense to keep registrars in the public system for a long duration as possible. For example, I have heard from a number of my psychiatry colleagues that the number of exams required to complete fellowship has recently increased which appears astounding given the shortage in that area. The other drawback they comment on is that they have trouble getting newly qualified consultants to stick around in the public system.

    With the boomer demographic continue to increase in age, a rise in age related physical and mental illness will naturally follow. The demand for general practitioners, generalist physicians, geriatricians and psychiatrists is projected to increase substantially, but as the difference in pay compared to procedural based specialities continues to widen, students are attracted to more lucrative areas (surgical sub-specialities, dermatology, radiology etc) instead. That in turn results in increased demand for the more popular specialities, and with increasing competition potential applicants will need more references, qualifications, research citations, experience etc, extending the time it takes to enter training.

    As it stands currently, the medicare reimbursement schedule rewards a clinician who sees multiple short consults, as opposed to longer more complicated ones. This appears to be unique to medicine and can be contrasted with other fields such as engineering where more complex work is rewarded accordingly. Until this anomaly is resolved there will continue to be an imbalance as junior doctors gravitate towards the more financially rewarding fields, the requirements to enter training will increase, training time will be extended, and shortages in other areas will continue to be exacerbated. Ultimately, our society will be worse of for it.

  8. Dr Georgie says:

    The training and education required to do our work these days is quite overwhelming. HOWEVER, I’m a 53 yo GP and have done masses of postgraduate training, fellowships, exams, etc etc. Have also raised four children. Currently work about 50 hours a week as well as assisting in running our business. I STILL feel like I am in training and will do so until I eventually retire. However, I enjoy it and realise there will always be a need to keep learning in this profession. People in other lines of work commonly change direction or their work becomes ‘extinct’ and they also have to continue education long term. Perhaps a different way to look at it would be to ensure that during all this training doctors get paid appropriately, have adequate rest and relaxation time, can have breaks during training(for family or other), and are acknowledged as ‘proper’ doctors despite being in some training program. Just because a doctor is a trainee in ‘plastic surgery on the 5th left eyelash’ (having done all the earlier more generalised training) doesn’t mean they can’t feel grown up or lead an ordinary life outside work and study. And they are earning a good living, unlike most other ‘students’.

  9. Sue Ieraci says:

    Hmmmm – I’m ambivalent about this. Let’s remember that a medical degree and registration allows us to practice a difficult profession and carry significant responsibility. Further training of course takes longer, but it is “on the job” training – while being paid to work – much like many other professions. In almost thirty years of interacting with an enormous number of both junior and senior doctors, I have seen the benefits of breadth of experience over finely-honed training. Do we really want to head towards even more extreme sub-specialisation? I admire clinicians who understand the entire human organism – not just their own area of sub-specialisation.

  10. John Porritt says:

    It’s fascinating [!] to read that variations in training of doctors ought to be in the academic aspects only. I suggest future training should be shortened but that to it should be added or included training in understanding (for students whose families, private school and university years have not obliterated such skill) how the people in the real world live and struggle, and actually think and form attitudes. Practical learning could include, eg, access to help in rural areas, discovery of the self-seeking attitudes of some appointees to medical boards or to state governments, and also real knowledge of how the public (of whom doctors were once thought to be the servants) in their variable ways think and are influenced. I lack, as can be noted, support of all those many currently graduating medical students who are simply though dangerously (for the people) intent on following medicine as a profiteering business.

  11. karen price says:

    To John Porritt: Who said all med students were from private schools? That would be an interesting study to see who is NOT getting into medical school these days compared to the “free” education of the 1980s. Maybe this is reflecting the higher cost of tertiary education nowadays, providing a disincentive for capable kids from lower socioeconomic backgrounds. To increase diversity in the University cohort, maybe more industry and govt sponsorships to offset the enormous costs of a medical school education rather than the unintended consequences of the homogenised interviewed UMAT’ed ATAR’ed scored lucky “one” who gets through all these non-validated hurdles to enter. Having done the interviews it seems the privately educated students perform, in general, better than the country kids or those from high schools who were “raw” talent, but unskilled in interview training. The very nature of the application discriminates against those from less fortunate backgrounds. From someone who worked her way through the then free medical school of the 1980s amongst a lot of my middle class high school educated friends. This working exposure taught me a lot more about the art of managing patients from all backgrounds than med school did!
    Shortening or lengthening is only a part of it, maybe ethics philosophy and mopping the floors of a fast food store or factory work might give med entry students the common touch?
    More training in the University of Life!! No easy answers.
    I dont see too much wrong with the medical students I teach although all so far, are from private schools.

  12. Bill Coote says:

    Some numbers: The average age of applicants in 2011 for 2012 entry into the CoastCityCountry GP Regional Training Provider (covering Woolongong, Canberra, NSW South Coast, Wagga and Riverina)for the 3 year FRACGP or ACCRRM program was 34 (males 36 and females 33). The national average was 33, males 34 and female 32. An AMG/IMG age breakdown (IMGs were 37% of applicants nationally and 51% in CCC) of these numbers would be interesting if available and would clarify the extent to which these averages are affected maybe by older IMGs and/or AMGs graduating much later than David Tiller suggests. It could also be that AMGs were delaying applying for GP training. Decisions regarding children are another factor in the mix – 62% of applicants (nationally) for 2012 were women (for CCC 66% were women). A small consolation, the previous year the CCC average age was 37 – with males 39 and females 36.

  13. Sue Ieraci says:

    Karen Price – I work with a lot of medical students and junior doctors who have not gone to private schools – most are the children of migrants who have lived a very different life to the typical cohort of decades past. Perhaps this depends on the demographic in which one works. WHile the children of post-war migrants (like myself) benefitted from a free university education, many of the current day benefit from their parents’ sacrifices and the addition of coaching. This cohort adds to the interesting mix in the medical workforce.

  14. Simon Hauser says:

    An important issue is that interns and junior doctors work less hours (which is a good thing) – this thus means that their hands-on practical experience is less than in previous times, so shortening training would further reduce their experience.

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