The looming intern crisis has received much attention over recent years. With the number of Australian medical graduates tripling from 1316 in 2001 to 3547 in 2015, stakeholders are rightfully concerned about the availability of intern positions for medical graduates. In 2016 alone, 234 international full-fee paying graduates who applied for an intern position in Australia missed out.

This situation will only worsen in coming years, as higher numbers of graduates are projected based on current enrolment levels. New medical schools at Curtin and Macquarie universities will also see their first batch of graduates enter the job market in 2021.

Even if the Commonwealth Government continues to guarantee intern positions for domestic graduates, another crisis is brewing in the profession.

What has received less attention is the growing disparity between the number of medical graduates and the number of specialty training positions, the latter having remained relatively unchanged over the past few years (here and here) for many specialties.

Let’s take orthopaedic surgery as an example. Commencing in 2009, there were 58 training positions nationally. This number has not increased in any year since then. In fact, there are only 38 positions commencing in 2018 — despite a doubling of medical graduates over that same period.

As a current intern, this growing disparity alarms me.

In 2016, virtually every medical specialty, including general practice, was oversubscribed.

It seems that little thought is being given to the growing pool of unlucky individuals who are unsuccessful in obtaining a position in a training program.

The explosion of medical graduates in recent years has spawned more junior doctors to enter the applicant pool for training positions for each given specialty. Without a commensurate increase in training positions, the result is more unsuccessful applicants in each given year who then re-enter the applicant pool the following year.

This situation creates a vicious cycle, whereby every year the number of new people entering the applicant pool increases (due to the increased number of medical graduates from the previous year) while the number of individuals re-entering the applicant pool also increases (because more applicants each year are unsuccessful and thus reapply the following year). The end result is an expanding queue of people competing for a limited number of training positions.

There are three consequences of this ever-growing bottleneck.

First, the average time it takes an individual to get onto a training program will be longer. In 2015, I attended a presentation by a Royal Australasian College of Surgeons representative who predicted that the average time for an individual to obtain a position on a surgical training program would go from postgraduate year 5 at present to postgraduate year 8 for our cohort.

Second, graduates will have to do more to stand out from the pack in order to obtain a position, which may be in the form of additional study, research publications and skills courses, with a significant financial burden and time demand.

Third, and most alarming, a significant proportion of applicants will never be successful in getting into a training program, despite repeated efforts, which may even become the majority of applicants if the status quo remains in some specialties.

In a previous era, the unlucky few that were unsuccessful could try their luck at another specialty or become a generalist. However, this is no longer practical. If you dedicate 5 or more years trying to get in to a particular specialty and fail, is it realistic to start the journey all over again with an alternative specialty, with no guarantee of success?

Moreover, with general practice now oversubscribed, people can no longer view that as a “fallback” option. Rather, the GP colleges can now be selective in who they choose and will no doubt show preference for those graduates who prove that general practice is genuinely their first-choice career. Somebody who spent the past 5 years as a surgical principal house officer now applying for general practice will no doubt raise eyebrows at the GP colleges.

The status quo is simply untenable. If training position numbers remain as they are, while universities continue to churn out medical graduates at current rates, then we are effectively staring down the barrel of a generation of Australian doctors who are only qualified to be career house officers.

This scenario benefits nobody. Shortages in the specialist services in rural and regional areas will not be addressed. Meanwhile, hundreds, possibly even thousands, of doctors will be left wholeheartedly dissatisfied with their career choice as they are starved of the opportunity to obtain specialty training. Some of society’s best and brightest will never reach their full potential.

The mental health of doctors has received much publicity in recent months after the suicides of several young doctors. Junior doctors already face intense pressure from working in a competitive hospital environment under intense scrutiny with extremely long work hours.

This looming crisis will only add to the pressure and anxiety that junior doctors face.

Bold action is required by the Commonwealth and state governments to control the number of medical graduates. Governments also need to fund additional specialty training positions to satisfy the future demands for these specialty services.

Paul Stevenson is an intern at a Queensland hospital.

 

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15 thoughts on “Specialty training places: the other looming crisis

  1. Anonymous says:

    The first problem is one of thinking about ‘positions’ as something falling from the sky. There are no teachers. The stretched clinical service provision landscape means expert clinicians can hardly devote any time to teaching training or research. Add to it the regulatory burden. Doctors playing politics and medico politicians playing doctors means real expert doctors are rare! Expertise is what patients expect from their doctors not their administrative or political skills. So called teaching centres have no meritocracy- only beaurocracy! I was trained in 3 different continents and I can say the average medical student a decade ago was much better trained than specialist trainees nowadays. A combination of low morale and lack of recognition and support of expert teachers is the main problem. Becoming a specialist is like becoming an artist, you can only make painters by simply increasing the ‘spots’ or ‘positions’ or whatever else you may call it.

  2. Rob says:

    Blimey! Don’t hold back will you.

  3. Anonymous says:

    Increasing specialist training positions though addresses your concern, but what about when you finish and there are even less Consultant positions? Becoming actively involved in research and developing research skills early in your medical career benefits you, the patients and the profession as a whole. Take an pro-active role and take charge of your career to stand out. Just remember your career in on the public purse, not like other esteemed occupations so fiscal spending is always a sensitive topic.

  4. Anonymous says:

    The first comment is correct: positions don’t fall from the sky.
    There is no necessary corollary between increased medical graduates and increased training positions; it is magical thinking to imagine that we can just increase the numbers of training posts. Funding, teachers, patient load, adequate procedural training are all factors.
    The author has identified the initial solution, which is to restrict medical student intake, but that is politically unpalatable if one is trying to break the stranglehold of bodies like the AMA and smash a closed shop to drive down fees.

  5. Gerard Gill says:

    I think we need to be reframing this matter. We run the risk of repeating the experience we endured when TB ceased to be a major problem. We had massive cohorts of TB physicians, thoracic surgeons. and nurses along with the sanatoria. All remained for 10 years longer than needed. We appear to be doing this in cardiology and cardiothoracic surgery as the new technologies change the need and cases decline but we need no new entrants for the next 20-30 years to meet anticipated demand. What the community needs is important not what a medical student or junior doctor feels should be their career.
    The perverse snobbery of teaching hospitals and some disciplines impacts on the attraction of doctors to rural locations and areas of need.
    In the rest of society individuals will have a series of careers. medicine is no different.

  6. Hugh Martin says:

    Specialist training positions require highly qualified teachers, a large number of patients with a wide variety of conditions and an institution prepared to employ the trainee. As what can be done for patients gets more and more expensive, the trainers’ time available for teaching gets less and less as their clinical load increases. With the restraints that “safe hours” impose, institutions are less keen to employ junior staff who do not give all their time to clinical work because some time must be set aside for learning. Even if both of these problems could be solved (the cost would run into hundreds of millions of dollars), places where the patient load is great enough to give a good training cannot be created by order. Putting trainees into jobs that provide inadequate learning opportunities harms the trainee and, eventually, the community. These are the reasons why the problem is a difficult one. It has nothing to do with the “closed shop” myth that is beloved by politicians who need a scapegoat.

  7. Greg the Physician says:

    My private hospital has recently downgraded advanced training positions in several physician sub-specialties to basic traing ones because of a combination of accreditation difficulties and cost factors. I wrote to the Chair of the relevant RACP education committee several months ago but have not received so much as an acknowledgement. The RACS is able to train registrars effectively in private hospitals, while the RACP doesn’t seem interested.

  8. G.A.Chapman. says:

    You could always go back to the default position that used to exist in the “good old days”.(50’s to early 60’s)
    Firstly, it was competitive to enter the Medical faculty based on Leaving Certificate results.
    Secondly, two thirds(400 students ) would fail First year (Sydney Univ.), so they didn’t waste their time “trying” to study Medicine.
    This left about 300 in 2nd year(including the repeats.) Of these, 100 failed 2nd year.
    So you could say the system was “cleansed” within 2 years, avoiding long term disappointment for the failed students.Also remember, that these were some of the brightest and best, who could just nit handle the ” pressure”, a situation you would be expected to cope with down the track.
    From 3rd year on, most students graduated.
    If you failed a year, you could repeat it, after showing “cause”as to why you should be allowed to proceed.
    Seemed to work pretty well in those days, perchance it deserves a rerun, or do Universities make too much money out of having students, who are “not allowed ” to fail ?

  9. Anonymous says:

    Just stop guaranteeing internship positions for graduates. 1. better to find out at 22 that you won’t be a doctor than at 32 or 42 when you finally accept that you won’t get on to a training program. 2. the universities may finally stop pumping out graduates if they can no longer promise a guaranteed job.

  10. Leigh says:

    I was recently on the interview panel for an unaccredited training job in a rural hospital. We had 28 good applicants, interviewed 14 outstanding ones to have a single position to offer. The applicants were exceptional – none of my cohort would have had a look in. This surplus is pushing boundaries to employ only the most eloquent of the applicants, does this make them good doctors, or only show ponies?

  11. Leigh says:

    Imagine this as a solution…

    With the excellent local medical graduates we should be offering 2x streams with bridges between. O&G has a high service provision requirement, with 24 hour cover required. We should separate streams of registrars into a training stream, and a CMO stream. CMOs could perhaps be paid a little more until they reach ~ Year 5 registrar level where the pay rate would plateau. Training registrars would learn on-call and acute care first (same as CMOs), but spend more time doing surgery and procedures, have the stress of high level exams and other current obstacles. There could be an easy “out” for trainees to move back to CMO if they were struggling.

    I wouldn’t mind working as a CMO, much less stress, still doing the hands-on work that I love while not having full responsibility…

  12. Anonymous says:

    Many doctors are turning to the lucrative locum life. With many places paying 100-150 and at some times 180 per hour, they see no financial reason to stick around in a training post may or may not ever happen. As a CMO you can still maintain your professional development qualifications with courses and doing a longer stint every year to get consultants to sign you off etc.

    Certainly there are many hospitals which will never be able to hold on todoctors longer than a few months because there is zero career progression in those places, you’ll never meet a consultant of any significant influence to enable you to enter advanced training, and have no interest in research which is sorely needed in CVs these days. So these places are doomed to be locum farms at extreme cost to the system.
    l

    let’s face it, most grads want to live in urban areas, and though some genuinely love the rural setting, it has been more of where the ones who couldn’t survive the bloodbaths in bigger centres have to go to and content with.

    And of course, the colleges keep screaming how we have too many doctors, and should but an embargo on foreign doctors. It’s a reasonable thing to want to provide local jobs first, but let’s not pretend that the Australian healthcare system is heavily dependent on non Australian doctors to keep the system running. They remain delusional and do not ask the question ” Why aren’t out local grads going to the non urban areas ? ” while condemning foreign trained doctors for taking up space in the urban hospitals.

  13. Anonymous says:

    The current situation is a direct result of misguided and ill informed government policy spanning 30 years. The current number of medical graduates in Australia is simply not sustainable and it is the cohort of bright young people who will pay the greatest prize. This policy of pushing up output so that magically, some will want to do obstetrics in back of beyond is a flawed strategy. As has been said before, the current system makes postgraduate teachers reluctant to contribute as they face sullen entitled desperate young colleagues believing they are the centre of the universe (as the medical schools have made them believe).

  14. Anonymous says:

    The problem stems from the medical schools. Numbers need to be restricted and the standard maintained throughout the course. The universities are now focussed on money and not quality of their graduates. Sadly that means that some who shouldn’t pass do, as the universities don’t want to fail anyone and lose out on years of tuition fees.
    The second problem is the colleges. They need to limit the number of training posts according to the demand.

    I agree with Leigh’s suggestion regarding the CMO. Not everyone has to be and wants to be the specialist. The hospital system needs skilled senior medical officers who can fill the roles of advanced trainees on a more permanent basis and reduce the need for more advanced trainees.

  15. Pitman says:

    The tsunami problem has its antecedents in the 1980s, when the Australian govt (and the AMA, but to a lesser extent) refused to admit there was a shortage of docs, particularly generalists. So it restricted HECS spots, which weren’t subsidized enough to keep med schools viable anyway.

    In the early nineties, schools were close to going broke. Two things saved the day: the internatiaonl student market, pioneered by Flinders when it was the first med school to go graduate in 1995 (precisely so that it could market itself to rich N. Americans); and the feds finally admitted the shortage and increased HECS spots early the following decade.

    International student numbers cannot go down significantly so long as the federal govt pays a pittance to schools for domestic students. Yet the market will crash if a significant number can get neither an internship/residency back home or in Australia. The balance has to be worked out better, but I wold think that anything more than 2/3 being able to stay among those who don’t return ‘home’ (as a single point if residence, consider that for Canadians there’s a 60% chance of getting residency back in Canada after graduating form an Australian school — this is much better than the 40% acceptance of Canadian FGAMS internationally). The only way to substantially bring down int’l student numbers would be to replace them with domestic full-fee spots — possible, but poltiically not gonna’ happen now that ‘equality’ in Australia means ‘free and subsidized stuff’.

    As to domestic numbers, they can come down given that HECS does not even cover their cost of school training (int’l students subsidizes the domestics at most schools). In fact, their numbers can come WAY down if Australia were to decide to have a Return of Service in the bush for several years for all grads. Those admitted to specalty colleges in rural areas where there’s a need and capacity could do the ROS late in training or later, when they’d actually be contributing more than sucking expertise. They could then train more juniors there. Thos who are admitted/streamed to colleges for areas where there isn’t capacity and need rurally could be required to do their ROS before or at the beginning of their specialty training, as rural generalist junior officers.

    I haven’t seen any better workable solutions. No matter what the solution is though, it’ll take a load of political guts.

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