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Not alarmist, just the boring truth

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The truth is often incredibly boring. It doesn’t sell papers. It doesn’t get people tuning in. It doesn’t win votes. And thus it follows that when things don’t make sense, one should assume incompetence before malice. But I’m finding it incredibly hard to suspend my disbelief when I stand back and take a look at the medical training system that we have in front of us today. 

I’m not trying to be alarmist. I’m not here to tell you all that medical training is broken, and we should burn the books, burn the witches and behead Ned Stark. But I hope that I can convince you at the very least that the current progression to Fellowship is entirely unnatural and is fertile ground for unhealthy professional culture. To really understand this progression, I want you to pair up with each other, junior and senior doctors alike, and I want you to compare your respective paths through your medical journey. I find that often people have no idea what is or was on the other side of the fence. Let’s begin.

We finish medical school as the ultimate in medical pluripotency: the intern. We complete a year of heavily regulated and supervised training where we meander through medicine, surgery, emergency and whatever else might lie in our path that year. We then transition to residency, where without the pressure of training progression, we expand our medical buffet of specialisation and become more attuned to our final path in the journey. Armed with the knowledge of our experiences in areas such as general practice, ICU and plastics, and well rested from the safe hours worked, we apply for a training college. We get onto a program and begin to complete the pathway to specialty. Along the way, we have kids, and we do this by working part time at points along the way to balance the load. We complete our final exams and we become a Fellow of our chosen College, and apply for jobs in what is a reasonably well-balanced workplace. Right? Wrong. The truth is boring, but the truth is the truth, and this picture definitely isn’t the truth.

We finish medical school as the ultimate in medical pluripotency: the intern. We apply for internships, and a number of us will fail to get them as State governments are defaulting on their COAG agreement to provide medical graduates with internships. Without an internship, a number of doctors are unable to progress to general registration and are out before they begin. Those who remain become residents. With no national body to oversee PGY2+ terms, and with health services hungry to provide services to increasing populations with shrinking budgets, these residents work terms that don’t provide any meaningful experience. This veritable army of night cover and discharge summary monkeys are forced to scrounge around for the breadcrumbs falling off the training table. The smart ones quit, locum and complete further study, but not without further financial and temporal penalty. We’ve built a system in which the best way to advance your career is to quit the system for a while; a perverse incentive. This of course leaves behind fewer residents to fill the gaps in the roster, who are already at breaking point due to being denied leave for three years.

Nevertheless, you move towards a College. You identify the entry requirements and you undertake the extra mile to become a candidate with a chance. In some instances, that means completing a $5000 exam before you’re even a trainee. Once in, you work full-time and then the rest of it. You complete graduate diplomas, Masters and PhDs to progress. You fill your CV with publications and courses that cost thousands of dollars to progress. But you do it anyway. Because at this point you’re the blackjack player with a hard twelve. You’ve sunk enough cost into this game that you can’t quit, and there’s a glimmer of a nine sitting on top of that deck. But there are many more face cards, and maybe it’s just me, but I swear I’m seeing more and more doctors folding and busting around me.

So, you make it through. With everyone else. You’ve completed a number of extra qualifications and courses. With everyone else. You’ve participated in the medical arms race, and you’re surrounded by tens of thousands of other nuclear nations who’ll do anything for that job. The fat has been trimmed and now we’ve hit muscle. Welcome to exit block; a nation of Australian Fellows who can’t move on to consultant positions because we’re doing more with less, in every sense of the phrase. Competition is one thing, but when you’ve got multiples of trainees to every consultant position, you don’t have a competition. You’ve got a war.

I told you I wasn’t going to be alarmist and I stand by that. My examples above are all based on real life cases. I believe firmly in having a competitive workplace. I believe that smart hard work should be rewarded in the workplace. But this is not the system we currently have. We have a system that rewards the single-minded.

This is nobody’s fault. But it’s definitely our problem. It’s up to us as a profession to recognise that this isn’t about doctors eschewing hard work. It isn’t about people wanting an easy life. This is about a culture that has not kept up with the times and it’s important for those working in well-run institutions to recognise that this is not the norm anymore.