Your career, your choice (but is it really?)
Throughout Australia’s health system a change is occurring. It is a change that has happened before, as a recent history littered with medical workforce policy failures gives testament to.
The evolution of the workforce balance in most large hospitals is now in a situation where, in junior doctor ranks, the medical workforce is in balance or, at worst, in oversupply.
While this is necessary, with high-level workforce planning predicting that the numbers of medical graduates now are approximately appropriate to meet future community demand, the transition to supplying this demand, beyond producing medical graduates will be challenging. This has been exacerbated by hospitals restricting their recruitment under adverse budgetary pressures.
The dilemma is no longer about numbers. Federal Government policy has overseen dramatic rises in medical student graduates over the last decade. The raw materials are present – now it is a matter of converting them into the finished doctors that the Australian people really need. This means confronting maldistribution: maldistribution in the location of practices, and maldistribution in the choice of specialty.
All medical students had career dreams when they started medical school. Most, driven by altruism, wanted to serve the Australian community, providing health care for those that needed it.
Many had fixed ideas about the way in which these dreams were going to be pursued. Plans to become neurosurgeons, ophthalmologists, or rural ‘jack of all trades’ general practitioners.
While the dreams and plans are still there, the health system has moved on. Today’s graduates face a conundrum: what happens when the community doesn’t need them as a heart surgeon or an intensivist?
Do today’s graduates still want to serve the Australian community when they are required as a psychiatrist instead of a cardiologist or a general practitioner in Quilpie instead of a surgeon in Toorak?
In policy terms, it is very easy to spout phrases like ‘we need more psychiatrists’ and ‘more doctors for the bush’, but how do you convert a junior doctor who has worked their way through medical school with the ambitions of becoming a cardiologist in inner city Melbourne into becoming a psychiatrist in Mildura?
Anecdotally, in some specialties it is already becoming clear that the training pipeline is not matched to community demand. Stories abound of newly graduated specialists either unable to find employment or accepting under-employment due to at-capacity public hospital departments and saturated private markets.
Overlying this is a mismatch in the location of practices, with some graduates prioritising lifestyle decisions to remain in cities over the possibility of greater employment in regional or rural areas. Ultimately, this is the product of personal choice triumphing over the expectation of community service.
This is the crucial issue facing medical training today – how do we balance individual aspiration and ambition with community need? How do we ensure the right mix of incentives and/or recruitment strategies to encourage the uptake of under-subscribed specialties and practice in under-serviced areas?
The answer has to lie in recruitment and career development during medical school. Some approaches are already in place, with a number of workforce measures for rural recruitment implemented with mixed success.
As yet, specialty distribution has not been adequately addressed. Greater exposure and improved experiences in under-subscribed specialties during medical school will be part of the solution. For instance, impending pilots of a community-based internship promise to improve recruitment to general practice.
Indeed, these types of approaches are likely to be the most successful. Co-opting or forcing junior doctors with established career plans can only result in personal dissatisfaction, and has the potential to adversely affect patient care and workforce morale.
The AMA has to continue lobbying on this front, although our position will be fraught. Is it a matter of advocating for the junior doctors facing these challenges, or for the health of the community that will suffer if these problems are not resolved?
Given the inherent contradictions of these positions, making an argument to satisfy both promises to be challenging.
Will is participating in ‘Your career, your choice?’ panel discussion at the 2013 Prevocational Medical Education Forum in November in Adelaide. A blog (http://www.prevocationalforum2013.com.au/blog/) has been set up to generate pre-conference discussion and raise critical questions.
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