We have doctor maldistribution not just a doctor shortage

Disclaimer: This is a broad and sometimes, personal overview of the medical workforce problems. My views do not represent any professional body I am associated with. They also do not even scratch the surface as to the gravity of this issue.

I was recently hearing about the growing concerns over graduate unemployment with only 68% of university graduates finding full-time employment within four months post-graduation. This number excludes those doing research or further study. It does include people who may be termed ‘under-employed’, people who are available for and want to work full-time but are unable to secure full-time employment.

Medicine has always had an aura of being a very secure job. In fact, we are being constantly told by the government that we don’t have enough doctors. And while that may be partially true, it is not the whole story. We have a doctor distribution problem, not just a major shortage. We have doctors in towns, in tertiary hospitals but not in rural towns, or certain specialties are under-subscribed.

We are fast heading to be following in the footsteps of our tertiary educated colleagues, where doctors will be unemployed or underemployed. And I’m not referring to a graduate in their early twenties. This problem is going to affect people who have finished specialty training, who are in their mid-to-late thirties and have families and other commitments. We are turning our future doctors into future Centrelink customers because we can’t seem to get the balance right.

Rural doctor shortages

One of the major reasons the government wishes to train more doctors is to address the shortage of doctors in rural and remote towns. As a young medical student and junior doctor attached to rural towns, the pain the residents felt at not having a regular doctor or long waits (weeks) to see the GP was incredible. A number of initiatives have been undertaken to try to get doctors to rural towns, including bonded medical positions, increasing medical school intakes for rural students and financial incentives. A number of doctors have also called for the creation of a permanent rural medical school to encourage those graduates to stay in the area.

Rural doctor shortages are in effect, a maldistribution issue. We simply cannot under the current system, staff doctors for all rural towns. It is a very complex problem and has significant concerns for inhabitants of these areas who feel underwhelmed by the medical care.

Do we train too many medical students?

At medical school, my graduating class was approximately 100 strong. That number tripled within a few years. When I went back to university to teach anatomy as a graduate, instead of the few students we had in a group when I did the same unit, there were now sometimes over 10. In 2005, there were 1320 graduates. In 2013, there were 2944 (from Medical Deans data). There are predictions of a doctor shortfall in the range of 2500 in the year 2025. And so, there is ongoing and mass increases in medical schools, not just by numbers at the same university but new medical schools. The most recent addition has been of Curtin University in Western Australia, which will commence in 2017, much to the distress of young doctors everywhere.

I believe that decreasing reliance on overseas trained doctors to fill spaces is important. However, it takes up to ten years to train a specialist doctor, a little less (but not much) to train a GP. With the increase in graduating medical students, we have created a serious bottle neck at the vocational level. Another maldistribution. We don’t need more interns, we need more specialists, especially in under-serviced areas like psychiatry and radiation oncology.

The intern crisis refers to the fact that every year, the government struggles to find intern positions for medical graduates. To be fully and unconditionally registered as a medical practitioner, a doctor must complete one year as an intern in a supervised post. So if you could not be employed as an intern and therefore not meet this requirement, you would not be registered and therefore be able to practice as a doctor. The government is always super pleased with themselves when they announce that they have found jobs for all interns. But they fail to mention that we now stick interns in every nook and cranny of the hospital, in jobs that did not exist before or in huge numbers in one speciality, thus risking diluting experience. The job guarantee ends here. Following this, a junior doctor can find themselves unemployed or underemployed as further vocational positions are not made available.

Without taking steps to increase the number of vocational training positions, we are creating a bottle neck for these junior doctors. Again, unlike counterparts from other tertiary degrees, are significantly older and caught in a system that they cannot do anything about. We have not increased training positions for these young doctors to go on and become specialists (including GP) to solve our workforce shortage. But it keeps happening throughout training too, because on the other side of specialist training, things are not at all rosy.

Our medical specialists are underemployed

In the past few years, my friends and colleagues who I have studied with at medical school have completed their specialist training. They are anaesthetists, surgeons, physicians and so on. I am also in this group. We suffer similar angst to medical students, because a number of new specialists are coming up against another bottleneck; the fight for a consultant position.

For surgery, workforce planning has been done on working out how many surgeons we need per 100,000 people (amongst other variables) and taking into account a retirement age of 60. Which is ridiculous to be frank. Any workforce planning, except maybe professional sports, that believes the retirement age is not going to increase is kidding itself. People are living longer, working longer and financial interests have changed. For instance, the GFC saw a number of previously retired doctors return to work as superannuation losses hit home. Our senior colleagues are not retiring, private practice is nearly impossible to break into and we have not at all accounted for this.

We are going to see an increase in junior doctors applying for training positions that simply do not exist. And I believe that we are currently training too many specialists. How can we justify the personal and community expense on training a specialist and have them underemployed or forced overseas at the end? Just to put in perspective, for surgical training, I spent anywhere between $10,000 to $20,000 a year out of my own pocket. And this does not take into account the societal cost of training a specialist. What a waste if we can’t actually employ these specialists. There is a significant maldistribution between specialities and as such, some of us specialists are facing uncertain futures, with nobody stepping up to the plate to better plan and coordinate training in this country. The HWA workforce planning document alludes to this problem in 2012. In 2015, little has changed.

So what next?

I don’t know. This problem is so complex and it seems we are in an incredible mess. But I think we owe it to our graduates (of university and specialist training) to sort some of this out. Some solutions may have more than one benefit, such as the introduction of part-time or interrupted training. This would allow flexibility that people now desire for families or research whilst allowing us to train more specialists over a longer time frame. Revising workforce planning so that the specialist colleges get a handle on what they’re setting its Fellows up for. We need to better incorporate the presence of IMG’s into workforce planning. Although we wish to decrease reliance on overseas trained doctors, this will not stop them from coming to and working in Australia. The senior consultants may need to look at ways of adding their younger colleagues to practice in a way that is financially, intellectually and clinically sound for all concerned.

I am also a firm believer that we need to give doctors (especially young ones) more strings for their bows. I think we should encourage doctors to pursue other avenues of study including law or business to allow them the ability to take on management roles for example. And this can only mean good things for hospitals who will benefit from well-rounded physicians and better run hospitals.

I wrote to my local MP (who is now our current Prime Minister) to express my concerns earlier this year. I received a pro-forma email back entitled ‘Education’ because clearly my concerns best fit into an ‘education’ problem. The email spent more time talking about women in STEM (also identified as a feminist from first email clearly) than about why improving doctor training issues was important. The email closed with an invitation to get in touch again if I desired. I did reply, and funnily enough, my second email has not been responded to.

I think it is time for the doctor maldistribution problem to be tackled in a meaningful way. Or else the next time you get a taxi, it may be driven by a doctor.

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