There has been a good deal of media interest in the shortage of general practitioners, particularly in rural areas. What has not received much attention is the lack of specialists, especially in our public hospitals, particularly those in rural and outer metropolitan areas.
Australia is short of doctors working in the public hospital system. This shortage affects all specialities, but particularly general medicine, radiology and geriatric medicine.
Why is this? There are a number of reasons.
We have not produced enough doctors. Belatedly, the Commonwealth Government has increased to some extent the number of medical student places in our Universities. However it takes about ten years from medical school entry for the young doctor to emerge as a fully trained specialist. The Commonwealth Government has also recently introduced a proposal to attract specialists from overseas. There are a large number of overseas-trained doctors already living in Australia; 222 of these are undertaking a year of supervised training in NSW hospitals in 2005, after a completing a qualifying examination. This represents an increase of 42 in the number of overseas trained doctors who joined the NSW workforce for supervised training in 2004. A further increase of overseas trained doctors is expected in 2006. These overseas-trained doctors require a substantial amount of supervision by clinical supervisors in their year of supervised training.
Many young doctors do not want to work the 60 plus hours a week in the public hospital system which was the norm for prior generations of doctors. The new graduates want a life outside medicine, to dedicate more time to their families and other interests. This reflects a societal change. There are, for the first time, more women than men graduating from our medical schools. There are data showing that during their working life women spend less time working in their profession than male colleagues. Many young male doctors are likewise not so willing to work ‘full time’. Rather than going into specialist training positions, working long hours and studying for specialist examinations, many young graduates are moving out of “career medicine” into the casual medical workforce. This group – the medical locums – may earn more in 2 full days (and have the rest of the week away from medicine) than their colleagues undertaking specialist training and working for the whole week. The medical locum group is the only section of the hospital medical workforce that is growing.
Australia has a vibrant private health system. Many specialists in the public system do not feel valued and are consequently losing their commitment to and engagement with the public hospital system and spending more of their time caring for private patients.
What are we to do?
First we need better data. Canada keeps track of their doctors after graduation. Australia does not. So we are not sure how many drop out of medicine after graduation or change direction.
We need to further increase the number entering our University medical schools. And we need to better support their clinical teachers. It is not generally recognised that in hospitals the bulk of undergraduate and postgraduate medical teaching is done by hospital specialists acting in an honorary capacity and not by academic teachers. Up to a quarter of medical students enrolled in some University courses are fee-paying from overseas. Most of these students will return to their country of origin and not become practicing doctors in Australia. The hospital specialists responsible for these students’ clinical training are not paid for this extra teaching role even though the students pay full fees to the University.
Our medical workforce management in hospitals is rigid and antiquated. Job-sharing is rare, often the onus is put on the employee to find a partner to job-share, working hours are inflexible, leave is scheduled to suit the employer, and supervision is not always what we expect. More flexible employment practices are needed if we are to attract doctors back into the public hospital system.
Most hospitals are staffed on the front-line at nights and weekends by ‘junior’ medical staff, often without on-site supervision. Some young doctors are concerned about the level of responsibility they hold under these circumstances. The opposite is also common – interns and young residents performing a lot of clerical and non-clinical duties (as they have for decades), which wastes their training and talents. This system has to change and quickly.
The traditional roles of doctor, nurse and allied health personnel have to be re-designed around the patient’s needs. Many procedures carried out by doctors could be done by non-doctors. Many medical duties could be done by other health professionals. In places where it has proven impossible to recruit doctors, nursing staff have been up-skilled to provide a higher level of clinical care. It is clearly possible to extend this model for use in public hospitals where better supervision is available, but would require a reduction in the strict demarcation of clinical roles.
Public hospitals are facing a significantly increased burden of care to cope with the ageing of the Australian population. We must start planning for this greatly increased workload in our hospitals by taking steps to implement innovative solutions now.
Australian hospitals make up the short-fall of young doctors by employing overseas trained doctors (who are here for a year or so) and by using medical locums. There is no universal method of assessing or remedying clinical skills of young doctors. They often feel that they are being used by the public hospital system. Certainly they feel under-valued. They perceive that their hospital employers often do not provide adequate supervision and on-the-job training. This function is filled by senior doctors acting in an honorary capacity.
Although the ‘pass’ rate of medical students in their final University year is close to 100 per cent, the pass rate of many Specialist Colleges for graduates moving into higher degrees may be half to two-thirds. There is a divergence between the community’s needs and the number of trainee specialists in various fields. For example, the community obviously needs geriatricians and general physicians, but the numbers entering these specialties is low, the numbers attracted to cardiology and gastroenterology (procedural specialties) is high. There is no workforce planning liaison. The Universities train medical students, the Colleges train specialists and general practitioners, and after graduation, trainees are employed by state health authorities.
Our hospitals are functioning very differently compared with thirty years ago. The private hospital system has grown, particularly in elective surgery. The patients entering the public hospital system are older and have multiple health problems. Patients are sicker, stay a shorter time and are subjected to more investigations with more sophisticated technology.
The morale of our hospital workforce is low. Disengagement and loss of commitment is a real issue. This issue is not confined to Australia. Indeed a very recent Lancet editorial (30 April 2005) echoed the mood of Australian clinicians: ‘Labour, Conservative, and Liberal Democrat politicians have all failed to address the single most important factor hindering the improvement of health services – the catastrophic collapse in morale among doctors.’