Does it take too long to become a doctor?

For many doctors, the pathway to becoming fully qualified is delayed by bottlenecks in the medical training pathway, as described in the first part of this MJA feature series.1 Some doctors spend years waiting to access specialty training, while there are fears that the increasing number of medical graduates may mean that some miss out on internships.

There are also concerns about inefficiencies in the vocational training pathway.

Dr Clare Skinner qualified as an emergency physician last year — 20 years after finishing high school. Her pathway is not exceptional. She entered the University of Sydney Medical School when she was 24; the average age of entry for this school. Before this, she had completed a combined BA/BSc and spent a year pursuing a career in science communications.

Some of the major “rate-limiting” steps for Dr Skinner came after prevocational training. She developed an interest in HIV and so began training to become an infectious diseases physician. This meant she was staring down the barrel of about 8 years’ training because, in addition to physician’s training, she thought she would need a Master of Public Health and either pathology or sexual health training.

As there is stiff competition for infectious diseases jobs, she also realised she would not be able to get stuck into infectious diseases work until she had completed basic physician’s training. She said this was incredibly demotivating.

“For someone who’s enthusiastic about something, the worst thing you can do is say, ‘hey, you can’t even touch this for at least 2 years’ ... I didn’t last very long doing geriatrics and general medicine [in basic training].”

Like a significant minority of junior doctors, Dr Skinner decided to change specialties. She had always had an interest in emergency medicine and accepted a position as a senior resident in emergency medicine. This was technically a step backwards, but Dr Skinner was happy in her new specialty. However, her year of physician’s training did not count towards any subsequent training.

The Australian Medical Council accreditation standards require specialty colleges to recognise prior learning.2 Professor Kate Leslie, Chair of the Committee of Presidents of Medical Colleges — which represents all the specialist training colleges, including for general practice — says that all the colleges do recognise prior learning, and that this process is continually reviewed.

However, many doctors are concerned that the current recognition of prior learning by specialty colleges is insufficient. The 2010 Australian Medical Association (AMA) Specialist Trainee Survey,3 published last October, states: “A common theme among junior doctors is that the ability to move between training pathways is restricted by insufficient recognition of prior learning”. Of 538 respondents to the online survey, only 25% agreed or strongly agreed that their college grants appropriate credit for relevant prior training and experience.

Additionally, 14% agreed or strongly agreed with the statement that: “The lack of recognition of prior learning offered by my college has impacted negatively on my career progression”.

Dr Rob Mitchell, Chair of the AMA Council of Doctors-In-Training, says that, overall, junior doctors seem content with the length of vocational training. However, he said the insufficient recognition of prior learning had big implications for some trainees — and the community.

“If we unnecessarily prolong training, then doctors aren’t working in the communities where they’re needed”, he says.

It’s not only junior doctors who are concerned about recognition of prior learning. Professor Simon Willcock, Chair of the Confederation of Postgraduate Medical Education Councils, says doctors wanting to make career transitions later in medical life also need more support.

Professor Willcock, who is also Professor of General Practice at the University of Sydney, says two common scenarios are general practitioners who want to switch to palliative care as they get older, and emergency medicine doctors seeking to use their clinical skills in a non-emergency setting as their “adrenaline levels drop off” in later life.

“We have to make sure we don’t make people go back and relearn what they’ve already learnt.”

Professor Willcock said there was a need to move away from “rigid disciplinary silos” and for more cooperation between colleges.

“We’re in an era when we have to look at the whole model of training doctors. Medicine is a linear model of training, right from undergraduate medicine to specialty training, whereas most other professions have recognised that careers are not linear — people chop and change.”

For Dr Skinner, the next rate-limiting step came with the college exams. Like many specialties, emergency medicine requires trainees to pass exams before progressing to advanced training. The four primary exams in emergency medicine can be completed in 1 year, but as Dr Skinner juggled research and other interests and had to resit one exam, it took her about 2.5 years. She says doctors who are able to pass all four exams in 1 year tend to be people with a lot of support, such as those still living with their parents.

Many specialty training programs also have compulsory research projects, which can present a barrier for trainees who are not naturally inclined towards research. Dr Mitchell says there is a pleasing move towards more flexibility in this area, such as colleges allowing trainees to do coursework in biostatistics rather than compulsory research.

“All trainees need the ability to interpret evidence, but not necessarily the ability to conduct a randomised controlled trial — striking that balance is important”, he says.

Organising the specific clinical rotations required can also delay progress for many trainees, and this process is likely to become trickier with increasing numbers of medical graduates.

Dr Skinner says: “I did bits and pieces that didn’t count because I really needed some other [placement], but that job just wasn’t available — that’s a very common experience”.

Professor Leslie says the colleges recognise that it’s becoming harder for trainees to access suitable training experiences.

“We are concerned about the doubling of the medical student output in the past 10 years and what that may mean for specialties where there are a lot more trainees. There’s a large group of trainees who may have trouble accessing the vocational training program that they have set their sights on.”

For some people, the potential difficulty of accessing particular training programs influences their career choices. General practice registrar Dr Krishna Ghosh initially applied for ophthalmology training but missed out, even though she had completed a PhD in vision research and done terms at Sydney Eye Hospital.

“I know that ophthalmology is very competitive, but I had done many years of research and publications. Looking back, I probably just didn’t have the political know-how”, she says.

She applied again the next year, but declined an interview. The thought of missing out again, and the long and demanding training program she would have faced, was a factor in her decision to train as a GP. Additionally, Dr Ghosh had already started a family when she was applying for vocational training — a situation that is becoming more common as trainees’ average age increases — which increased her reluctance to embark on a lengthy program.

Dr Mitchell says there are also concerns that, as medical graduate numbers increase, some doctors may have difficulty progressing from basic to advanced training. Some training programs require doctors to secure a separate advanced training position after completing basic training.

Professor Leslie says colleges are aware of this concern and try to encourage prospective trainees to be proactive about organising their training. “We’re working with training sites to ensure efficient rotation of trainees, and access to mandatory courses.” However, she recognises that increasing student numbers will put the pressure on advanced training.

An eagerly anticipated report released late last month by Health Workforce Australia (HWA), Health workforce 2025, found that these concerns are justified.4 The report predicts a significant mismatch between demand and supply of advanced vocational training programs in coming years.

“Based on the modelled community demand for specialist medical services; the number of expected graduates and a continued migration flow, the number of doctors seeking to gain a place on an advanced specialist training program will increase in excess of available advanced training places”, the report states.

The report predicts that in 2016, there will be 3867 doctors seeking entry to advanced specialist training (including in general practice). The latest Medical Training Review Panel data show there are currently only 2817 first-year vocational trainee positions.5 By 2025, the HWA report estimates that demand for advanced training places will exceed their availability by almost 1300 places.

The AMA said the report showed that there was a desperate need for governments to fund extra prevocational and specialist training places.

“Without these extra training places, thousands of junior doctors will not be able to achieve specialist qualification, and the community will not realise the full benefit of its investment in increased medical school places”, said AMA President Dr Steve Hambleton in a statement.6

Colleges and governments are looking to innovative training models, such as private-sector training and simulation training, and are also considering aspects of competency-based training to ensure an efficient training pathway.

Some colleges are already using elements of a competency-based approach — where trainees progress through training based on their mastery of particular aspects of the specialty rather than a strictly time-based progression.

Some believe there needs to be an increased emphasis on competency-based training so that particularly talented practitioners — or those who have transferred from other specialties — can progress more quickly. Associate Professor Christine Jorm, coordinator of the Personal and Professional Development Theme at the Sydney Medical School, questions the strict time frame of specialty training.

“For instance, why does it always take 5 years to become an anaesthetist? What if a trainee is really good — could they do it in 3? It’s a heretical idea — but it’s worth thinking about”, she says.

Most people who spoke to the MJA believe there needs to be a balance between time-based and competency-based training. Dr Mitchell says competency-based training works well for tasks that can be easily objectively measured, such as procedures, but is not as well suited to higher-order skills such as clinical reasoning and judgement.

“Competency-based training isn’t the panacea for clinical training — it has a role but it also has its limitations. As long as people are aware of those limitations, it can be used well”, he says.

Professor Leslie agreed, saying the Committee of Presidents of Medical Colleges supports the Australian Medical Council view that experiential aspects of training are important. “You can break something down into a series of building blocks but when there’s a high level of judgement required, the overall competency is greater than the sum of its parts.”

In fact, given the increasing difficulty of accessing required training experiences, she says competency-based training may increase the duration of training in some cases.

Medical colleges and governments are increasingly looking for training opportunities outside the traditional public teaching hospitals to increase training capacity.

Professor Leslie says that all colleges have the capacity to train more registrars — if the training positions are available — and most believe that it is a necessity that more specialists are trained to meet community demand.

“We are very responsive to requests for expanded training environments.”

However, she says there are barriers to private practitioners training junior doctors, such as a lack of resources including office space, a lack of training and a lack of dedicated teaching time, as exists in the public sector.

She says there is pleasing progress towards better support for supervisors in the private sector, such as through the federal government’s Specialist Training Program, but she called for more support.

Dr Mitchell echoed her calls to expand the Specialist Training Program, which he says not only expands training capacity but also allows trainees to gain valuable experience in the private sector, where about half of all patient contacts occur.

Dr Skinner was 37 when she finally became a completely independent emergency physician. She had watched her high school friends earning six-figure salaries in other professions while she was still technically a trainee.

“It’s a lot of time to be at the behest of other people. You get very limited say on your rosters or your rotations during that time. In medicine, we have the most delayed adolescence of any group.

“As a registrar, you’re not pulling the sorts of salaries that compare with professional people your age in other industries. We have a very delayed adolescence economically as well.”

Dr Skinner, who is now a senior lecturer in medical education at the University of Sydney, says the increasingly advanced age of trainees also makes it difficult to fulfil the requirements of training programs. “The expectation that you’ll pick everything up and move your life for 3 to 6 months to satisfy a training requirement is much easier at 25 than it is at 35, because of partners and children and mortgages and life catching up with you.”

Although she loves her choice of specialty and emphasises that overall she had a positive training experience, she has seen other doctors exhausted by the time they complete training.

“I think that a lot of people are genuinely burnt out by the time they finish. I think that’s why we’re seeing people divert to the private sector in droves the moment they get their subspecialty qualification”, she says.

While Professor Leslie acknowledges that training is long, and specialty training programs are constantly under review, she says the quality of training is the more important emphasis.

“We are focusing on quality, and while we’re trying to be as efficient as possible, we’re primarily committed to producing high-quality graduates who meet the needs of our community and who, more importantly, advance medical knowledge and practice, not only in Australia and New Zealand, but around the world.”