Over the past few weeks, there has been a number of media articles about a growing crisis in General Practice in Australia, including this informative article in the SMH. 2 significant pieces of government information landed this week which help to shine further light on why General Practice is in crisis in Australia.
Tax Office Data Shows General Practice Falling Behind Other Specialties
The first piece of data came from the Australian Taxation Office which showed that for the financial year 2019-2020 incomes for general practitioners, whilst relatively healthy compared to other occupations in Australia continue to lag well behind all other medical specialties in Australia, apart from Pathologists. This information has been well reported in the media.
Medical Board Report Explicitly Shows That General Practice is in Crisis and on a Steep Downward Trajectory.
This report documents how each specialty college, including the 2 specialist General Practice colleges, in Australia assesses specialist doctors from other countries (SIMGs) in terms of their comparability to the equivalent Australian specialist under what is termed the Specialist Pathway. This assessment, therefore, determines the suitability of SIMGs to practice and apply to work in Australia.
As someone who regularly assists SIMG doctors with the process in Australia. I regularly monitor these reports. And for 2021, I was prepared to see that there had been a reduction in the number of applications and assessments for SIMGs. But even I was blown away by what this report revealed.
The number of assessments and approvals of SIMGs was significantly down across the board. Between the years 2015 and 2021, the average number of SIMG doctors deemed as comparable (and therefore eligible to apply for work as a specialist in Australia) across all specialties was 590 Specialist IMGs.
In the year 2020 which was the first year to be affected by COVID-19 this number took a small dip down to 491 SIMGs approved as comparable. But in 2021 this number has crashed to only 177 SIMGs being approved!
Only 9 International Doctors Were Approved to Work as General Practitioners in Australia in 2021.
For General Practice the picture has become even dimmer. In 2020 84 Specialist IMG GPs approved as comparable across the 2 general practice colleges. In 2021 this number sunk even lower to just 9 overseas trained GPs approved to seek employment in Australia!!
To me, this is the strongest indicator or confirmation to date that General Practice is in Crisis in Australia.
This number of only 9 Specialist IMG GPs comes off a high water mark of 308 approvals in 2018. If you look at the graphic below you will see that normally Australia relies on around 200 to 300 General Practitioners from overseas being approved to work in Australia under the Specialist Pathway under its strategy of providing a sufficient general practice workforce.
What is most worrying on this graph is that even before 2020, there was a significant dip in approvals in the year 2019. The message here is that it would be foolhardy just to attribute the current concerns about the General Practice workforce to the impacts of COVID-19.
We need to understand the reasons why both overseas trained doctors and Australian medical graduates are not embracing General Practice as a specialty in the numbers that they used to and which we need them to.
A long-term freeze on the indexation of Medicare billing items has undoubtedly hurt General Practice more than other specialties as it is generally more difficult for GPs than other specialists to charge gap fees in order to keep up with the costs of running a practice.
Regular government changes to the processes of alternate pathways for IMG doctors to enter General Practice, such as the phasing out of the General Practice Experience Pathway for the new Fellowship Support Program also cause confusion.
The Australian General Practice Training Program, which is the main program by which Australian medical graduates can train to become a General Practitioner is also undergoing significant change in 2023. Moving responsibility for training from the previous Regional Training Providers back to the Specialist General Practice Colleges. Hopefully, this change will be as smooth as possible and not lead to further disruption in this vital workforce.
This week the Medical Board of Australia released the findings of the first-ever national medical training survey (MTS). As someone who has previously championed and developed these types of reports on the New South Wales level, it is truly pleasing to see this report launched. And boy did they release some findings!
With the results of 59 headline questions reported across several different segments, including interns, prevocational and unaccredited trainees, IMGs and specialty trainees. With the main report running 249 pages, several other reports drilling down to College level, State and Territory level and even an Aboriginal and Torres Strait Islander report. As well as an online interactive dashboard and a page where you can customize your own reports. There’s truly something for everyone in it.
So, what are some of the key findings from this report? Key points from this survey are that greater than 75% of doctors in training are happy with their training and workplace, however, 22% had experienced some form of bullying, harassment or discrimination. Most doctors in training are working safe hours but a concerning amount are still working in excess of 60 hours and even 90 hours per week, with surgery being one particularly bad specialty for this. Contrastingly far too many doctors in training aspire to enter a specialty like surgery than there is the actual capacity or need for. The survey shows that individual doctor career plans are out of alignment with medical workforce planning. Finally, even though we do have information about how medical schools are now performing as part of the medical training pipeline this information is surprisingly absent from the survey.
Let’s drill a bit further into some of the key initial findings from the survey.
Overall Impressions Of the Medical Training Survey.
The Medical Training Survey will be run each year to get
feedback from doctors in training in Australia (and in time their supervisors)
to (according to the Medical Board of Australia):
better understand the quality of medical training in Australia
identify how best to improve medical training in Australia, and
recognize and deal with potential issues in medical training that could impact on patient safety, including environment and culture, unacceptable behaviours and poor supervision.
It will take a while to assess the impact of this report.
What we will need to see over time is the collection of data and the monitoring
of trends to see whether the presence of the survey itself can spur on positive
change.
There is some hope that it might do that. As similar surveys which have been running in
the United Kingdom for some time now have shown improvements on parameters such
as the extent to which Foundation doctors felt adequately prepared for their
posts by their medical school has improved over time.
Image from the UK medical training survey depicting a sharp
rise in “preparedness” from 2012 to 2013 (previous surveys would show this
trend as going upwards from a lower level, but the 70% appears to be a natural
barrier to further improvement). Source gmc-uk.org
Overall Most Trainee Doctors Are Happy.
With all the negative stories associated with the lot of
trainee doctors in Australia over the past few years. It may be tempting to conclude that trainee
doctors in Australia are a deeply unhappy lot.
However, that’s simply not the case.
And whilst, those stories should not be ignored and whilst
there is empirical evidence of trainee doctors in Australia being exposed to
adverse experiences in the workplace at unacceptable rates. This experience is thankfully not the experience
of the majority.
In fact, 78% of the survey respondents indicated that they
would recommend their current training position to other doctors (agreed or strongly
agreed), followed closely by 76% of respondents being comfortable recommending
their workplace as a place to train (again agreed or strongly agreed).
International Doctors Are Even Happier According to the Medical Training Survey.
I get asked a lot by international doctors if hospitals in Australia are good environments for IMGs.
Here’s a table that shows you that overall IMGs are actually
even happier than interns about their training post and workplace.
82% IMGs would recommend their training post to another doctor,
compared to 75% of interns. And 80% of IMGs would recommend their workplace to
another doctor, compared to 75% of interns.
Doctors In Training Are Still Working Too Much.
The survey shows that the majority of doctors in training are
now working under 49 hours per week.
However, 17% are in a risky area of working up to 59 hours a week and
there are concerning outliers with 13% reporting working greater than 60 hours
per week, including up to 90 hours or beyond.
What is also interesting is that whilst one might expect that excessive work hours are more of a problem for specialty trainees when one compares the figures between, say interns and specialty trainees the difference is the other way with 16% of interns working over 60 hours a week and only 12% of specialty trainees working over 60 hours per week.
But if we go a bit more granular and check out a specialty
like surgery, we see more of what we expect to see.
52% of RACS trainees report working greater than 60 hours a week. If you spot a worse group than this on the survey, I’d love to know about it.
Where Did That Unrostered Overtime Go?
Also, only 47% of doctors in training report being paid for unrostered
over time, which is a deep concern.
There Are Still Too Many Doctors In Training Being Exposed to Bad Behaviour.
22% of doctors in training report personal experience of bullying, harassment or discrimination and 27% report witnessing this. This is on part with other reports conducted around this issue, including one I helped write a few years back.
Similar to our report findings only 35% of the recipients
and 29% of the witnesses reported reporting this behaviour. Which again is consistent with other
studies. What is most worrying is the
level of non-witness report as this is probably the key statistic to be
focussing in on here.
If there is a silver lining to all of this it is that 52% of
recipients who reported bullying, harassment or discrimination received a
follow up to their report. Now 52% may
not seem all that great. But this is
actually a pretty good baseline result given what we know so far about the
skills and capabilities of senior colleagues in handling the difficult issue of
bullying, harassment and discrimination.
Career Aspirations Greatly MisMatch the Reality.
The MTS also included questions about career planning and
intentions. Apparently 16% of Interns were unsure whether they did or did not
have a training plan. In my book that
means you don’t have a plan.
But check out the next table for an example of poor
expectations management!
According to another medical workforce data set, the Health Workforce Australia, Medical Education and Training Dataset there were 1051 accredited surgical training positions in Australia. Now bear in mind that these 1051 positions aren’t just occupied by an individual doctor for one year but several years in order to complete a training program.
Contrast this with the fact that 26% of the interns,
resident medical officers, senior residents and unaccredited trainees indicated
they were most interested in pursuing surgery as a career. That’s a raw number of 351 of survey respondents
alone. If we scaled it up to include those in these cohorts who did not
complete the survey then we are probably talking 1500 to 2000, when the true
capacity is around 200 to 300 per annum.
If we look at the other end of the spectrum we then see a specialty such as psychiatry which traditionally struggles to attract trainee doctors sitting at only 4% when in fact it has capacity for and needs more trainees than surgery. By the way, psychiatry also ranks in the top 5 professions for salary in Australia, along with Surgery. Just saying.
I was disappointed to see that this particular question was
not asked of international medical graduates.
This would be important information to have.
We Are Not Connecting the Dots (Yet) Between Medical School and Doctors In
Training.
So the last key finding is really a non-finding. I was
surprised to see with all the effort that went into making this survey right a
failure to ask a really obvious question about the transition from medical
school to being a doctor-in-training.
As we have alluded to in the United Kingdom survey this has
been a key and consistent question in their national report. And it is an important one as we need to
ensure that various parts of the medical training continuum are connecting with
each other.
What is even more surprising is that this question does get asked in Australia. It is asked as part of a survey led by the Australian Medical Council but with the participation of the Medical Board of Australia in a separate survey called the Preparedness for Internship Survey. This survey showed that 74% of respondents (interns) felt their medical school training had been sufficient.
I believe it’s a mistake not to include this question in the national training survey as it helps us to connect some important dots with other questions. Hopefully, over time, the Medical Board will find a way of combining the results of both surveys.
I would encourage you to go and have a look at the survey
yourself. Play around with it and see what you find.
In this post, I haven’t even touched on things like the differences between various States and Territories or touched on very much issues around specialty training or other specific groups.
I would love to get your feedback on the type of follow up
post you would like to see to this one.
Related Questions About the Medical Training Survey.
Question. What is the Medical Training Survey (MTS)?
Answer. The Medical Training Survey is a national,
profession-wide survey of all doctors in training in Australia. It is conducted
in a confidential way to get national, comparative, profession-wide data. With
the aim of strengthening medical training in Australia.
The survey is designed to be quick to complete and done on
all manner of online devices and has the support of key stakeholders, such as
doctors in training groups, employers, educators, the AMA and regulatory bodies.
Question. How does The Medical Training Survey happen?
Answer. The Medical Training Survey is open during August
and September of each year, which coincides with the medical registration
renewal period for most doctors in Australia.
The survey is run independently by research agency EY
Sweeney. The survey is confidential, and
data is gathered from online entry. Only aggregated data is ever reported, with
the minimum threshold being ten (10) data points on any item and group to
report back.
Question. Who can do the survey?
Answer. All doctors in training in Australia can do the
survey. This includes interns, hospital medical officers, resident medical
officers, non-accredited trainees, postgraduate trainees, principal house
officers, registrars, specialist trainees and international medical graduates.
Career medical officers who intend to undertake further postgraduate training
in medicine can also participate.
