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From: Rescuing Medical Education Conference
Stamford Sydney Airport
O'Riordan St (cnr Robey St), Mascot
18 February 2005
Dr. Mukesh Haikerwal
Vice President, Federal AMA
Thank you. Good afternoon.
I thought I was a relatively young doctor until I looked back on my medical school course. It was the youngest medical school in the country - overseas, of course, in Britain. I don't know about the standards of training, I think they're actually quite good still, but time will tell.
What actually happened was at that time it was the youngest course, and we had this new structure where we had this new fangled idea of having sociology and psychology in a topical man's society, which took one fifth of what you did, and the other four fifths was the usual structure and function stuff.
It's interesting how the pendulum keeps sort of swinging. People talk about those sorts of things, and there are trends. But I think fundamentally medicine is about not just the science but the art and it's important to get the balance right. But fundamentally we have to keep the science at the outset of our teaching and training because ultimately that's what the public come to us for - for the difference between the scientists and the other practitioners out there.
Thank you for giving me the opportunity to speak, Bruce and Stephen and ADF.
Before I talk the specific issue, which is medical school places and getting the mix right, I just want to set the scene. Obviously Bib Birrell has done a lot on that, about the way in which policy is developed and how we've come to a situation of a medical workforce shortage.
The AMWAC - Australian Medical Workforce Advice Committee - has made great strides in collecting and analysing data. But of course this data has been flawed and certainly analysis has been flawed. The AMA access ecomonic study from three years ago was quite instrumental in showing the workforce shortage amongst general practitioners and that's now the sort of data that AMWAC's using to calculate the new shortfall that we have. And of course there's a shortfall in every speciality, I believe, bar paediatrics.
The policy, of course, of the 90's has been a highly successful policy in limiting GP numbers. This sort of policy of reducing numbers has been a weakness of the Australian system but it's not just Australia that suffers from this. We're seeing workforce shortages across the world, including countries like the UK and Canada.
Government, of course, is slow to change and the workforce policy settings make the whole situation very difficult. The reasons for this include the fact that the time which it takes is like the turning circle of the Queen Mary II, it takes an awful long time for things to actually work through. Of course, the long length of time that people take to train, and the long lag between the policy change and outcome, makes the whole situation very difficult, especially when there are changing tensions within systems, as we've heard.
We know that Australia has a GP shortage of around 3,000, and shortages exist in all specialities. Even the best estimate cannot allow for those that work part time, which of course is another part of the equation. The doctor drought is unlikely to ease in the foreseeable future and there is no doubt in the interim the Governments will continue to use doctors from overseas to fill the gaps, as well as those trained in Australia as overseas students, who are allowed to stay. And that's, of course, what Bob Birrell has been talking about too.
Turning to the other side of the ledger, however, for many years medical school intakes have been around 1,200 a year. Governments have developed a strong grip on supply through the control of undergraduate places, access to Medicare Provider numbers, and funding for teaching in teaching hospitals.
Recent Government decisions in Australia will result in significant increases in the number of medical school students. The number of schools have increased from 12 to 18 in a relatively short period of time. It's been said, albeit in jest, that when there is a medical workforce shortage, just put in a new medical school. By 2008 the total medical school intake will increase to somewhere between 2,200 and 2,400, depending on the number of domestic students offered full fee paying places. It will be some time before the increased number of medical students will result in more doctors on the ground, of course.
The creation of training positions, of itself, does ameliorate some of the workforce shortages. This is especially true in general practice where trainees do provide a significant number of services. The impact at the end of training should be the final measure of success, however.
More than ever, younger doctors are keen to pursue a greater balance between their work and personal lives. These doctors remain deeply committed to patient care, however they will simply not be prepared to devote the same long hours as doctors of previous generations, either in training or indeed in practice. This needn't be seen as a shameful trend but perhaps an enlightened path whereby happiness and skilled intense work can be simultaneously balanced.
We also have to take into account the growing participation of women in the workforce, which has significant workforce implications. Quite rightly, there is an expectation that not only must medical school places be distributed on merit, but that being female should not preclude career options. At various points in their lives women will need time for raising their families. Why should we, as a caring profession - indeed as part of contemporary society - seek to reduce the contributions that women can make to medicine. As in the rest of society, women must be encouraged to excel, to succeed and to persist. So too must men who would like to know their families, maintain their friendships and have pride in their work.
We also know that the medical workforce is aging. Australia faces substantial workforce losses as the Baby Boomers retire. The goal of early retirement as a societal norm to dream for is almost within the clutches of some. They will grasp it in succeeding generations. Satisfaction rates amongst some disciplines, most notably general practice, are falling. It is likely that this will result in further shrinking of the workforce unless there are significant policy changes on the part of Government.
Retention is as important as training and recruitment. Doctor demand has also risen, spurred by an aging population - more people living longer in the community with more illnesses, more medications and more chronic and complex care needs. The effect of income is that as we become wealthier we demand more and higher quality complex services. More intervention that, in the past, may not have occurred.
Looking at surgery, for example - Professor Birrell's forecast - the need for about 50% increase in the number of surgeons in twenty years time. To achieve this goal the AMA's own analysis shows that this would require a 60% increase in surgical trainee numbers if we started now. If we wait much longer, we would have to double the number of surgical trainees.
Despite all the errors of the past workforce planning efforts, keeping in mind the above factors, it is difficult to argue that the overall increase in medical school numbers will overshoot the mark. Australia will need many doctors, just to replace those who leave the workforce, let alone to satisfy the inevitable growth in needs.
However, given the long history of poor workforce planning we do not need to see all the wheels of the car --- we do need to see, sorry. That's what the Government says. Steps need to be taken to ensure that planning now focuses on making sure that we can provide clinical training during medical student's school years, along with sufficient intern and post graduate training places. Training infra structure cannot be conjured up from thin air, nor can sufficient numbers of beds and operations. Nor indeed the experienced, skilled and committed medical teachers that are a prerequisite for a high quality training regime.
There is significant potential for chaos to erupt because issues get tangled up in Federal / State wrangling and about who will pay. There are always some murmurings that State Governments are prepared to dig their heels in, as the Federal Government has increased medical school numbers without regard to the ability of States to provide the necessary resources.
The AMA has undertaken extensive analysis of how medical school numbers will change over the next six years. In the politics fuelled environment of the last Federal election a number of new medical schools were announced. Last year the ANU opened its doors, while this year Bond, Griffith and Western Australia's Notre Dame came on line. Wollongong, along with Sydney campus of Notre Dame, are hoping to be up and running by 2007, and the University of Western Sydney looks to take its first intake in 2008. Although nothing has been confirmed, there are suggestions from some quarters that maybe another medical school will be announced for regional Victoria. Maybe Victorians such as myself will not feel left out so much.
Along the line, someone also appears to have decided that eighty students should be the minimum annual intake for medical schools. Other than a brief Hansard reference there's no real insight into the data underpinning this number, although it now seems to be concrete Government polity. For smaller medical schools such as Newcastle, Flinders, Tasmania and James Cook this has meant that they will all be able to increase their numbers of students.
Besides giving support to the privately funded medical schools, Government changes will allow 10% of domestic students to be enrolled in full fee paying places. Adelaide, Griffith, Melbourne, Monash, Newcastle, Sydney, along with UQ, have all taken up this option in 2005.
Then there is a despicable trend towards bonding. Unfunded bonded places, placing students in an untenable position of accepting a place only if they agree to work in an area of need at the end of their specialist training.
The topic of full fee paying places is an issue in itself. While the AMA is not opposed to the introduction of full fee paying places we've certainly expressed a clear preference for fully funded HECS places that will allow everyone a fair shot at medical school, based on ability rather than on financial circumstances. It is now a feature of Government policy, and to some extent the AMA's focus will be on ensuring that the costs of full fee paying places are reasonable, and do not deliver the wrong medicine - that medicine is only for the rich.
What does all this mean? In short, the intake of students will rise quite steeply until 2008, when it is likely that around 2,400 domestic students will be enrolling in medical schools each year. The projected output of medical schools will increase from the 1,200 of last to around 2,500 by 2011.
If we look a little more closely at the figures, there is a significant variation between the increase in each State. Queensland is the big winner with 115% jump in graduate numbers, closely followed by New South Wales with 105. Victoria and South Australia are at the end of the queue with 20 and 18% increase respectively, and if you take into account, the HECS funded places have actually gone down in certain states, including Victoria. I'm not sure if anyone would argue there's much workforce planning behind the distribution of places.
As I said before, despite the magnitude of the overall increases, it is difficult to argue that they are not all needed. In fact, we can see significant benefits for the medical workforce, at both the professional level and personal level.
Coming to safe hours - following extensive consultation with the profession, the AMA has been a strong advocate for safer working hours for doctors. At the heart of this is improved patient safety. More and more evidence is now emerging about the dangers of long working hours in the medical profession. Recent studies published in the New England Journal of Medicine have highlighted that there is a significant increased risk of medical error when doctors are rostered for extended shifts, and that they are more likely to be involved in motor accidents when driving home after those shifts.
Other industries have moved to control working hours, and have addressed the risk of fatigue related mistakes and accidents. The airline industry, for instance, comes to mind. Sleep researchers have also quoted the risk of long working hours and the consumption of alcohol. Recently we saw a case of a young doctor in Queensland having to face an unsatisfactory professional conduct case after failing to properly treat a young patient who was brought into their emergency department, while the doctor was 20 hours into a 24 hour shift. Tragically that patient died. The judge in the matter stated certain points, including one quote, which is "one does not need medical evidence to know that anyone who's in the 20th hour of continuous duty must have reduced capacity to assess the situation when it presents itself". He also stated that "if this tragedy should lead to the abolition of such brutally long shift hours, which must itself reduce the standard of care available to all patients, that would be a good thing".
There are those who blame the culture of the profession for long hours. However at the end of the day, the hours that doctors are required to work are a function of workforce numbers. The AMA has raised awareness of safe hours as an issue, and there's no doubt that many hospitals have improved their rostering hours as a result of this, but the proper cause is the workforce shortage.
If we are to make any progress towards reasonable hours work, then our workforce needs to expand quite significantly. The first step is an expansion of medical school places.
Coming to work life flexibility - similarly the AMA has also led the way on trying to help doctors achieve more balance between their work and personal lives. We must face the fact that many people who are now entering the medical profession want more balance in their lives. They are no longer able or willing to devote the long hours to practising medicine that many of us grew up with. Family commitments, the fact that both partners have a job, the growing number of older students entering the medical schools, outside interests, and the phenomenal growth of female participation, have all changed the whole culture of the workforce.
We've seen people leave. We've seen people retire. The medical indemnity crisis saw people leave the profession, some for good, and that's a really sad thing.
I was going to talk about overseas trained doctors but I don't think I really need to do that because that's something that has been done very well by Professor Birrell and I won't go down that road.
We've seen problems in the jurisdictions, turning their attention to issues about the way in which they recruit people, and the fact that they provide very little in the way of backup for people doing teaching and training. We've seen staffing cuts, bed closures, cuts to surgery lists, the loss of out patient services, the loss of college accredited training positions, along with a stream of departures from the public system because people get completely disillusioned.
This is not the sort of environment that's going to be conducive to teaching and training people when they come out. There's a very real danger, unless the issue is given real attention and real resources, we'll end up with a training bottleneck, with many doctors unable to find positions, and standards may well be relaxed to shoo on people into the system, rather than necessarily maintain standards.
At the end of the day, the Commonwealth announced the new medical school places, and wants to make sure that the additional investment on the part of the taxpayer doesn't go down the gurgler. If that is their wish, they really have to put further input into training, and the training will have to be in other institutions rather than public teaching hospitals. The private sector certainly comes to mind.
The Australian Health Workforce Officials Committee is examining the requirements for intern places and is due to report later on this year, and that's of course part and parcel of having enough positions for people when they come out through the system.
Members of the AMA Council of Doctors Training have met with the universities on a number of occasions to explore potentials for other methods of work, including the Wollongong University model where people go into the community to work very early on through the system.
There are very many other things going on just now, including the Medical Specialist Training Steering Committee, which is chaired by the Chief Medical Officer, John Horbath. This is also looking at ways of exploiting the private hospital sector, as ways of teaching and training people.
To finish, we face critical shortages in a changing medical workforce that is increasingly looking for fewer hours. What the profession now needs to focus on is quality. We need to ensure that Governments provide the necessary resources and infra structure to maintain the quality of training for which Australia has a world wide reputation. This will involve engagement and co-operation. If necessary, we will need to hold Governments to account, otherwise the talents of many young doctors will be wasted and long term patients will suffer.
The most important thing is the science that holds us apart, and the art that keeps us more compatible with our patients.
I'm sorry I was rushed, that them's the breaks. Thanks very much.
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