Doctors in the waiting room

When we think of health, especially at this time of the year, we tend to think of our own bulging bellies and alcohol-soaked grey matter. Meanwhile, it is also the time when our health system suffers strain from a lack of staff and enormous demand from elderly, homeless, and just plain lonely, people.

This is the message of the latest public hospital advocacy team, the Hospital Reform Group. The group announced its concerns in December in Sydney and tabled a solution, which naturally is just more money.

But for those of you who find yourself in overcrowded waiting rooms, spare a thought for the training doctors manning their stations. Their wait is of an entirely different magnitude and an increasingly unjust one.

The recent draft report by the Productivity Commission into Australia’s health workforce acknowledged there was indeed a widespread shortage of doctors and its causes were rooted in government policy.

The federal health department believes that doctors create their own demand, and so strain the health budget. It supported measures in the 1990s to ration the supply of doctors and service provision. Medical student places, specialist training places and Medicare provider numbers were all restricted.

However, the government and its advisers in the Australian Medical Workforce Advisory Committee got their numbers badly wrong. They underestimated the demand for medical services and overestimated the number of hours doctors were prepared to work, with more doctors retiring early or working part-time.

This shortage is now acknowledged by all the relevant stakeholders.

But the solution is a mischievous one where there is a growing collusion between governments and the “learned colleges” to trap new arrivals in the public sector. The training of specialists is a complex task and regulated by governments and the aforementioned specialty colleges.

After completing their undergraduate years of university training, doctors must go through many more years of training until they can work independently and bill the government. While they complete their training, they are forced to work for a comparably low salary in the public hospital system.

One of the main issues is the conflict between “training” and “service provision”. Medicine is the ultimate form of on-the-job training. Training doctors learn their trade while providing an essential service to the community.

While the importance of having well-trained specialists is not in question, this balance is becoming skewed towards service. Training programs are not merit-based, but dependent entirely on time served. This time served is becoming longer and for spurious reasons. The time taken to produce an independent specialist from the day they enter university is approaching 15 years.

In the modern age, some people have had three careers before many doctors have even begun one.

The president of the College of Psychiatrists, Julian Freidin, openly admitted this fact in the December 2005 issue of the Medical Journal of Australia. “Over the five years that psychiatrists work as registrars, they spend only a short time training. They are working to keep the state system from falling apart.” he said.

The same could be said of any other medical specialty.

Colleges have come under fire from health bureaucracies and the Australian Competition and Consumer Commission for over-regulating the number of juniors in specialty training. While the Australian Medical Workforce Advisory Committee makes suggestions regarding medical workforce composition, the colleges ultimately decide the number of training positions available.

The government has a vested interest in producing far more junior trainees in order to cope with the demand for services. The catch comes later. While the government wants colleges to allow more doctors to enter into training programs, it refuses to increase the number of advanced training positions.

Put more simply, the government wants to create a bottleneck at the point of becoming a specialist.

The Royal Australasian College of Surgeons argues that 100 junior surgeons are already waiting to progress through their training but cannot do so because of too few advanced positions.

This is the holy grail for the state health ministers. They imagine a system run by junior doctors who cost far less to employ than specialists, but who arguably do the same work.

Meanwhile there is a growing demoralisation on the part of training doctors. A survey this year by the NSW Australian Medical Association found that the level of morale among training doctors was the lowest ever recorded. The survey was done by anonymous questionnaire and wasn’t statistically relevant, but it was still an indicator of growing dissatisfaction.

While the mantra of market forces and deregulation are called upon in almost every other sector, training doctors must cope with a growing resistance for them to ever access market forces. They are the last socialists in the market economy, only forcibly so.

If the trend continues, future medical graduates will begin their careers only to realise they have been duped into a job working as cheap labour to prop up a disintegrating public health infrastructure. Meanwhile, they will be told that it is in their best interests, because they need to be “trained”.