Impact of the COVID-19 pandemic on junior doctor careers

Frontline healthcare workers have been central to the COVID-19 pandemic response. For most in the medical profession this required an adjustment to a new way of working in an established career, while for junior doctors (JDs) it emerged in the very early and formative days of their career. The implications of working in the pandemic may have significant consequences for JDs, in particular disruption to career progression.

The first Australian case of COVID-19 emerged in January 2020 at the start of the new medical training year. While JDs willingly responded to the emerging crisis they encountered an uncertain clinical scenario, the possibility of redeployment, and risk to self and colleagues.^1,2 As the Australian Medical Association (AMA) points out training pipelines have been significantly disrupted and, as a result, JDs currently face uncertainty of career progression.³ Key concerns for JDs are redeployment resulting in missed rotations and training opportunities; anxiety regarding cancelled examinations and learning activities; and bottle-necking of the workforce with delayed progression and reduced opportunity to progress in 2021.⁴

The potential impact on JD wellbeing was recognised early by the AMA Council of Doctors in Training (AMACDT).¹ Prior to COVID-19, Australian JDs reported very high levels of psychological distress at rates higher than the general population or other professional groups.⁵ The 2019 Medical Training Survey indicated that 75% of the JD cohort were concerned they may not successfully complete their training program and achieve Fellowship.⁶ COVID-19 has magnified these concerns and further understanding of career disruption and its consequences is critical for ensuring adequate support for the current JD workforce, and for future medical workforce planning.

Redeployment

Progression through the Australian medical profession typically follows a linear trajectory commencing with internship, residency, training registrar positions and Fellowship enabling independent practice. Colloquially known as the “lost tribe” the cohort of post-intern, pre-vocational doctors have fewer protections than interns or College training program candidates. Their day to day work is organised by their local hospital employer. The AMACDT has highlighted the tension between the workforce needs of a health service and the training needs of the JD cohort.³ Health services control the distribution and deployment of the JD workforce and whilst under contract JDs have an obligation to meet the directives of their employer. Redeployment to areas of patient need to address the COVID-19 pandemic rather than sought training placements causes anxiety for members of the JD cohort.

While internship requirements are defined by the Medical Board of Australia⁷ the JDs prevocational residency years allow for exploration of areas of professional interest. Given the competitiveness for Specialist Medical Colleges’ (Colleges) training positions, JDs see securing experience in particular training rotations as critical to demonstrating their commitment to a specialty and perceive they are unlikely to be accepted into the training program without them. Exposure to these work environments also assists in building professional networks and securing referees for the College application process.³ Redeployment away from perceived critical training rotations is a serious concern for the JD cohort.

In many hospitals there are few opportunities for JDs to experience particular specialty areas and even when such a rotation is secured, in the highly dynamic context of COVID-19, they can be redeployed away from these highly valued job opportunities. This presents challenges for JDs when Colleges indicate that experience in these areas is expected or viewed favourably in the selection process for training positions.^8,9 The work of JDs in a pandemic is organised at the local level by senior medical and health management leaders with a remit to staff critical patient areas such as fever clinics as a priority over JDs preferred rotations. This creates a point of stress for JDs as they look to position themselves for selection to a national training program with no control over the work opportunities that may optimise their career chances.

Training opportunities and examinations

Colleges have a broad range of expectations for satisfactory progression through training, including case load experience, log books and examination expectations. COVID-19 has resulted in cancellation of some outpatient clinics, elective surgeries, and non-essential procedural activity and reduced specialty specific clinical learning opportunities for trainees.³ In addition, trainees have been expected to work outside their specialty field further reducing experience essential for career progression. Educational opportunities such as Annual Scientific Meetings and candidate workshops have been postponed.¹⁰ Scheduling of final examinations has changed. Given that many examinations require candidates to clinically examine patients, deliver oral presentations and at times travel interstate or overseas, the ability to proceed in the context of a pandemic remains under significant scrutiny.

Colleges are approaching the challenge of the pandemic by deferring, rescheduling, redesigning or cancelling exams.⁴ Significant challenges are currently being faced by the geographically variable re-emergence of the second wave of COVID-19 and border lockdowns, particularly for trainees located in Victoria and for Colleges that utilise the National Testing Centre in Melbourne for centralised exams. As the safety of candidates, examiners and simulated patients cannot be guaranteed the conduct of exams in Victoria is currently uncertain.¹¹ An alternative, to conduct the exams in another state and quarantine Victorian candidates for two weeks before attending, would place immeasurable pressure on the frontline workforce. Colleges are developing alternative models of examination delivery such as virtual exams; however candidates have had no preparation for this style of assessment generating further anxiety.^11,12 The AMACDT reports deferred and cancelled exams as the greatest concern for those on training programs.¹³ The uncertainty around exam scheduling exacerbates anxieties, as preparation for recently cancelled exams may have taken significant time, cost and personal sacrifice.³ This is particularly concerning for those who anticipated moving to independent practice and consultant roles on completion of final examinations. For these trainees, and for JDs in the training pipeline, a clear training end-point is no longer in sight.

The AMACDT advocates an innovative and flexible approach to meeting training requirements, including workplace-based assessment, a reduction in reliance on Fellowship examinations and setting realistic benchmarks for passing.¹³ However, even in the face of a new and rapidly evolving situation, Colleges must uphold standards of education, training and assessment as defined by their accreditation with the Australian Medical Council.¹⁴  This tension constitutes an additional point of stress for JDs. Despite all efforts to proceed, the unprecedented disruption to examination and assessment procedures in the pandemic leads to great uncertainty for progression of candidates to Fellowship and ongoing career development.

Bottlenecking

“Bottlenecking” of the workforce is a major concern for College trainees, prevocational JDs and international medical graduates. As a result of the inability of current College candidates to progress, there is a risk that new training places and job opportunities may be reduced in 2021.¹⁵ For training programs with basic and advanced components, progression requires both completion of exams and employment in an accredited training position. Failure to progress at the expected rate may result in a surplus of JDs for positions available. Furthermore, some Colleges have not yet indicated their intention regarding acceptance of new trainees in 2021.³

International medical graduates (IMGs) are also impacted. Cancellation of examinations will delay completion of training pathways until 2021.¹⁶ As a result, IMGs may experience delay in progression to general medical registration with the Australian Health Practitioner Regulation Agency (AHPRA). These delays may impede progression to the next stage of a medical career in Australia, including specialist training programs.³

Traditionally there has been workforce progression allowing some JDs to step up to more senior roles in the second half of the year and resultant workforce gaps are often filled with visiting JDs from the United Kingdom and Ireland.^3,11 However, given the current limitations on international arrivals these opportunities may be lost with JDs rostered to positions dictated by workforce demand and, should a workforce deficit persist into 2021, and senior trainees are unable to progress, the JD cohort may find themselves in a holding pattern of unaccredited registrar positions and increased competition when training applications re-open. As there is no policy to mandate the progression of these doctors, and no guarantee of sufficient training places for all JDs, this cohort finds itself at risk of both short and long term delay in career progression.

Conclusion

This paper opens a discussion about JD concerns for career progression as a result of the COVID-19 pandemic and represents a starting point to a broader discussion on the impact of COVID-19 on Australian JDs. It identifies the key concerns of JDs as redeployment, examination uncertainty, a bottle-necked workforce and potential failure of career progression. It highlights tensions between local workforce demands, experiences required for career progression, and the requirements of training, accreditation and registration bodies.

Further work is required to understand the true impact of the pandemic on career progression and the personal, professional and mental health consequences in the JD cohort.  It is imperative that their experiences of working in this pandemic are understood to enable both the provision of adequate support for the current workforce, and for future medical workforce planning.

References

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2. Coughlan C, Nafde C, Khodatars S, et al. COVID-19: lessons for junior doctors redeployed to critical care. Postgrad Med J. [Internet]. 2020 June [cited 2020 August 15]; 0, 1-4. Available from: https://pmj.bmj.com/content/postgradmedj/early/2020/06/24/postgradmedj-2020-138100.full.pdf. doi:10.1136/postgradmedj-2020-138100
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