The rising tide of medical graduates: how will postgraduate training be affected?

The supervision of prevocational and vocational trainees, from internship to completion of specialist training, is central to both patient safety and effective clinical learning.5 Clinical supervisors are not only responsible for monitoring trainees’ performance, setting term goals, teaching, guiding learning, and modelling professional behaviour,6,7 but are also increasingly being asked to contribute to structured trainee assessments. A new comprehensive framework for prevocational training,8 expanded college assessment requirements such as the mini clinical evaluation exercise (mini-CEX),9,10 and the new workforce-based assessments for some international medical graduates11 will further add to the workload. The steep rise in trainee numbers will only exacerbate the already substantial demands on supervisors.

In most settings, trainee supervision is largely driven by the enthusiasm and goodwill of senior clinicians. This is seldom remunerated directly (although some employment contracts stipulate teaching and supervisory duties) and often incurs a substantial opportunity cost for consultants. With the estimated growth in trainee numbers, this pro-bono system is unlikely to be sufficient. There is a real risk of supervisor disengagement and burnout, which could ultimately influence clinical outcomes.12 A recent review by the Australian Government Productivity Commission echoed these concerns and proposed dedicated income streams to better support training.13

Although it is essential to reaffirm the pro-bono model on which most daily supervision depends, it is vital to provide other forms of recognition for teaching and training infrastructure. Conjoint university appointments are one form of recognition. Financial remuneration must also be addressed, such as session-based teaching payments for private practitioners who undertake teaching. Hospitals, colleges and postgraduate medical councils can engage frontline educators more effectively by offering appropriate financial incentives. The Australian General Practice Training14 program exemplifies one such approach that is already in place, providing educational support and federal payments to supervisors in private practice settings.

Supervisors also need adequate administrative assistance to contribute to orientation sessions, trainee feedback and rostering. This would free them to spend more time teaching and supervising. Centralised medical training and education units already operate in many teaching hospitals, offering efficiencies by integrating administrative support for a range of training programs.15 However, there is a pressing need for greater consistency and transparency in determining how much funding is provided for clinical educators and support staff at each site.

Senior trainees also have an important role in teaching and supervising junior trainees. A recent survey reported that prevocational trainees believe registrars often play a more substantive teaching role than senior consultants.16 More can be done to engage this group in training junior doctors. Introduction of novel roles such as the “medical education registrar”,17 and crafting of longer-term career paths may increase the number of trainees who take on supervisory responsibilities.

As trainee numbers increase, there will be increasing competition for access to some clinical experiences, a challenge typified by access to emergency department (ED) terms by interns. Most postgraduate medical councils regard ED terms during internship as “unsubstitutable”, arguing that interns need graded increases in autonomy and must become familiar with undifferentiated and critically ill patients.18 The steep rise in intern numbers will soon stretch the supervisory capacity of many EDs. This dilemma has inspired the More Learning for Interns in Emergency (MoLIE) project in Queensland, which delivers complementary “off-the-floor” teaching to interns during ED terms. MoLIE aims to maintain the quality of the learning experience, while minimising the burden on supervisors (Dr Victoria Brazil, Emergency Physician, Royal Brisbane Hospital, personal communication).

The quality and capacity of postgraduate training can also be enhanced through greater use of clinical simulation centres. Unfortunately, Australia lags behind Europe and North America in its uptake of these technologies,19 which allow procedures and skills to be taught in safe, supervised settings. Substantial funding will be required for the great potential of clinical simulation to be realised.

The application of existing training standards to new training positions will be a central challenge for colleges, postgraduate medical councils and health departments. Although most states are at quite early stages of planning, it is likely that these new posts will be in expanded settings (such as private hospitals, general practice and community health services), or will involve greater use of public hospital opportunities (through shift splitting, reduced overtime and reduced average workload).20 Accrediting bodies must ensure that the teaching, supervision and support available to new trainees through new training positions are consistent with existing posts.

New vocational training positions are already being introduced in private settings through the national Expanded Settings for Specialist Training Program.21 As this scheme expands over the coming years, each post must be monitored closely by accrediting bodies. Importantly, private hospital patients must be clearly informed about the new role that trainees will have in their medical care in these settings.

Ultimately, we believe that the need for consistent standards across a diverse range of settings may be best served through robust, centralised governance and cross-disciplinary institutional accreditation of clinical training, as occurs in the United States under the powerful Accreditation Council for Graduate Medical Education.22

Rising trainee numbers and new training settings will have significant implications for average wages and working conditions. Overtime is likely to decrease, as hospitals use rostered shiftwork to contain wage costs and improve safe working hours, while funding new training placements. This will affect trainee wages. As more graduates percolate through the system, the locum workforce is also likely to shrink. The proliferation of non-award industrial arrangements in private settings will also require careful consideration. Undoubtedly, industrial organisations will be following these changes closely.

As the number of graduates rises, the demand for training placements will increase substantially. When this demand exceeds supply and graduates begin to compete for placements, particularly in more popular specialties, training bottlenecks are likely to arise.

It is difficult to predict how soon these bottlenecks will occur and how significant they will be, given the numerous factors that influence progression through training (Box 1). Accurate predictions are also difficult as longitudinal workforce data are limited,1 and the supply of new training placements has not yet been established. In some states, uncertainty remains about the guarantee of employment for foreign graduates of Australian universities.

Bottlenecks may arise as trainees wait to move from prevocational to vocational training, and are even more likely during the transition to advanced training in some disciplines. This is already the case for popular specialties such as gastroenterology. As graduate numbers peak after 2012, innovative solutions will be required to find training positions for these new medical cohorts, in both public and private sectors. A marked mismatch between applicants and positions would risk prolonging training and exacerbating job uncertainty among junior doctors. Although specialties that are currently less popular may benefit from increased numbers of applicants, it cannot be assumed that workforce growth will be a panacea. These specialties will still need to address real and perceived factors underlying their low recruitment rates. Without attractive training options, some trainees may choose to leave the system entirely.

The recent public outcry by junior doctors in the United Kingdom after the introduction of Modernising Medical Careers (MMC) illustrates the political consequences of poorly managed changes to the medical workforce.23,24 MMC was launched in 2003 as a far-reaching government overhaul of postgraduate medical training throughout the UK. Concerns about inadequate consultation and job insecurity reduced its popularity, and when a new recruitment process left thousands of trainees unable to find work in 2007, the profession and the public lost confidence in the reform process. Recommendations from the subsequent MMC Inquiry provide important lessons for Australian medical workforce planners and political leaders contemplating the impacts of rapid changes to the medical workforce (Box 2).24