The murky politics of medical workforce training

Most agree on what the problems are in medical training, but the strategies to address the issues are in disarray

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Tony Abbott’s decision in 2015 to back a new medical school in Western Australia was derided as a mad “captain’s call” to match his gold-plated parental-leave scheme and the knighting of Prince Phillip.

“It’s a calamitous captain’s call by Captain Chaos. That’s the only way to describe it, because it’s going to create chaos with the medical training of students,” then-AMA president Brian Owler said.

The only explanation for the then-prime minister’s decision and his dash to Perth to announce it, Professor Owler said, was an attempt to lift the flagging popularity of WA premier Colin Barnett.

Curtin University’s medical school proposal was criticised as a self-serving bid for prestige, and a waste of resources at a time when too many graduates were competing for too few clinical training positions, without requisite numbers of consultants and supervisors.

Two years later, as the school steers its initial cohort of 60 students through their first year, Foundation Dean, Professor William Hart, says the critics have been proven wrong by new workforce figures showing WA’s GP training is tracking below replacement level.

“The so-called controversy over whether Curtin Medical School should be created, and whether Western Australia needed a third medical school, has been put to bed well and truly,” Professor Hart told The Medical Republic.

“The most recent workforce information totally vindicates the decision.”

The WA Health Department’s Medical Workforce Report, published on September 29, predicts a shortfall of 1450 WA-trained medical practitioners by 2025. The deficit includes an estimated 974 GPs, while the remaining number reflects projected shortages across 18 specialties.

While the report focuses primarily on non-GP specialists, WA’s Chief Medical Officer Professor Gary Geelhoed makes it clear in his executive summary that the current model of medical workforce planning across the board is dysfunctional and on “an unsustainable fiscal path”.

“Analysis of the workforce data shortfall shows that general practice is the largest specialty group at risk in WA, and the current vocational training program is failing to meet maintenance replacement requirements, let alone the additional increases required by increasing demand,” he writes.

The report proposes monitoring medical graduates and their chosen specialties as part of a system-wide approach, calling for more “coherent” understanding of workforce trends, needs and resources, and “appropriately managed and targeted” investments in training.

For short- and medium-term strategies to deal with shortfalls, it recommends upskilling senior registrars and IMGs to obtain fellowships, funding for consultant positions and targeted interstate and overseas recruitment.

But in the longer term, it says reliance on IMGs is risky because changes in policies or circumstances in supplying countries can halt supply in a short period of time.

Curtin, located in Perth’s east, is focused on preparing undergraduates for general practice training with an emphasis on rurality and socioeconomic disadvantage.  Its intake will rise by 10 places per year to reach 110 in 2022, at which point the school plans to negotiate to add international students.

“Our challenge as a medical school is to give (students) context and experience such that rural general practice, or rural generalism, is an attractive proposition for them,” Professor Hart said.

“What we can do is plant the seeds – by giving them positive experiences and positive role models and contextualising the cases they study in their problem-based learning … around rurality and indigenous health and the other issues we want them to be interested in.”

With targets of 25% rural-background students and 5% indigenous students, Curtin is running an outreach program in WA secondary schools and offering bonus points for students from disadvantaged and rural backgrounds.

“One of the key challenges is to raise the aspirations of students in rural schools,” Professor Hart said.

The former GP who set up the Gippsland Medical School, since absorbed into Monash University’s School of Rural Health, is disappointed that a short lead time from October accreditation to intake in January meant only 8% of students in the first cohort came from rural backgrounds.

“I have no doubt that where a person lives and their experiences of living and working in an outer metropolitan disadvantaged area or a rural area influences their willingness to work in those areas after they graduate.”

Australia’s 20 university medical schools are expected to turn out 3567 graduates this year, with a recently stable cohort of international students making up 17%.

The explosion in student numbers in the past decade has led to a forecast oversupply of 7000 doctors by 2030.

In the near term, a shortfall of 569 training places for new graduates is expected next year. Without new investment in prevocational and specialist training, the shortage is projected to reach 1011 places in 2030.

Even so, proposals for new medical schools keep coming.

The latest approval, on Queensland’s booming Sunshine Coast, came after a fiercely political campaign, including a social media blitz aimed at the Prime Minister Malcolm Turnbull, after Assistant Health Minister Dr David Gillespie declined to release any new commonwealth-supported places.

The state’s Labor Health Minister, Cameron Dick, slammed a suggestion that the school, to be run by Griffith University, could make up the required number of 50 places with fee-paying international students.

“Don’t come to Queensland without a minimum of 15 additional medical places for the Sunshine Coast Medical School,” Dick said in a statement addressed to Minister Gillespie and Health Minister Greg Hunt. “And those places need to be for local Queensland students and not international students, as the Turnbull government has been proposing.”

In the resulting trade-off, Melbourne, Monash and Wollongong universities bartered away the 15 funded places on the understanding they could create the same number of spots for full-fee-paying international students.

Announcing the go-ahead in August, Minister Hunt termed it a “vitally important community project”, only made possible by the advocacy of two local LNP members, one of whom, Ted O’Brien, is back in the seat of Fairfax after regaining it from Clive Palmer.

The AMA called it a case of “horse trading” in place of good medical workforce policy.

“This comes on top of the decision by Macquarie University to establish a new $250,000 medical degree course, a move that prices a medical degree out of reach for many of our best and brightest students,” AMA President Dr Michael Gannon said.

“The policy focus must be on the maldistribution of doctors and shortages in particular specialty areas, not supporting universities to boost their bottom line.”

Macquarie’s four-year, $256,000 post-graduate degree – variously criticised as an “appalling cash grab” and a waste of training resources – will be available to 40 domestic and 20 international students.  It includes clinical placements of five months in India.

At the other end of the scale, a venture by Charles Sturt and La Trobe universities is still in play, seeking a redistribution of 160 places from urban-based medical schools to launch the proposed Murray-Darling Medical School in three regional cities in northern Victoria and southern NSW.

According to the school’s founding dean, Professor John Dwyer, a government-commissioned report by independent consultant Ernst and Young has recommended the the school go ahead  “but not for two or three years”.

“From our point of view, the principle has already been accepted by the government,” he said, referring to the Sunshine Coast’s example of a redistribution to avoid a net increase in commonwealth-funded places.

“In the face of the ever-worsening statistics about the health of rural Australia, we think we have a very logical case for the partnership … to put this medical school together.

“The fundamental issue is, nothing is being done at the moment, and nothing that has been done in the past 20 years has seen any significant increase in the number of Australian-trained medical graduates going to the bush. Still fewer than 10% go to the bush.”

Professor Dwyer said medical educators were in agreement on how to address the rural-urban maldistribution of doctors but strategies were in disarray.

“We are not running rural-specific curriculums and not using the plans that we all agree are essential – for a pipeline of kids from the country who want to work in the country to be fed into postgraduate training opportunities in the country.  We are all on the one page in saying that’s a crucial development.”

The Murray-Darling reallocation plan, of course, would mean a clash with big city-based universities, including Sydney University and the University of NSW, which operate rural clinical placements.

The UNSW is the only Group of Eight university offering a full medical education in a rural or regional setting.  So far, this is confined to a small campus at Port Macquarie, on the NSW mid-north coast.  The first intake of 14 students will be expanded to 25 next year.

UNSW medical students can already spend up to four years of their six-year degree at campuses in Griffith, Wagga Wagga, Albury, Coffs Harbour and Port Macquarie.  But interest jumped after the six-year Port Macquarie option was announced, according to the clinical school head, Professor Lesley Forster.

“That was very exciting,” she said. “On top of that, a number of parents said to us, you have changed our family’s life.  You have made it possible for my son or daughter to do medicine.
I could never have afforded to send them to Sydney. That has been heartwarming.”

When the UNSW rural clinical program began in 2000, there were plenty of doubters.  “People said you can’t train a doctor in a country town. You need a big teaching hospital,” Professor Forster said.

“But our students have done brilliantly, the local doctors are very committed, and we’ve won the university medal for graduating top of the class on numerous occasions.”

The so-called rural training pipelines, kicked off with a modest $94 million investment by Dr Gillespie, essentially mean linkages that will allow doctors to do the bulk of their training and transition into jobs outside urban centres.

“Our aim is to develop the pathways so we can say to a kid who shows interest, we can make a pathway so that you don’t have to head off to Sydney. You can do your training in the country and become a rural GP with a special interest, or a cardiologist, or an anaesthetist.  We will work out how you can do it.  That’s our plan,” Professor Forster said.

Professor Richard Murray, Dean of Medicine at James Cook University and President of the Medical Deans of Australia and New Zealand, says the workforce imbalance creates an opportunity to effect important changes, but the struggle won’t be over soon.

“In many ways, what comes out of Australia’s specialist training system is almost random.  It’s an unplanned system with really emergent phenomena,” he said.

“No other country has so dramatically expanded its medical education, doubling the number of medical schools and almost tripling the number of graduates in a little over 10 years, while paying almost no attention to the further training beyond medical schools to obtain a specialty fellowship.

“It’s sort of like doubling the number of primary schools and not building more high schools.”

The medical deans and the presidents of medical colleges recently formed an alliance to help lead a solution, he said.  “We have agreed to commence a project to take this forward as a profession-led conversation. That’s in addition to things governments might do, both state and federal.  We are of a view that this really needs a whole-of-government approach.

“The state and territory governments and public hospitals have to be part of the conversation about how we flip the model of specialist training, so that some portion, perhaps one-third, can be based in regional Australia and rotating into capital cities, rather than the other way around.”

The goals are a better regional distribution of medical workforce and a better balance of specialty distribution.

“You really have to pay attention to the training pipeline, and a very important part of that is to move a large dollop of medical specialist training outside of capital cities and into the regions.”

No conclusions have surfaced as yet from a review of the number and distribution of medical schools and medical school places, announced last year by Minister Gillespie.

“The assessment has been undertaken, taking account of workforce modelling and data, two decades of workforce distribution policies, the expansion of higher education places and the government’s priorities to address the maldistribution of medical professionals across regional, rural and remote Australia,” a Health Department spokeswoman said.

“Once finalised, the government will consider the report in the coming months as part of its overall the health workforce strategy.”