You Can’t Afford One ‘Bad’ Year – Covid-19 Compounds the Medical Training Crisis

Sep 15, 2020

Written by Tim Lindsay

Tim Lindsay is an Australian doctor and epidemiologist working in academic medicine.

In light of Covid-19, Dr. Tim Lindsay reflects upon the disproportionate impact that one ‘bad’ year can have on a junior doctor’s prospects for career advancement against the backdrop of the medical training crisis in Australia. 

I remember vividly, almost 10 years ago to the day, sitting in a fracture clinic as a final-year medical student talking to a then PGY-2 doctor about their application to orthopaedic training. At the time, I was an aspiring surgeon myself and the doctor’s advice was firm and straightforward – do the Melbourne University anatomy course or risk being ranked lowly and accepted interstate, as they had been. 

Little consideration was given to unaccredited years, master’s degrees, publications – or not getting onto the training program at all. Back then, baseline eligibility for training was simple. It usually consisted of compulsory rotations completed during Internship, and any experience in the specialty of interest. Successful applications during PGY-2 were common. For those happy to take a little longer, unencumbered by regulations, juniors felt free to experiment with different specialties before making an application.  

Fast forward a decade and today’s applicants now face a far more arduous, rigorous, and complex application process. Phrases such as “completion of at least 26 working weeks of orthopaedic surgical experience within the last two years, at PGY-3 or higher,” must be navigated, along with mandatory courses, exams, and evidence-based CVs. These prerequisites are subject to change year on year, although they have thankfully stabilised somewhat in recent years after a period of great flux early last decade.  

Justification for eligibility criteria is rarely, if ever, given. What is clear is that these changes have made it increasingly difficult for juniors to apply to more than one surgical specialty in a given year. This, in turn, has clouded the rate of successful applications. 

Take for example, the data presented in the 2009 Royal Australasian College of Surgeons (RACS) Activities Report. It highlights that only 29.3% of applications to Surgical Education and Training (SET) were successful. However, a little over 31% of candidates applied to more than one specialty. Therefore, when the success rate is adjusted to reflect the number of candidates versus the number of positions, over 50% of those applying to SET received a training offer. 

For aspiring surgical trainees, the 2019 data compare unfavourably. Although at first glance, the 2019 overall application success rate of 36.2% looks like an improvement, only 7.5% of applicants applied to multiple specialties. So, the true applicant success rate has fallen to around 39%. But even that is not a fair comparison, as the 2019 data excluded unsuccessful orthopaedic applicants, and paediatric surgery had no intake. Therefore, the applicant success rate was likely far lower than the numbers suggest. What is clear is that it was much tougher to get onto training in 2019 than 2009. 

Somewhat paradoxically, a falling applicant success rate has emerged despite a tightening of prerequisites and eligibility criteria, which means that applicants are arguably more dedicated, committed, and knowledgeable in their area of interest than ever before. I suspect that RACS hoped that by increasing eligibility requirements, an equilibrium would form between those meeting the criteria and the number of places. This, clearly, has not occurred and so the criteria continues to tighten almost year on year. 

Estimating how many applications there might be under the old rules is anyone’s guess, but perhaps one reasonable way to quantify it would be to compare the number of doctors taking the Generic Surgical Sciences Exam (GSSE) to the number of successful SET applicants. 

Until 2015, a position on a training program was a requirement to take this exam. Since then, it has rapidly transformed from being inaccessible for non-SET candidates, to a bonus, to now a baseline prerequisite. As a $4,000 plus exam that takes a recommended 6-12 months to study for, it is reasonable to assume that those who sit it do not do so lightly; they are serious about a surgical career. Since 2015, 3,572 non-SET candidates have sat the GSSE at least once, of whom 3,079 have passed. By comparison, 1,297 SET offers have been made. So even after you pass this difficult and competitive exam, your odds are only slightly better than 1 in 3 of getting into surgical training. It is scary to think that the majority of people who pass this exam will never be accepted into surgical training. Imagine the outcry, for example, if the same were true for the Australasian College of Physican’s written exam. 

All this means that aspiring surgeons need to be more vigilant than ever in preparing an application. Again, the numbers support this. In 2009, 5.8% of all applications failed to meet even simple eligibility requirements, and so were ineligible. In 2019, despite the honorous prerequisites, not a single ineligible application was made.  Gone are the days where gap years, locuming, or even international study can be undertaken lightly. Increased competition means that rotations that fulfill the prerequisites for a SET application are in high demand and, anecdotally at least, fought over fiercely. I believe that collegiality in medicine has suffered greatly as a result.       

Yet the Covid-19 pandemic has demonstrated that for even the most diligent and dedicated trainee, fate can cruelly intervene. Take for example a resident whose long awaited rotation in their specialty of choice, the one that would be of the correct minimum duration, without interruption, at the right time of year, and would finally ensure their eligibility for the program, was suddenly replaced by HR with a reliving stint in the middle of a block.

The unfortunate combination of the graduate tsunami of the 2010s and abysmal workforce planning, resulting in a gross mismatch between demand for training positions and the number available, has ensured a rigid, onerous and unequal system at the best of times, let alone when the world has been turned upside down by a pandemic. 

- Dr. Tim Lindsay


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Or the doctor who was interrupted by: increased caring duties, parenting duties or the doctor who bravely requests to transfer from their Covid inflicted supernumerary role in a subspecialty unit, to work in a strained Emergency Department or Intensive Care Unit, or the doctor who contracts Covid-19 from a patient due to a lack of PPE and has to take sick leave. 

As a profession we should be uplifting these doctors and championing them. Not making them choose between helping others, or pursuing excellence, and suffering career stagnation or ruin. 

It is important to note that some programs do have concessions for life events such as parental leave, or career development such as graduate study. But these too often come with their own, strict time restrictions. Anyone who has done a PhD will tell you that they rarely go to plan. Although I am not a parent myself, I suspect that the same theory holds true. The unfortunate combination of the graduate tsunami of the 2010s and abysmal workforce planning, resulting in a gross mismatch between demand for training positions and the number available, has ensured a rigid, onerous and unequal system at the best of times, let alone when the world has been turned upside down by a pandemic. 

In my experience, the usual response to an article like this is something along the lines of: be patient or if you’re good enough it will all work out. The irony is not lost on me that often those spouting that line are also the ones who benefited the most from the previously liberal system. Regrettably, I find that the irony is often lost on them; compassion and empathy, all too rare. 

Indeed, it is worth reiterating that it now often takes as long to be eligible for training, as it took those completing fellowships as little as 5 years ago, to complete training. If the switch from predominantly undergraduate medical students to graduate ones is taken into account, what was routinely 12 years from high school to consultant practice is now more commonly 20 plus. And remember, the best estimate is that around two-thirds of aspiring surgeons will never access a training position. Rather, with the introduction of a ‘3 strikes and you’re out’ rule— whereby applicants can only apply to SET 3 times before being precluded from submitting any further applications — these doctors will likely be thrown on the training scrapheap somewhere around 8-10 years into practising. 

For those working as unaccredited registrars, 2019 provided some hope. Following the revelation of Dr Yumiko Kadota’s unacceptable experience working as a plastic surgery registrar, it appeared that the tide was turning after years of inertia and apathy. It was  reported that Dr. Kadota’s experience prompted a promise of an investigation into the plight of unaccredited registrars in NSW, led by the NSW Health Minister, Brad Hazzard. The sense that I got from my colleagues was that there was cause for cautious optimism.  

Regrettably, little by way of meaningful reform has developed. In my opinion, the Australian Medical Association has been shamefully quiet. I contacted the office of NSW Health Minister, Brad Hazzard, to seek a comment and an update on the promised enquiry into unaccredited registrars, however Mr. Hazzard’s office had not replied by the time of publication.  I did notice however,  that some hospitals have renamed unaccredited positions with titles like ‘provisional’ registrar. Perhaps, this represents progress?     

I have long argued that the Australian training system is outdated and no longer fit for purpose. But with its increasingly arbitrary hoops, made by colleges without justification or articulated cause, Covid-19 has shown it to be something else: cruel. The time for an urgent overhaul is long overdue. The question now is: who in power will be brave enough to lead genuine reform? 




*A note: It is important to note that each college has their own eligibility criteria and the author encourages you to look carefully at your own college’s requirements. The author has made all attempts to represent the data presented accurately and fairly, but as  the original data is not publically available they had to make calculations based on aggregate data.  The calculations are therefore likely imperfect, but the author believes that they nonetheless accurately convey the nature of the training landscape.

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