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14 Mar 2018


We’ve got a distribution problem in Australia, across multiple domains. We have a workforce that suffers from a large supply and demand gap for Australia’s outer urban, rural and regional patients. We have traded programs that provide positive regional experiences during training for punitive ones that restrict rather than reward. We speak of rural medicine in these stereotypical terms of a life hard done by, with a single GP miraculously providing the anaesthetic while simultaneously taking out the appendix and the baby. None of these approaches are helpful and what’s more concerning is that none of them frame medicine in a realistic light.

If you haven’t taken a look at the training pathways in Australia at the moment, I’d ask you to spend an hour or two familiarising yourself with the options available to trainees in today’s training environment. In the absence of a clear focus on what makes a good pre-vocational trainee and without meaningful accreditation across the pre-vocational space, we have residents being screwed over by a workforce with an insatiable appetite for service provision, and universities that have deftly taken advantage of the anxiety around securing training positions.

Most trainees now have more letters after their names than their bosses, and for what? There’s an information divide, between what colleges expect of a good prospective trainee and what pre-vocational doctors think are the desirable qualities in prospective trainees. We’ve previously described this issue as the CV arms race, and to their credit the Colleges are starting to make moves against it in selection processes. This shift can’t come quickly enough. We’re drowning in post-nominals when what we really need are high quality medical practitioners.

On top of this arms race, we’ve built wonderful ivory towers within medicine. You apply to medical school and once accepted, the word of the Faculty is dogma. Then we enter the workforce, and the word of the Health Service is dogma. Once we progress to vocational training, the word of the College is dogma. Fifteen years later you have to ask yourself: exactly who are we serving with this model? With no co-ordination during the transition between these three periods, how can we build a profession that serves the Australian population while also providing a meaningful medical career? Doctors in training scramble over themselves in the belief that ‘centres for excellence’ are the place to be, spending as many months as possible in these tertiary and quaternary centres to the exclusion of experiences in primary and secondary centres. Excellence is the quality of being outstanding, and I would argue that when you silo your training in a singular centre you are anything but outstanding.

What’s interesting about this situation is that if you ask any senior faculty member in any College, or any director in any department in Australia, none of them show much interest in hiring fellows with limited geographical experience. Yet here we are, doctors in training, prioritising sexy, heroic medicine. We often choose fellowships based on how meaningful they are to us, rather than how meaningful they may be to our community. Choosing exodus over excellence makes you a better doctor.

When you move between primary to quaternary you see the full spectrum of the lives of our patients. It’s not impossible to appreciate the barriers in rurality without doing time in retrieval medicine, but it’s a darn sight easier, more meaningful and more memorable. It’s not impossible to understand how medicine works in a resource restricted setting without practising in one, but I’d take the advice of the specialist who has worked in a regional community over the one who hasn’t, every time.

We have a workforce that doesn’t make sense any more. We have politicians who are intent on building medical schools in their electorates without any regard for the evidence of whether or not they’ll help or hinder. We have a pre-vocational group of doctors that are increasingly being thrown to the wolves of service delivery with scant regard for the long-term investment in their training. We have vocational programs that focus on spending time outside of big buildings rather than focusing on spending time inside small ones.  This matters because the barriers between these phases of training are all artificial. It’s the same ship, we’re all in it and there’s no-one at the helm.

This isn’t a problem that will be fixed by one Government program, or one College decision, or one Vice Chancellor’s strategic mission. It will be fixed by us. Every time we prioritise experiential learning over theoretical learning, we fix this problem. Every time we pressure government to do the right thing for our patients, we fix this problem. And every time we talk to our trainees about reality in medicine rather than heroism and fiction, we fix this problem. The solution is in the conversation. So go and take charge of it.


Published: 14 Mar 2018