How can Australia have too many doctors, but still not meet patient needs?

The statement “we have plenty of doctors in Australia” would probably not pass the pub test. Especially if the pub was in a regional city, a remote town or a less-than-leafy suburb. But it is true all the same - statistically at least.

With 3.5 practising doctors for every 1,000 people in 2014 (4.4 per 1,000 in major cities) we’ve never had so many. In 2003, there were 2.6 doctors for every 1,000 people in Australia, which is closer to the proportion in similar countries now, such as New Zealand (2.8), the UK (2.8), Canada (2.6) and the USA (2.6).

Yet at 2.6 per 1,000 was when we decided we were “short” and went on to double the number of medical schools and almost triple the number of medical graduates in a little over a decade.

And then there’s this question: if we are now so flush with medicos, why do we still need to import so many from overseas? To fill job vacancies, the Australian government granted 2,820 temporary work visas to overseas-trained doctors in 2014-15. In the same year, Australian medical schools graduated another 3,547.

This heroic level of doctor production and importation is right up there internationally. Among wealthy nations, Australia is vying for the top spot, with only Denmark and Ireland in the same league of doctor-production for population.

So why do we have too many doctors, but think we have too few?

Our approach to medical training

In a Medical Journal of Australia editorial published today, we examine the question of “work readiness” in our new medical graduates from arguably the most important perspective: what the community needs from future doctors.

To what extent is our medical training system producing doctors who will be providing the high quality, person centred, affordable health services we need, given we are an ageing population living with higher levels of chronic and complex health conditions?

There have been arguably three problems with the Australian approach to the medical workforce to date. First, we didn’t finish the job of production; second, we’ve allowed too much medical specialisation in major cities; and third, our models of health care and the ways we pay for it are out of step with where community needs are heading.

1. Production

Back in the early 2000s, the biggest issue relating to the training of Australia’s medical workforce was a shortage of doctors in regional and remote areas. So, in addition to boosting medical student numbers overall, we set up rural clinical schools and regional medical schools, and increased admission of students who were already residents of rural areas.

While results of these policies have been positive in terms of graduate rural career intentions and rural destinations, the job was really only half done. What we didn’t do is reform the training that goes on after medical school.

That involves internships and training for one of 64 specialty fellowships, including general practice. Because of that, too many of our medical graduates are now piling up in capital city teaching hospitals, locked in a fierce competition for ever-more sub-specialised training jobs.

Meanwhile regional Australia remains hooked on a temporary fix of importing doctors from overseas. Hence the recently announced funding for 26 new regional training hubs. The aim is to “flip” the medical training model, so the main training is offered regionally with a city rotation as required.

2. Excessive specialisation

There’s no question we need a reasonable number of doctors who are experts in a narrow field. However, there’s now an imbalance between an inadequate number of medical generalists and excessive numbers of specialists in every major medical field.

Regional Australia in particular needs more generalists; that is rural generalist GPs, general surgeons, general physicians and the like.

3. Financing and models of care

Health expenditure is driven by three main factors: growth in population, providing more care for each patient and the increase in the proportion of older people with increased complex care needs.

Improvements in health-care technology means we can diagnose illness more accurately, less invasively and earlier, and we have more effective treatments.

However, in a system that pays on the basis of every service provided (regardless of need) there is also a risk of provider-induced demand. This can lead to inappropriate medical care, with examples in unwarranted eye, knee and back surgery, imaging, colonoscopy, and medication for depression and other conditions.

An undersupply of doctors is associated with lower rates of health-care use, whereas oversupply or mis-distribution can lead to higher rates of inappropriate care. Balancing the distribution of doctors according to need has important consequences for health-care costs.

Time for action

Make no mistake, Australia’s current health system is good by world standards. But the headwinds are building. The population is ageing, we’ve got more people with chronic and complex health-care needs, and the costs of new medicines and technologies continue to escalate.

Having injected a massive boost of doctors into a fee-paying healthcare system without regard to population need, workforce mix, geographic location, health-care models or financing reform, we have put the future at risk.

Let’s not let this bold experiment fail for want of follow-through. We need more urgency in providing the incentives and training opportunities to get our growing junior medical workforce into the specialties and areas that are underserved.

We have to stop allowing medical specialty training to be driven by the work rostering requirements of metropolitan hospitals. We must increase the number of specialist training positions based in regional centres.

And we especially need to expand the number of broadly-skilled rural generalists and get serious about efficient, team based, health-care models. This requires cooperation by all governments, medical schools, specialist colleges and the profession - and the time to act is now.