4.1 Purpose
The future supply of medical specialist trainees has been modelled according to the Reference Group 2 Terms of Reference, which require that the Reference Group assess the impact of increased demand for training positions.An in-principle agreement by the Medical Specialist Training Steering Committee to implement expanded training arrangements without adversely affecting the public hospital workforce also necessitates that modelling of the future trainee workforce is undertaken. This agreement was largely based upon outcomes of consultations undertaken by Applied Economics, consultants engaged to assist Reference Group 2 in its work.
The methodology used in this analysis has been based on a mixture of historical data, modelling the change to intake of medical school students as a result of policy announcements, and a small number of assumptions regarding the attrition of the workforce during various stages within the continuum of education and training.
The results are approximate figures, representing the quantum of numbers which are expected in future years. The results should be interpreted as indicative rather than definitive. Even on a conservative basis, however, they support a need for expansion of training into settings outside public teaching hospitals.
4.2 Medical School Students
In 2004, significant increases to the intake of university medical school students were announced. An additional 605 medical school places were announced between April and July 2006, to be introduced between years 2007 and 2011.The majority of Australian medical doctors enter the profession through Australian medical schools. Additionally, the attrition between attaining a medical school education and a medical career is very low. Therefore, the increases to medical school intakes are anticipated to have significant effects on the future number of medical specialist trainees, and subsequent medical workforce.
There are a myriad of other reforms and social changes to medical education, which have not been included in the modelling due to the complexity and uncertain nature of their impact.
The following such issues have been identified:
- increased caps on fee paying medical school students;
- uptake of new fee paying medical school student caps, by universities;
- uptake of new fee paying medical school student caps, by potential students;
- intake of international medical students;
- introduction of postgraduate medical courses; and
- differing length of postgraduate medical courses compared with undergraduate courses.
The impact of new medical school places on the intake and graduation of students has been based upon historical data between 2000 and 2005, which is published on the internet by the Committee of Deans of Australian Medical Schools (CDAMS). Data for domestic students in year 2006 was obtained directly from CDAMS, and the number of international students in year 2005 was added to this sum.
A lag of five years has been incorporated in the modelling, to allow for progression through medical education before graduation. This is an approximate average, as course lengths vary between four and six years. The standard attrition rate used by the Australian Government of 3.5% was applied between medical school intake and graduation. The ramifications of increases to the cap on full fee paying students have been deemed too complex to be included in these analyses.
Using these methods, the approximate medical school intake will increase from 1,660 in 2000 to an estimated 2,866 by 2011 (a change of 173%). This subsequently has a flow on effect of an increased number of graduates from 1,195 in 2000 to 2,766 in 2015 (a change of 231%).
Based on the increase described above, the trend for the continuation of intakes and graduates to 2016 and 2020 (respectively) is presented in Figure 1. The R-squared values of 0.9606 for medical school intakes and 0.9734 for medical school graduates indicate that the trend is a reliable prediction. However, it should be noted that there are many variables which could affect the continuation of this trend.
Figure 1: Medical School Intake and Graduates - Trend
4.3 Medical Specialist Training
After completing university based medical school courses, students must complete a postgraduate training year (also called prevocational training) in order to attain registration with medical boards. Depending upon the specialist training college, trainees may then commence specialty training after postgraduate year one, two, or in later years of training.4.4 Data limitations
It is not possible to estimate the actual movement through postgraduate training years and into specialty training programs because dependent data is not collected, nor is it available in a consistent trend from which to calculate rates.3To calculate meaningful national training and workforce projections, a number of data limitations would need to be addressed such as:
- The flow of successful candidates from the Australian Medical Council overseas-trained doctor system into career paths, for example into postgraduate training, specialty training or leaving the medical profession is unknown.
- The rate of progression between postgraduate training years to specialty training.
- General attrition during medical specialist training. This is currently unknown, but is estimated as being quite low. College assessment failure rates would provide indicative information on attrition; however there would be difficultly in accounting for those who re-sit their assessments, and those who exit the profession for other reasons.
4.5 First year specialist vocational trainee supply
Broadly, in the absence of data on specific attrition and rates of training completion, it may be assumed that the numbers of specialty vocational trainees will also increase by approximately 605, when new increased numbers of medical students progress through the education and intern training system.Given that the average Bachelor of Medicine course duration is five years, and an average of two years postgraduate training would also be undertaken before entering vocational training, these increases could be expected to be evident in approximately year 2011.
Analysis produced using other conservative attrition rates produces the following trend for the change to the number of trainees.
4.6 Meeting Community Need
One of the Reference Group's Terms of Reference is to consider the "impact of the increased number of training positions demanded by new medical school and Australian Medical Council graduates on the number of training positions required to meet community need."The various workforce planning bodies of AHMAC undertake modelling of national supply and demand of the medical workforce. A complexity of this task is that the demand for health services may be supply side-driven, thus inferring that the greater the supply of services, the more demand as a result of the behaviour of health service providers and consumers. In this context, 'community need' is a difficult concept to quantify.
Traditionally supply has been examined with reference to a large range of factors including the average age of doctors, whether they are nearing retirement, workforce participation rates (i.e. hours worked), and the entry of new doctors - trainees.
AMWAC annual reports provide an indication of growth in supply through increases to specialist training places. Implementation has been reported as follows:
Table 3.33 AMWAC medical workforce reviews, recommended increase in advanced training positions and number of training positions in 2005, by discipline
| Specialty | Number of training positions at the time of the AMWAC reviewa | Recommended increase in training positionsb | Recommended total number of training positionsb | 2005 positions (increase) |
| Anaesthesiac | 478 (2001) | 34 (2003) | 512 (2003) | 411 (-1) |
| Dermatology | 42 (1998) | 10 (2002) | 52 (2002) | 60 (18) |
| ENT surgeryd | 40 (1997) | 20 (2000) | 60 (2000) | 57 (17) |
| General surgeryd | 176 (1997) | 40 (2000) | 216 (2000) | 260 (84) |
| Ophthalmologye | 79 (1996) | 12 (2006) | 91 (2006) | 101 (22) |
| Radiology - radiodiagnosis | 200 (2001) | 60 (2004) | 260 (2004) | 263 (63) |
| Radiation oncology | 52 (1998) | 12 (2000) | 64 (2000) | 77 (25) |
| Urologyd | 33 (1996) | 9 (2006) | 45 (2006) | 51 (18) |
a - The year in brackets after the number of training positions refers to the year the workforce review was completed (using training and position numbers from the previous year)
b - The year in brackets after the number of training positions refers to the year by which the recommended increases should ideally be in place
c - In 2005 the data provided are the number of registered, financial trainees. Also note that from 2004 the ANZCA training program changed to include a basic component (years 1-2) and an advanced component (years 3-5) - the 2005 number is the number of advanced anaesthesia trainees only. The data presented for 2004 and 2005 is different from that used in previous years. Previous years only included trainees in years 1-4 as the fifth year was a provisional fellowship year. This data now covers years 1-5.
d - Figures are 2004 data obtained from the RACS College Activities Report, 31 December 2004. Actual 2005 figures will be published in the College Activity report in early 2006.
e - From 2004 the RANZCO training program changed to include a basic component (years 1-2) and an advanced component (years 3-5). Although only advanced figures are reported throughout this report, to enable comparison with the 1996 figure, the 2005 figure cited in table 3.34 is the total number of opthalmology trainees (basic and advanced).
Source: AMWAC, Medical colleges.
Table 3.34 AMWAC medical workforce reviews, recommended first year advanced trainee placements and number of first year advanced trainees in 2005, by discipline
| Specialty | Estimated first year trainee intake at the time of the AMWAC reviewa | Recommended first year trainee intakeb | First year trainee intake 2005 | |
| Cardiology | 24 (1999) | 24-28 (2000-2003) | 39 | |
| Cardiothoracic surgeryc | 5 (2003) | 5 (2002-2011) | 2 | |
| Emergency medicine | 95 (2002) | 130 (2004 onwards) | 90 | |
| Gastroenterology | 12 (2000) | 22 (2001-2002), 23 (2003-2008) | 20 | |
| General practice | 450 (2000) | 450 (2001-2003) 570 (If overseas doctor intake is below 200 per year) | 624 | |
| Geriatric medicine | 16 (1997) | 25 (1999 - 2000), 22 (2001 - 2003) | 33 | |
| Haematological oncology | 14 (2002) | 17-20 (2002-2007) | 18 | |
| Intensive care | 16 (1999) | 24-26 (2000-2008) | d | |
| Medical oncology | 13 (2002) | 15 to 18 (2002-2007) | 19 | |
| Neurosurgery | 9 (2000) | 6 to 8 (2001 onwards) | 6 | |
| Obstetrics and gynaecology | 53 (2004) | 60 (2005 onwards) | 53 | |
| Orthopaedic surgeryc | 32 (1999) | 38 (2000), 40 (2001), 44 (2002-2005) | 42 | |
| Pathologye | 44 (2002) | 132 (2004 onwards) | 58 | |
| Paediatricsf | 58 (1998) | 35 from 2001 | 66 | |
| Psychiartyg | 111 (1999) | 124 (2001), 131 (2002 onwards) | 102 | |
| Rehabilitation medicine | 15 (1997) | Increase up to 125 (1998-2000) | 24 | |
| Thoracic medicine | 13 (1999) | 16 (2001), Increasing by 2 per year up to 24 (2005) | 18 | |
a - The year in brackets after the number of trainees refers to the year the workforce review was completed (using trainee numbers from the previous year).
b - The year in brackets after the number of trainees refers to the year by which the recommended changes in trainee placements should ideally be in place.
c - Figures are 2004 data obtained from the RACS College Activities Report, 31 December 2004. Actual 2005 figures will be published ni the College Activity Report in Early 2006.
d - Data unavailable. The nature of the intensive care training program means that the great majority of trainees are in the third, fourth or fifth year of the training program. This is because often training years 1, 2 and 3 are undertaken in a primary specialty such as anaesthesia, medicine or related disciplines. It is therefore, not possible to accurately estimate the number of trainees in intensive care in their first year of training (which is only likely to be a small number of trainees); however over the period 1997 to 2003, the total number of intensive care trainees has increased by 79, from 108 to 187.
e - The RCPA has identified approximately 130 positions which could be filled if accreditation, funding and trainees were available.
The distribution of trainees amongst specialties is determined through many factors not the least of which is trainee preference. The following table illustrates the reality of distribution of trainees in various training programs.
| Distribution of training places by entry to specialty training | Number | Proportion | |
| General practice | 626 | 32.98% | |
| Adult medicine | 274 | 14.44% | |
| Surgery | 240 | 12.64% | |
| Anaesthesia | 159 | 8.38% | |
| Psychiatry | 142 | 7.48% | |
| Emergency Medicine | 122 | 6.43% | |
| Paediatrics | 89 | 4.69% | |
| Pathology | 58 | 3.06% | |
| Obstetrics & gynaecology | 56 | 2.95% | |
| Rehabilitation medicine | 30 | 1.58% | |
| Medical administration | 27 | 1.42% | |
| Ophthalmology | 22 | 1.16% | |
| Dermatology | 17 | 0.90% | |
| Radiation oncology | 15 | 0.79% | |
| Public health medicine | 12 | 0.63% | |
| Radiologists - Radiodiagnosis | 9 | 0.47% | |
| Total | 1898 | 100.00% | |
Source: Medical Training Review Panel, Ninth Report 2005, p.55.
It is anticipated that the expansion of training settings will enable trainees to fulfil unmet educational opportunities whilst also expanding the capacity of the current training system to provide for future increased numbers of medical school graduates. The future increases to medical school intakes are designed to address these needs, however it should be noted that the quantum and providers of funding for training as well as provision of medical services may change in the future.
4.7 Conclusions
The increased number of medical school students in years 2007 to 2011, in addition to the increases from 2003 to 2006, indicates that the number of doctors flowing through the education and training system and requiring specialty training positions will also significantly increase.The duration of the continuum between education, training, and full qualifications entail a lag time between the increase in specialist training numbers and increased numbers of doctors.
A gradual implementation of expanded specialist training settings will be required to ensure no reduction in service delivery capacity within public hospitals. The results of this analysis indicate that at a national level full implementation would be possible from 2011 onwards. However, in some specialties, a more rapid implementation may be appropriate and possible.
3 A number of bodies, including the postgraduate medical education councils and specialist medical colleges, are involved in monitoring trainees as they progress through the continuum of medical education. This range of bodies collects data only for discrete periods of training. As the data sets are neither continuous nor comprehensive, it is currently not possible to effectively track trainee progress through the various levels of medical training.