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14 May 2019


Limbo n.

  1. An uncertain situation that you cannot control and in which there is no progress or improvement.
  2. A dance or contest that involves bending over backwards and passing under a horizontal pole lowered slightly for each successive pass.

Interestingly, both of these connotations can be strangely apt descriptions of the experience of unaccredited or service registrars (vernacular dependent on your State).

As Australian medical graduate numbers more than doubled in the five years from 2010, the number of College-accredited training places in many specialty programs have been much slower to rise.

The sudden influx of prevocational doctors superimposed on the variously positioned training bottlenecks has resulted in an ever-expanding prevocational potential space, oedematous with those intent on pursuing an oversubscribed specialty with tight constraints on entry and training numbers.

Where once a simple concentration gradient set up by a universal deficit of doctors facilitated continuous passive flow of PGY2+ into whatsoever vocational training program they desired, active transport is now required. CV buffing, hoop jumping, fee paying active transport.

Yet for some specialties ‘selection’ into training has equated simply to getting a job at an accredited site alone. Flow into these has remained effectively uncapped, a function purely of the workforce need of Royal Hospital of the Day, rather than a more nuanced capacity of that site and crucially its supervisors to train, let alone community need for specialists at the other end. In these cases we are finding oedema in the dependent advanced training or fellowship parts, pushing largely into private practice.

The original policies increasing student numbers were brute force attempts to solve medical workforce by flooding the system and assuming doctors would just trickle out to where they were needed. And yet while you could very realistically spend the length of an oversubscribed training program waiting to get on it; general practice, psychiatry and pretty much any health service MMM2+ are coming up short. Suffice to say brute force hasn’t panned out too well. The Australian medical workforce paradigm has shifted from a demand to supply driven model in many areas, and we are scrambling to find balance.

In the meantime, being a trainee can be a bit of a thankless experience.

Several months ago the blog of Dr Yumiko Kadota’s experiences as an unaccredited surgical registrar went viral. It described experiences of unsafe working hours, unfair rostering, bullying, sexual harassment, inadequate supervision, and an all too common sense that she was powerless to change the situation for fear of retribution, fear of remaining in unaccredited limbo. Unable to progress, but simultaneously being asked to bend over backwards, pushed ever closer to the ground.

The worst part of the fallout for me was that very few doctors were surprised. Shocked, yes, but not surprised. Some of us have experienced some or all of what she did, or we have borne witness to it through our colleagues and friends. There will be countless other marvellous doctors, perhaps some reading this, for whom the only difference in their situation is their necessary silence, bound by the hope, not even the promise, of a training position.

Dr Kadota had left training and indeed medicine by the time her story gathered media attention – only now, unbeholden to any supervisors, assessors, referees (often all the same person) can she speak freely.

Her story touches on so many of the problems that have plagued our profession with increasing public scrutiny of late. Most aren’t unique to unaccredited or service registrars, but they hold the least power to change their lot. So it’s up to the rest of us.

The best way to support unaccredited registrars and indeed all trainees is to start with making every doctor in training job compliant with employment law and various enterprise agreements, so even life in limbo is sustainable. (I’m looking at you, six months of nights).

CDT has also recently called for the accreditation of all prevocational medical roles by the various state-based postgraduate medical councils, to ensure minimum supervisory and educational quality for all posts occupied by doctors in training. This will require additional resourcing from COAG, and would ideally include reinstating funding to the Confederation of Postgraduate Medical Education Councils to encourage national consistency of standards.

Even without College oversight, each of these jobs is a valuable source of training opportunities, whether they are being realised or not. Some might be appropriately transformed into College-accredited training positions where this is feasible and in line with community need, and we have encouraged Colleges to review their criteria, especially in regional and rural settings where more innovative training and supervisory models may be required. Others jobs might be promoted to a broader pool of trainees who would benefit from the experience without seeking fellowship in the same specialty, such as paediatric jobs for budding general practitioners.

But I would also suggest we need to start by reframing the role and the language we use to describe it. ‘Unaccredited’ has connotations of unqualified or unsuitable, even rogue, while ‘service’ registrar connotes a blinkered line worker without educational or professional development needs, which couldn’t be further from the truth.

Thank you Dr Kadota for telling your story. It’s now imperative that we learn from it.

Published: 14 May 2019