The hidden lives of Australia’s unaccredited registrars
Given the value of the products they make, medical schools have always been big business, but a big business which thrives most when driving the conveyor belt ever faster.
It doesn’t so much matter where the money is coming from — from the state, from overseas, from the debts amassed by medical students themselves or from their families.
Except in Australia, over the last decade, the production line has been running out of control.
The AMA, in a fiery position statement on workforce supply released last month, refers to the doubling of domestic medical graduates from 1544 in 2007 to 3066 in 2020.
But despite this productivity, it notes that the increases have not resulted in better access to medical professionals in rural and remote areas.
Nor have they boosted numbers in specialties facing serious undersupply — such as psychiatry and general practice.
That is a significant fail given the investment involved.
The reasons are complex but among them is that fascinating and under-researched sociological force that drives increasing sub-specialisation at the expense of the generalist expertise needed by most patients.
Since 2013, the annual compound growth of subspecialist physicians and surgeons in Australia is running at 4.5%. This is more than twice the growth rate (2.1% a year) for general physicians and surgeons.
The federal Department of Health paper where these numbers appear suggests it’s fuelled in part by “consumer demand”, by the narrow scope of some clinical fellowships, along with doctors responding to medicolegal risk.
And yes, there is also the psychology: the varying prestige which the medical profession collectively attaches its wide-ranging talents.
The AMA position statement lays into the half-arsed planning that has gone into the medical workforce over the past 30 years, referring to a “parade” of expert bodies tasked with applying some rationality to a system which doesn’t think with one brain.
But beyond the bar charts and timeline graphs, the demand-and-supply analysis, the demographic computations and population modelling, is a very human story.
The lack of focus on specialist training capacity following the decision to ramp up medical graduate production has resulted in “the glut of doctors” beyond PGY 3 now carving out a precarious, high-stress existence as unaccredited registrars.
No-one doubts that the hospital system would collapse without them.
To give you an idea why, unaccredited registrars in the public hospital system in NSW number around 1100 — or at least it did back in 2019. It’s no doubt more now.
“The unaccredited service registrar experience is characterised by intense competition for entry into college training programs and poor working conditions, including excessive and unsafe hours, poor supervision and job insecurity,” the AMA position paper states.
“An increasing number of these doctors are considering a career outside of medicine.”
That captures only half the story. Their dependency on a system that can chew them up and spit them out has succeeded in rendering them virtually mute. Vulnerability encourages silence.
One exception was Dr Yumiko Kadota, who back in 2019 wrote with blunt, vivid eloquence of her failed attempts to become a reconstructive surgeon.
She was destroyed, she said, by long hours, stress and sleep deprivation.
“I was physically alive, but spiritually broken,” she wrote shortly after walking away.
“I am handing back my dream of becoming a surgeon. I have nothing left to give.”
She later published a book, Emotional Female.
In it there is a chapter where she speaks of her time as an unaccredited registrar and the “soothing monotony” of her motorway commute along the long flat grey road to the hospital just before the onslaught once she walks through the gates.
On this day, the onslaught begins with a call from an ED consultant.
“I don’t care about your f***ing hand surgeries. You need to come here now! We have a man with a severe facial injury bleeding out of his face.”
“When I got to the ED,” Dr Kadota writes, “the trauma bay was in chaos.”
“An elderly gentleman had bandages all over his head. A piece of wood had been flung towards his head from a mulcher and gone through his cheek straight into his mouth, ripping the gums off the bone.”
She told ED staff he needed an urgent CT scan of his brain.
“’The facial injuries can wait,’ I said. ‘I can stitch his face back together once we know that he doesn’t have a more serious head injury.’
“I power-walked down the labyrinth of corridors to the front desk of the operating theatre to inform the anaesthetist and nurse in charge.
“Then I went back to my f***ing hand surgeries.”
A few moments later she is told ED has called a Code Crimson.
Fearful of operating on him without having excluded a head injury, she again requests a CT scan. But she learns that another consultant contacted by a registrar on her behalf wants her to go ahead.
“I heard the urgency of the nurse’s voice as she was handing [the patient] over, the beeping of his monitors, the wheels clunking down the corridor, and the sound of steam coming out of my ears.
“When I unwrapped his bandages I could see where the bleeding was coming from.
“A little spurt from the superior labial artery, near the upper lip.
“I asked for a 3-0 Vicryl tie. All those years of tying purple threads as a student always came back to me in these moments.
“‘The bleeding has stopped. We can now take our time and proceed,’ I said in my calmest voice.
“Inside, my own blood was doing circuits around my body at breakneck speed, but on the exterior I kept my cool.
“I kept thinking that this patient should really have gone to the CT scanners.
“Now he was here, it made sense for me to fix his face, but I was also mindful that I still didn’t know what was happening inside his skull.
“The procedure was finicky and time-consuming. It took me two hours to reconstruct his face.”
Afterwards, Dr Kadota requested a CT scan, saying she paced up and down the operating theatre as she awaited the results.
It turned out her patient had a large subdural haemorrhage so his skull could accommodate the blood.
“It was a near miss [but] my heart was overwhelmed with dread as I asked the switchboard operator to dial the neurosurgical registrar.
“Would I get criticised for operating on the patient before he’d had a CT scan?
“Would I get yelled at even though I’d requested Emergency to get him the scan?
“Maybe I should have been more assertive.
“I wished I had more power.
“I wished I could have told the Emergency Department that I wouldn’t accept this man until all the appropriate measures had been taken.
“But as an unaccredited registrar, you couldn’t do that. I was just glad the patient hadn’t died.”
The reaction to Dr Kadota when she first wrote about her experiences — the gruelling workloads and the physical and mental toll of working hundreds of hours of overtime each month — seemed reassuring.
NSW Health ordered a review along with an internal survey of hospitals.
Then came the discussion paper with 10 draft suggestions offering protections, including mandatory training plans along with the published details of the training and education available.
Since then nothing has happened.
The survival-of-the-fittest battle among junior doctors for the limited training places now available in the specialties most in demand does explain some of the reasons why the breakdowns and suicides of younger doctors continue.
There is an obvious need to address the muddled, ad hoc, piecemeal approach to medical workforce planning in Australia. It’s failing everyone – taxpayers, patients and health professionals.
The AMA wants better controls on the production of doctors by medical schools, not least that Commonwealth Supported Places are distributed according to community need, with a focus on increasing the generalist and rural medical workforce.
But better workforce planning will help address the human costs of the current system.
Indrani Tharmanason, the mother of Dr Tasha Port, who took her own life three years ago having lost hope that her application for the paediatrician training program would be successful, recently spoke to Australian Doctor.
She talked of her daughter’s struggles — the stress, the isolation, the uncertainty, the way she began to lose weight, talk less and become increasingly introverted, the way she struggled to reach out.
At one point during the interview, Ms Tharmanason said: “For doctors, the fear of seeking help is the fear of losing the thing they love.”
Many unaccredited registrars trying to secure the career they had envisaged when they won a place in a medical school will know the hard truth in what she says.
Paul Smith is Australian Doctor’s editor
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