Putting doctors under a data microscope

Few of us, on a trip to our family doctor, would pause to reflect we are participating in a $163 billion industry that is the single largest part of our economy.

The health care sector employs more people than any other in Australia, and contributes 10 per cent of our GDP. And, compared with other parts of the economy, it is unlikely to experience a slow-down in demand – our population is growing and getting older, with chronic diseases fast overtaking others in consuming health care resources.

At the same time, the health care system is subject to gross inefficiencies and poor allocation of resources, says Professor Tony Scott, Program Director of Health Economics at the Melbourne Institute of Applied Economic and Social Research, and someone who considers the economics of health more than most.

“It’s a paradoxical sector,” Professor Scott says. “Under-treatment of chronic conditions exists in parallel to over-diagnosis and treatment.

“There are considerable inequalities in access to healthcare. We do not have enough doctors in rural areas – yet we have too many specialists in metropolitan areas.

“People in low socioeconomic areas tend to access health care less frequently, and we have a serious equality problem in our public and private sector system. These inefficiencies can prolong illness and cause harm and even death.”

According to Professor Scott, the solution to these problems lies in understanding their causes.

“At the core of these inefficiencies, we find significant structural and funding issues within the healthcare system. The way in which patients and doctors make decisions also plays an important role.”

Professor Scott and his research team consider how doctors make decisions, and, more broadly, what factors drive how our medical workforce is distributed, which may underpin some of the inequalities of access.

“Doctors are at the front line of our health care system, and to work effectively, each needs to be highly trained and motivated. But they also need to be supported by effective and organised supply lines. If the supply of doctors to the front line is inadequate – if they are sending the wrong types of doctors, if doctors are in the wrong locations – then they will be overwhelmed and ultimately ineffective.”

Professor Scott leads the Medicine in Australia: Balancing Employment and Life (MABEL) survey, which has been providing a rich and unique set of data about our medical workforce for the last ten years. It is managed by the Melbourne Institute in collaboration with the School of Rural Health at Monash University.

Globally unique in its scope, MABEL is the only national dataset that examines the working lives of doctors – where they work, the specialisations they choose, when they take parental leave or sabbaticals, when they decide to retire, and the factors that influence these decisions. MABEL also asks doctors how satisfied they are in their careers.

Health workforce snapshot

MABEL provides unique insight into how policy can address medical labour supply in the health sector. Research using the survey and other administrative data has been informing some of the biggest issues in health care over the last decade:

• For every new GP, there are nearly 10 new specialists. Fifty per cent of medical graduates went into general practice in the 1970s and 1980s, compared with only 30–35 per cent from the 1990s–present.
  
• Where medical students train has a significant effect on their decisions to work in rural or urban areas. Completing some rural training increases the likelihood of GPs practising in rural areas for at least five years.
• There is a significant accessibility gap between rural and urban regions, with psychiatrists, paediatricians and endocrinologists in particularly short supply in rural areas.
  
• Female participation is on the rise. Women make up 42 per cent of GPs and 29 per cent of specialists in the medical workforce in Australia.
  
• 87 per cent of doctors are moderately or very satisfied with their work, with hospital non-specialists tending to be the least satisfied.
  
• Doctors spend an average of 16 per cent of their working time on non-clinical tasks, such as management, administration and teaching.
  

Aggression in the workplace

MABEL data has shown that over one year, more than 25 per cent of doctors experienced physical aggression from co-workers (‘internal’ aggression); a staggering figure that was highlighted in 2015 by revelations of endemic bullying and harassment among the surgical workforce.

Aggression from patients or carers (‘external’ aggression) is also a constant problem.

Overall, female doctors reported experiencing higher levels of aggression; however, when broken down by doctor type, the data shows that male GPs tend to experience higher rates of external aggression, while female specialists experience higher rates of both internal and external aggression. Factors that reduced the risk of encountering aggression in the workplace included being more experienced in medicine (for women) and being older (for men).

Unsurprisingly, in both cases, the data showed that exposure to aggression affected doctors’ job satisfaction and wellbeing. Regardless of doctor type, level of experience, location or gender, exposure to workplace aggression was negatively associated with job satisfaction, self-rated health and satisfaction with life.

Research using MABEL data has identified solutions to begin to address this concerning trend. Lead author Dr Danny Hills, a registered nurse and a researcher at Monash University, says the issue stems from a number of gaps in systems and training.

“The data highlights the need for education for clinical supervisors, improved reporting structures to make it easier for vulnerable workers to report bullying or aggression, and for long-term work health and safety legislation around a safe, aggression-free workplace,” Dr Hills says.

“However, strategies also need to take into account the different factors, such as location, gender and professional experience, which affect how workplace aggression is experienced.”

Gender and work

It is unsurprising that gender equity poses a challenge in the medical profession, with a tradition of male dominance for many decades, particularly at the highest echelons of practice. Issues of gender equality were also brought to the fore by the surgeon bullying scandal, and MABEL data highlights common challenges and pressures for women in medicine.

Female participation is on the rise, with more women working in general practice – 62 per cent of GPs under 35 years old are now female. But female GPs earn around 2 per cent less than their male colleagues.

Having children has a considerably greater impact on career for women than men. Women in medicine shoulder the burden of childcare, so much so that female doctors in training often choose specialisations according to their perceived family-friendliness, such as general practice, where part-time hours are easier to come by.

This can lead to a startling effect on earnings, further widening the gender pay gap. Women GPs under 40 who have children earn over $30,000 less than those without children, quite the opposite to male GPs with children, who regardless of age earn about $45,000 more than their peers without children (known as the “breadwinner” effect).

This gap is largely accounted for by reduced hours, but even after adjusting for hours worked, the gender gap remains.

Supply and demand

The opening of a number of new medical schools in the last ten years has led to concerns about an oversupply of graduates, with many medical colleges and associations highlighting a shortfall of intern places, which are essential for medical graduates to complete their training.

Professor Scott points out the paradox is that people in rural areas are still chronically under-serviced by health services – enticing enough doctors to rural practice continues to prove elusive for government policymakers. But as with most career choices, the decision to move to (or remain in) the country comes down to each doctor’s professional and personal preferences, and it’s here that MABEL data really comes into its own.

From pinpointing the exact financial incentive that would persuade GPs to move to a small rural town ($68,000–$116,000, depending on the size of the town) to dispelling the myth that regional specialists face limited career prospects, MABEL provides a wealth of practical information to inform rural workforce policy. In fact, although rural incentive and retention programs have been in place since the early 1990s, MABEL has provided some of the first empirical evidence about which types of these schemes might work.

Results suggest that providing rural GPs with locum relief for 4–6 weeks a year, GP retention payments and rural skills loading would all increase numbers in rural areas. Similarly, rural training pathways are incredibly important to address rural health care shortages: GPs who have completed some of their training in rural areas are likely to continue practising in rural areas for at least five years.

Psychiatrists, paediatricians and endocrinologists are among the specialties in particularly short supply in regional areas. Rural or regional practice can be seen as career-limiting, yet data from MABEL is now showing that regional specialists are equally satisfied with their careers as their metropolitan colleagues are.

Focus on the future

None of these issues have simple solutions, and they will likely be present in some form in another 10 years. Professor Scott believes doctor oversupply will continue to be a big issue in the future and, with this in mind, MABEL research is beginning to examine the effects of increased competition on doctors’ fees, and how this translates to changes in access to care.

Good government policy will be critical to addressing the parallel problem of maldistribution of doctors in rural areas, with a focus on rural training pathways and effective incentive programs a must.

If one thing is essential to good policy, it is good data, which is why it is crucial to continue research in this area with programs like MABEL, says Professor Scott.

“There really is nothing like it anywhere in the world.”

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