The pathway and the hierachy
To become a doctor, one must pass medical school, which can be either an undergraduate or postgraduate degree for 4-6 years. I did a six-year undergraduate degree, which included an Honours research year when I was in fourth year. Then, you become an intern. Each state is different in Australia. In New South Wales (NSW), it is ballot based and there is a tiered system. As a migrant, I was in one of the lowest tiers despite being educated in Sydney, and I was not offered a position in the first round of internship allocations. I had also applied in Victoria, which has a merit-based system and I was given a first-round offer to be an intern at the Alfred Hospital in Melbourne – and that’s where I went.
The internship year includes at least one term in the Emergency Department, a medical rotation, and a surgical rotation. After internship, most doctors will do 1-2 years in residency depending on the specialty you’re interested in. In NSW, the first year of residency is still a broad year covering a range of specialties, but in Victoria you start to streamline. I always knew I wanted to be a surgeon, but I chose to do a Critical Care residency, which would guarantee me a term in Intensive Care. This is something I wanted to do because I wanted to be competent in caring for the severely unwell patient, and is a pre-requisite for most surgical programs.
After residency, a doctor becomes a registrar. Registrars rotate around different public hospitals for 6-12 months at a time to provide their service to different areas of the state. This also exposes the registrar to a variety of case-loads, as different hospitals have different specialisations and patient demographics. For example, Concord Hospital in Sydney is one of two hospitals that look after patients with severe burns, whilst the larger city-based hospitals do a higher number of reconstructive cases.
This year was my eighth year of being a doctor, and my fourth as a Plastic & Reconstructive Surgery registrar. The registrar is in charge of the daily running of his or her specialty at the hospital. This includes rounding on inpatients, who are admitted to hospital via the Emergency Department, or those who come in for elective surgery. The registrar also attends clinics, which follow up patients who have been discharged from hospital, or new patients referred by GPs or other specialties for an opinion or review. The registrar will also assess patients in the Emergency Department or inpatients admitted under other specialties who are referred to him or her.
Registrars apply for advanced training programs to become a consultant in their chosen specialty. Entry into these programs can be extremely competitive, and there are rigorous standards throughout the program with a final examination at the end before that doctor becomes a fully-qualified consultant. Most advanced training programs are 4-6 years long.
Each department has consultants, who supervise the registrars. The level of supervision depends on the consultant and the level of experience of the registrar. If the registrar is competent and experienced, the registrar does the decision-making and operating with the approval of the consultant over the phone. Other consultants are more involved, and will come into the hospital to see patients admitted under their name and be involved in the operations. Consultants often have a private practice outside of their public hospital arrangements, and so public hospital duties can be a low priority for some, whilst others dedicate their time entirely to public health.
I often get asked what it means for a doctor to be “on call”. There is always one person who is on call for a specialty. If it is a small specialty, it may be the consultant. For bigger units, there is both a registrar and consultant. On-call duties last for 24 hours at a time. The on-call registrar is the first point of contact if an Emergency Department or a doctor from another specialty needs to refer a patient or would like advice on how to manage a patient who has a problem related to that specialty. For example, if a patient has a broken finger, that patient should be referred to the registrar on-call for Hands (which is either the Plastic or Orthopaedic surgery registrar depending on the hospital).
Even after the on-call registrar has finished his or her duties for the day, the on-call does not end when he or she gets home. You must be contactable for the full 24-hours, which sometimes means you might get a call in the middle of the night, and some of these calls require you to physically go back to the hospital to see the patient. If the call is about a non-urgent condition, that patient either gets seen the next morning or at the next clinic. The on call is usually distributed equally between the registrars, but this is not always the case, as you will learn in my next blog post.
I hope that this explains the system of doctors working in public hospitals in Australia.