Neurosurgery has been practiced as a distinct specialty in Australia since the early 1930s. The Neurosurgical Society of Australasia, which includes more than 95 percent of the neurosurgeons in Australia and New Zealand, was formed in Melbourne in April 1940. Membership in the NSA is voluntary, and the society currently has 264 members throughout Australia and overseas.
There currently are approximately 120 actively practicing neurosurgeons and a population of 21 million in Australia, resulting in a ratio of roughly 1 neurosurgeon to 175,000 people. Most neurosurgeons primarily are engaged in private neurosurgical practice while maintaining an association with a “public” (government-funded) hospital. Consequently, the vast majority of neurosurgical departments are mostly staffed by “sessional” neurosurgeons who spend up to half of their working time in the public hospital, and the rest in private practice. There are very few full-time hospital neurosurgeons, and these tend to be mostly in the larger departments. While many neurosurgeons may have an honorary title with a university, there are very few who are employed through the university as academic surgeons. The reason for this is multifactorial, with lack of opportunity for advancement and financial reasons probably among the major considerations. In addition, most universities require applicants for senior academic positions to have formal research qualifications, which few neurosurgeons possess.
The Royal Australasian College of Surgeons provides training and education in nine surgical specialities including neurosurgery, in which it admits surgeons to fellowship. The RACS is accredited by the Australian Medical Council for delivery of specialist medical education and training, and this is instituted through the nine specialty boards. The final examination in neurosurgery is an exit exam, usually taken in the final year of training and administered by the RACS. The Board of Neurosurgery is responsible for the selection of trainees, accreditation of hospitals for training and the training program. Consequently, the RACS in essence is responsible for selection, training and examinations in specialties of surgery, including neurosurgery. At present there are approximately 55 neurosurgical trainees in Australasia, with some also studying in Singapore.
The neurosurgery training program in Australia recently has changed from a five-year program, which could commence in the fourth year after finishing medical school and general rotations through surgery and medical specialties, to a six-year program that can commence two years after finishing undergraduate training. The course includes a compulsory year of research. It is hoped that this will encourage neurosurgeons to go into academic neurosurgical practice in the future. It is noteworthy that many Australian medical schools now have followed the “North American” model and have instituted graduate medical programs in which the medical course is undertaken following an undergraduate program in sciences and humanities.
The number of hours most neurosurgical trainees work per week is variable, but most centers limit trainees to 70 hours per week. In the past they worked much longer hours, but there is now a strong push to further reduce the number of hours trainees can work per week, and such a reduction may seriously impact training.
In the past neurosurgical training has been aimed primarily at producing general neurosurgeons. Given the recent trend toward subspecialization, most major neurosurgical units now have well-developed specialty programs with some neurosurgeons restricting their practice to subspecialty areas. Subspecialization has been easily achieved in the few high-volume neurosurgical departments, but this achievement is more problematic in smaller departments where there are fewer patients.
Neurosurgery in Australia is mostly restricted to the six major state capital cities, although there are also neurosurgical programs in Townsville in far North Queensland, in Newcastle just north of Sydney and in Wollongong just south of Sydney. As a result, patients may have to travel considerable distances to access neurosurgical care, and there are special problems relating to emergency neurosurgery in remote locations. Most states have instituted a well-organized retrieval or emergency transport care for patients in remote regions.
All Australians are covered by a type of national insurance scheme (“Medicare”), which entitles them to free medical care in public (government) hospitals. In addition, approximately 35 percent of the population has purchased private insurance, which will cover them for most of the cost of being a private patient in a private hospital. In general, the quality of neurosurgical care in the public hospital system is very high, but there are access issues for nonurgent or elective surgery.
Medical liability litigation and insurance is of major concern to all practicing neurosurgeons. For example, liability premiums for neurosurgeons increased nearly 300 percent from 1995 to 2005, and annual insurance premiums are now in the range of $39,000 to $59,000, depending on the state. Subsidies announced by the Australian government in 2003 offset premiums to a degree, but the medical liability system remains of great concern to physicians.
The major problems facing the Australian medical system include serious medical workforce issues, particularly in remote and rural regions, and adequate funding of public hospitals to cope with the increasing burden of elderly patients and complex illnesses. In addition, a poorly understood and not often recognized serious problem is the inability of the Australian system to attract surgeons (including neurosurgeons) to an academic career. It is these clinical academics who will be training the next generation of the medical workforce, including neurosurgeons and other specialists.
Andrew H. Kaye, MD, is professor of surgery and head of the Department of Surgery at the University of Melbourne, and director of neurosurgery at the Royal Melbourne Hospital, Melbourne, Australia. The author reported no conflicts for disclosure.
For Further Information
- Medical Indemnity: Final Details of the Incurred but Not Reported Indemnity
Contribution. Australian Department of the Treasury, Press Release, Aug.
1, 2003, https://assistant.treasurer.gov.au/DisplayDocs.aspx?pageID=&doc=pressreleases/2003/073.htm&min=hlc
- Medical Indemnity Report, Medical Indemnity Industry Association of Australia, July 31, 2008, www.miiaa.com.au/media/files/587.pdf
- Neurosurgical Society of Australasia, www.nsa.org.au