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| Journal of the New Zealand Medical Association,
22-October-2004, Vol 117 No 1204
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Analysis of the Advanced Choice of Employment (ACE) scheme
for facilitation of first-year house officer appointments in New
Zealand
Richard Pole, Gregory O’Grady, Brandon Adams
Recruitment and retention of junior doctors has become an
issue of public interest in New Zealand due to well documented workforce
shortages.1 Ongoing media publicity about
junior doctors seeking increased remuneration overseas has heightened
concern,2,3 as has evidence that high student
debt encourages emigration of medical
graduates.4
One important component in the retention of junior doctors
is attracting and appointing graduates into the New Zealand workforce. From the
mid-1970s to the 1980s, postgraduate year 1 (PGY1) appointments were coordinated
via a centralised recruitment scheme (MATCH). There is little available
documentation about the success or otherwise of MATCH, but it was abandoned in
1989.
Since then, a ‘hands-off’ recruitment model has
operated, with individual District Health Boards (DHBs) responsible for all
aspects of PGY1 recruitment. This model was protracted by multiple transactions
extending months beyond the first announcement of job offers, allowing little
certainty for employers and employees. The model may also have further
contributed to overseas emigration of graduates as those graduates uncertain of
New Zealand employment sought positions in Australian Hospitals.
In 2003, New Zealand’s DHBs collectively implemented a
new scheme for coordinating the recruitment of first-year house officers. Named
Advanced Choice of Employment (ACE), the scheme was designed for
‘efficiently matching applicants with their most preferred employer and
vice versa, with the sole purpose of speeding the job offer and acceptance
process’.5
We conducted a review of the ACE scheme to determine its
success. We hereby publish our results to enhance understanding of the scheme
for future graduating doctors and their employers, and to fill a gap in the
literature regarding optimal workforce transition from undergraduate training to
the medical workforce. The review also reveals new information regarding the
junior doctor workforce in New Zealand.
Overview of the New Zealand ACE schemeIn 2002, all 21 of New
Zealand’s DHBs committed to a centralised recruitment strategy for
first-year house officer positions. In 2003, an independent body (the ACE
Centre) was established to coordinate the scheme and advertise it widely through
website, booklets, presentations, and as part of a recruitment
‘road-show’ visiting four major centres. The ACE centre published a
series of deadlines to ensure the scheme worked to a preset timeframe.
Applicants for PGY1 positions in New Zealand were required
to make a single application to the ACE Centre via internet or post. Candidates
were asked to provide curriculum vitae, nominate three referees, and to
‘list the DHBs you are applying to in order of
preference’.6 Applicants did not rank DHB
by whom they did not wish to be employed.
The ACE Centre collated applicant details and electronically
transferred them to those DHBs listed by the applicant. DHBs were blinded to
their potential employees order of preference. DHB staff assessed these
applications by individual methods and returned a list of desired employees to
the ACE Centre, again in ranked order of preference. DHBs did not rank those
candidates who they deemed unsuitable for employment. DHBs also reported their
quota of available first-year house officer positions to the ACE
Centre.
The ACE Centre used a computer algorithm to impartially
match the two ranked preference lists received from applicants and DHBs.
Candidates were matched to their most preferred hospital that had ranked them
within their quota boundary of available positions through repeated iterations
of the algorithm. After matching, the ACE Centre approached all matched
applicants on the same date with employment offers.
It was intended that unmatched applicants would be invited
to enter a second round of matching later in the year (2003), when revised
quotas of unfilled PGY1 positions were returned from DHBs.
The same process was used for facilitating PGY1 employment
in 2004, however application was only available via the internet.
MethodsTo determine the ACE
scheme’s success, recruitment data was made available by the ACE Centre
for 2003 and 2004. This data was used to determine the number and type of PGY1
applicants and to assess how successful the ACE scheme was at facilitating their
employment. Comparison was made between secondary and tertiary DHBs for total
applicant numbers, number of applicants per position available, and ranking
priority of applicants.
Qualitative satisfaction of the ACE scheme was assessed
via an email survey of trainee interns graduating in 2003. New Zealand
Registration Exam (NZREX) and overseas applicants were not surveyed. Questions
included satisfaction with the ACE process, and determined aspects that were
problematic.
ResultsIn 2003, 304 first-year house
officer positions were available at the commencement of the first round of ACE.
404 completed applications were received from four groups: 316 New Zealand
citizen/permanent resident trainee intern (TI) graduates (Group 1), 15
non-resident trainee intern graduates (Group 2), 53 overseas trained doctors who
had successfully completed the NZREX exam (Group 3) and 20 doctors who applied
from overseas (Group 4). All 304 positions were filled within one round of
matching, thus making further rounds unnecessary.
In 2004, there were 299 first-year house officer positions
available. 413 completed applications were received from 291 Group-1 applicants,
43 Group-2 applicants, 53 Group-3 applicants, and 26 Group-4 applicants. All 299
positions were filled within one round of matching.
Analysis of successful (or otherwise) application by group
type is presented in Table 1.
Table 1. Applicants for first-year house officer
positions
*Includes
withdrawals.
In 2003 and 2004, several applicants failed to achieve
employment due to a relative shortage of positions, so (in 2003) several DHBs
subsequently created additional first-year positions and conducted recruitment
independent of ACE. Seventeen of the 19 unmatched Group 1 applicants
subsequently secured PGY1 positions in New Zealand. No additional PGY1 positions
were secured by any Group 2, Group 3, or Group 4 applicants. In 2004, no
additional positions had been created by the time of writing
(September).
The majority of successful applicants were employed by their
most preferred DHB (72% in 2003 and 86% in 2004). In both years, 96% of
successful applicants achieved employment in one of their top four choices
(Table 2).
Table 2. Preference ranking achieved by successful
applicants
Most applicants ranked more than four locations (2003 mean
8.7; 2004 mean 8.5).
DHBs containing tertiary services received more applications
than DHBs containing secondary services (p<0.01 for 2003, p<0.02 for
2004). In 2003, tertiary service DHBs received a mean of 237 applications,
whereas secondary service DHBs received a mean of 170 applications. In 2004,
tertiary service DHBs received a mean of 260 applications, whereas secondary
service DHBs received a mean of 205 applications.
DHBs with secondary services processed more applications for
each position filled (p<0.01 for 2003 and 2004). The mean number of
applications per secondary service hospital position were 23.7 in 2003, and 34.2
in 2004. The mean number of applications per position for tertiary service
hospital position were 7.8 in 2003, and 9.7 in 2004.
More applicants voiced preference for working at tertiary
hospitals, ranking them higher in their preference lists than secondary
hospitals. The mean number of applications processed by tertiary hospitals in
which the hospital was ranked among the applicant’s top four most
preferred working destinations was higher in 2003 (56%) and 2004 (50%) than
those processed by secondary hospitals in 2003 (27%) and 2004 (24%) (p<0.01
for 2003, p<0.02 for 2004).
Qualitative331 trainee interns were surveyed
in 2003, with 83 (25.1%) respondents. Despite a low response rate, trends in
opinion were discernible for three aspects of the ACE scheme: general
satisfaction, transparency, and unmatched candidates.
General
satisfaction—Thirty-three respondents (39%) made positive comments
about the speed and/or ease of using ACE. Forty-three (59%) respondents made no
comment on satisfaction. One respondent voiced dissatisfaction and preference
for the previous system.
Transparency—Of
23 respondents who commented on transparency, 22 stated that they did not find
the process transparent enough. The majority of these respondents identified the
non-publication of the matching algorithm as their chief concern. Two responses
expressed a lack of confidence in the ACE centre to handle employment
documentation.
Unmatched
candidates—Candidates who were unmatched expressed disappointment
that there was no second round of matching. Two respondents stated that they
thought that ACE guaranteed all New Zealand graduates a PGY1 job.
DiscussionThis review demonstrates the ACE
scheme to be highly effective in assisting smooth transition from education to
the PGY1 workforce. In its first two years, ACE successfully facilitated matches
for all available PGY1 positions in New Zealand within one round of
applications. This recruitment was achieved with much greater efficiency than in
previous years, when multiple rounds of individual negotiation between employers
and applicants would extend the process over a number of months beyond the first
announcement of job offers.
The scheme successfully accounted for applicant’s
preferred working locations, placing the majority in their most preferred
location and the high majority in one of their top four most preferred
locations.
The success of the ACE scheme accords with overseas
experience. In Victoria (Australia), a state-wide ‘match’ has been
run annually for a number of years and manages to allocate (on average) 98% of
applicants to one of their top three choices of
employment.7 In the United States, a large
nationwide ‘match’ is used every year to allocate positions on
residency programmes.
Qualitative survey trended towards satisfaction with the
scheme among respondents. This outcome may be biased by the fact that only the
most successful group of applicants were surveyed, although applicant success or
otherwise should not be equated with satisfaction with the ACE process. Although
not surveyed, satisfaction was likely to be higher for the 2004 cohort as
applicant concerns from 2003 were addressed. For example, to address
transparency concerns the ACE matching algorithm was published in the applicant
guidelines, league tables of percentages of successful applicants were
published, and an online tracking system was made available to allow applicants
to electronically track the progress of their application.
These improvements were coupled with a significant education
programme to assist potential applicants in understanding the ACE process,
including dispelling the myth that ACE guarantees all applicants a job, or
indeed has any control over individual DHB employment decisions.
The ACE scheme lessens the administrative burden on
applicants and their referees who now fill out only one application form or
reference per candidate. However, one associated detracting factor highlighted
by this paper is the heavier administrative requirement on employing DHBs who
must process a large number of applications; the burden likely falls more
heavily on secondary hospitals as they receive more applications per position
available and presumably have fewer personnel.
Secondary service DHB were generally less preferred by
applicants than tertiary hospitals; this echoes a recognised difficulty in
recruiting medical staff for the provincial
workforce.1
A further benefit of ACE is in creating a centralised
clearing-house of applicant data, which may allow improved workforce planning as
new information is generated each year. For example, this review reveals a
‘bottleneck’ with excess doctors vying for employment at the first
post-graduate year of experience.
The widely publicised shortage of junior doctors generally
occurs after this first year of medical experience when graduates emigrate fully
registered and more experienced.8 In addition
to overseas students at New Zealand medical schools, additional applicants have
recently been generated in larger numbers through a retraining programme
(NZ-REX) for overseas doctors resident in New Zealand formerly unable to seek
employment due to non-transferable qualifications.
Although there is an excess of PGY1 applicants, the 2004 ACE
data shows there are currently insufficient New Zealand resident Trainee Intern
graduate (Group 1) applicants for the early workforce. Data presented for 2003
(Table 1) misrepresents this fact because a number of non-resident trainee
intern graduates (Group 2 applicants) applied as New Zealand resident/permanent
citizen (Group 1) applicants in the first year of ACE.
Therefore applicants from Group 2 and Group 3 fill an
important gap in the New Zealand PGY1 workforce, although this review also
reveals that such applicants are disproportionately unsuccessful when applying
for first-year house surgeon positions.
One unexpected effect of having a centralised clearing house
of applicant data was an increase in the number of PGY1 positions offered in
2003 after the 304 advertised positions available through ACE had been filled.
This extra recruitment occurred when DHBs were made aware of unmatched
candidates and took independent action outside of ACE. The resulting increased
retention of graduates may not have been possible in previous years when PGY1
employment data was not collected and distributed by a central body. It is
likely that several of these extra positions were produced by opening vacant
second-year positions to first-year candidates.
The ACE scheme should have a strong future in New Zealand.
It is effective in smoothing workforce transition with appointments compatible
with applicant wishes, and ACE may also provide a useful tool to monitor the
junior medical workforce and contribute to retention of graduates.
Author information:
Richard Pole, House Surgeon, Nelson Hospital, Nelson; Gregory O’Grady,
House Surgeon, Nelson Hospital, Nelson; Brandon Adams, House Surgeon, Hutt
Hospital, Lower Hutt
Acknowledgments:
Thanks to the ACE Centre/DHBNZ for the release of data used in this
project.
Correspondence: Dr
Richard Pole, 53A Tipahi Street, Nelson. Fax: (03) 546 1680; email: richard.pole@actrix.co.nz
References:
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