Issue 21 / 4 June 2012

HUNDREDS of students graduating from Australian medical schools this year may not get an internship in 2013.

The Australian Medical Students’ Association has been concerned for years that the rapid and sustained increases in medical student numbers would, at some point, lead to the clinical training system failing to provide sufficient internships for graduates.

The number of medical graduates has rapidly doubled from 1633 in 2006 to this year’s predicted 3512. With the lack of adequate workforce planning over a number of years, it’s no wonder that our health systems are struggling to keep up with graduate numbers.

In 2006, and again in 2010, the Council of Australian Governments (COAG) guaranteed “to provide high-quality clinical placements and intern training for Commonwealth-funded medical” students.

Despite these guarantees, it is concerning that many state agencies have advertised fewer internship positions than the estimated number of domestic applicants. In these states, the job prospects for Australian-trained international students are even more alarming.

International students, who make up about 15% of graduate numbers, are not guaranteed an internship in any state or territory, and are generally prioritised after domestic students in the allocation systems.

Our estimates show that, overall, 456 medical graduates will not gain an internship that is required for full medical registration, and will therefore not be able to work as doctors in Australia. As domestic students get first allocation, it will be international students who will bear the brunt of this lack of places.

Many of these students will be forced to seek internships overseas after being trained specifically for the Australian health care system and the complex medical needs of its ageing population.

The prospect of medical graduates not being able to continue training in Australia represents an appalling lack of workforce planning by governments and universities. It is concerning on a number of levels.

First, producing medical graduates without jobs will not solve the shortage and maldistribution of Australia’s medical workforce, and will leave graduates unable to serve communities in need.

The recent Health Workforce 2025 report predicts a modest undersupply of doctors by 2025 in a range of likely scenarios. It also highlights that Australia’s current reliance on overseas-trained doctors goes against many conventions to which Australia is a signatory.

We are now in a ridiculous situation where, on the one hand, Australia produces more doctors than internship positions, forcing doctors to continue their internship training overseas, yet, on the other, we continue to rely on vast numbers of overseas-trained doctors to meet Australia’s health needs.

Second, significant federal, state, university and private financial resources go into training a medical graduate, all of which is wasted if that graduate cannot practise. The waste of immeasurable and valuable clinical resources is equally significant given the various pressures of increasing student numbers.

Third, this situation has significant implications for the sustainability of Australia’s medical education sector. As many of those students likely to miss out on internships are international full-fee paying students, a loss of confidence in graduates’ ability to continue training in Australia may precipitate a decline in demand for international full-fee places at Australian medical schools.

Many medical schools are significantly reliant on international student revenue, the loss of which may have severe consequences for the quality of medical education in Australia.

Progress on this issue in the coming weeks will be critical for those medical students concerned about their future careers.

Sufficient funding and support must be provided to health services to ensure that the maximum number of quality internship positions is available for Australia’s medical graduates.

It will not suffice for university medical schools, and state and federal governments to simply blame each other for the problem and hope that it will somehow resolve itself.

Governments and their agencies must recognise the significance of failing to provide medical graduates with internships and the ability to continue the training that is needed for Australian medical school graduates to fully participate in Australia’s future medical workforce.

Mr James Churchill is the president of the Australian Medical Students’ Association.

Updates on the internship crisis are available the Australian Medical Students’ Association website. AMSA has also started a petitionHealth Ministers of Australia: Train the doctors Australia needs.

Posted 4 June 2012

22 thoughts on “James Churchill: An intern crisis

  1. valkyrie20 says:

    On the question of priority, I agree that Australian trained doctors should continue to be given a preference over non-Australian for all the virtues mentioned. As far as I know, this preference has been in place for a long time: State trained Aussies, outside-State Aussies then non-Aussies , and finally IMGs. This rule has been in place for a long time. The problem with the mismanagement of new intern positions is a new one.

  2. valkyrie20 says:

    It is interesting to read how the entire issue had shifted to the non-Aussie trained IMG and fee paying interns, when the real “enemy” is not these, but the mismanagement of workforce and funds, which is now even more apparent in Queensland. Queensland Health is proposing a freeze in wage annual increment on doctors and a removal of overtimes and recalls, which in turn will impact on all our wages. Having worked in Victoria and Queensland for 6 years now, I can reassure most of you that the pie is large enough for everyone , as I am sure some of you will agree. To achieve this lies in the correct management of resources which the govt badly needs.

  3. Rose says:

    Fee-paying interns-a good idea- may expect better training and less responsibility than paid interns-who will train them?. Another option is to increase interns as Julian suggests, which could be funded by a reduction in overtime for existing interns – could someone study the existing overtime paid to all interns to see if this is feasible? While Rob has a point, award wages are now a fact, so we need to look a budgets and try to increase training places within the budgets , because rural Australia is short of doctors.

  4. T says:

    Dear S,
    I do sincerely hope you will be graduating from a top tier Medical School!
    The majority of the increase in interns do not actually come from International students, but from both full fee paying and supported domestic students. This comes with the opening of various new medical schools around the country which have generally less stringent entry requirements than some more established schools.

    Last I heard there is a medical school which actually accepts students who have failed the GAMSAT. And yes these are the domestic students who you will be competing with. But if you are in a state that judges via merit, you shouldn’t be worried; unless you happen to be in NSW, then I wish you luck in the ballot to come!

  5. Physician Perth says:

    Providing intern jobs is the tip of the iceberg. The majority of graduates are entering physician training with the RACP now the biggest provider of post graduate medical training in Australia. There are insufficient advanced training positions for doctors who pass the FRACP part one meaning that after four years of post graduate training, doctors could find themselves without ongoing employment. The RACGP should be training more GPs but have failed to do so. The RACS has made little effort to increase training positions and to be honest there are insufficient surgeons and specialist physicians in the public sector to provide adequate training anyhow. The medical students who miss out on intern positions should count themselves lucky as they can seek alternative employment before exposing themselves to four years of fruitless post graduate training. Rather than committing your lives to the treatment of your fellow man, drive a truck on the mines. You’ll be paid more, have less responsibility and have guaranteed time off work. Invest your money wisely and you can retire at 50.

  6. Syd Bell says:

    Can anybody else remember that when the medical course was shortened and the hospital residency extended from 1 to 2 years wasnt the first year internship supposed to be 50% working and 50% continuing education? Certainly at the hospitals I attend this does not happen and the interns are lucky to get one hour a week formal training. From my point of view they need a lot more than this but if the commitment was honoured there would be no shortage of places.

  7. Peter B says:

    Seems to me the above issue is a strong argument for reducing or elliminating the IMG 10 yr moratorium, especially for graduates of countries like NZ (with which we have some shared colleges for heavens sake), also Ireland, UK, Canada… as these docs have done their internships and don’t need to take up a training place, and are ready to go out to work at the coal face where they are still under-doctored, but resent being coerced into this. I know if the present laws had applied when I came here from NZ in 1989, I would just not have come – full stop. Yet I have rendered (still rendering), full time GP care, for the last 23 years, and I did not cost Australia one cent to train. Isn’t it a no-brainer, as they say…?

  8. Brisbane GP says:

    A second bite of the cherry …. There is a bit of misonformation here. Overseas students come to Australia to Medical School for many reasons. But the bottom line is that many CANNOT go back to their country of origin for internship, as they are regarded as foreign graduates. I doubt that universities, when taking their money, inform them of this – that you won’t get internship here, and you won’t get one in your home country. The issue here is lack of planning from governments who respond to a politically popular vocal push. And then the universities jump on the bandwagon.

  9. Jono says:

    As a doctor working in Western Australia’s public health system in both metro and country areas it is plain to see almost 50% or so of our junior medical officers are not domestically trained. A large number of the roles being filled by these doctors are more than suitable for provisionally registered interns with fantastic supervision of both registrars and consultants.

    The flow on effect by employing international doctors from the third world (stealing them from countries that need them more than us) either remaining career RMOs or as registrars and blocking career-minded local graduates is a phenomena that is repeating itself over and over. Our metro hospitals are full of now general registration overseas trained doctors with citizenship/residency who have not desire to continue there education become GPs/specialists.

    I do not understand also why we continue to rely on and train UK JMOs to prop up our medical system (they have done the same thing over supplying JMOs), when a large amount of them are only here for a short term, have no long term aspirations to remain in Australia. When us as Australians who would like to gain additional experience in the NHS are blocked.

    The general public wants locally trained doctors they are sick to death of doctors who have no understanding of our colloquial expressions, culture and communication needs.

  10. S says:

    Daman Langguth I think you in fact are the misinformed one. Yes originally students may have not been aware about the internship shortage (as in the ones currently graduating) but there is definitely ample information available now for international students yet they still queue to enrol in Australian universities and expect the Australian healthcare system to accommodate them at the expense of Australian citizens. Considering the cost of an MBBS in Australia is in excess of half a million it can hardly be said that these 552 international students are “less well off” not to mention that a significant number of these students are Canadian hence the closer than USA idea doesn’t hold true either. I agree its immoral for Australian universities to continue taking international students when internships aren’t available but why should the careers of domestic graduates, such as myself, suffer because of their greed?? Last time I checked the purpose of Australian medical schools was to provide Australia with a competent and self-sustaining medical work force, not to sell degrees to the wealthy but not so smart of the world.

  11. Kevin B Orr says:

    After WW11 there was a great increase in the numbers graduating in medicine. Those discharged from the forces, having matriculated, were allowed to enter any faculty they liked. So from 250 graduates one year the numbers rose rapidly to 750 with consequent need for more intern positions, though not compulsory then. This was partly overcome by having interns working in small country hospitals for the first time and increasing the number of city intern jobs with the extra living out and not being paid. I certainly learnt a lot from my intern post in Grafton and was not deterred from eventually reaching a senior surgical position in a teaching hospital.

  12. Senior Medic says:

    A lot of foreign trained doctors have worked in the Australian system for over 10 years and understand the system well. Many are also foreign trained specialists and have passed the local AMC exams. Surely these AMC certified foreign doctors are more experienced and qualified than a first year Australian graduate and could be given provider numbers (like a first year Australian RMO) with the proviso that they “teach”/”supervise” interns as part of their CME? This will solve the intern supervision shortage and make use of the foreign talents we accept.

  13. daman langguth says:

    Anonymou S is seriouly misinformed. The students are not aware of the low chance of getting intern places, why would they enrol pointlessly. In addition, Australian degrees are cheaper and we are closer to Asia than the US. Students who are less well off may choose Australia, and they ofeten think that the training may be better, righly or wrongly.

    I agree with Valkyrie20, most of us with any cerebral function realised the training place problem, and it doesnt stop with interns. There do not exist enough suitable training places to cope and there never will as the states try to cut services and the feds want to drive down the cost of health care (and encourage the populace to see underqualified pseudo-docs

  14. S says:

    Why is it considered such a travesty if international students don’t get an internship position? As far as I am aware, they are full informed about the prospect of getting an internship in Australia before enrolling (and if they weren’t initially, new students definitely are) and yet we still have no problem filling international spots. Why should domestic graduates receive a poorer clinical experience during internship in over staffed hospitals so that we can accommodate non-Australians who’ve brought their degree?? The simple fact remains, these students weren’t smart enough to get into medicine in their own countries so why do we want them working in Australian hospitals.

  15. C says:

    last week we had 6 new medical students turn up to our, as usual, very busy Emergency department. Supposedly we are now expected to train them. Surprise suprise, planning has been very poor and the clinicians are meant to be happy to carry the burden !

  16. Valkyrie20 says:

    The problem which was raised has been an issue in the past 3 years and has been forecasted to worsen, not just from the perspective of interns but trainees as a whole. This has been highlighted in the Royal College of Surgeons workforce analysis, which describes the situation now as a ‘crisis’. The responsible authorities make it sound very complicated and is quite adamant that the current problem stems from everything else, but their lack of creativity and organization. To illustrate this, we in a medium-sized district hospital, have 2 SET, 6 PHO, 3 residents and only 1 intern looking after 5 surgeons, 2 of them are part-time. The disproportion of junior:senior ratios doesn’t make sense. The hospital can clearly put more interns and less residents. The workload is certainly there, but the hospital refused to pay them. To top things, residents and interns aren’t allowed to cover nights because they need a ” senior” person present. Real reason : money.

  17. Camilla Andrews says:

    Agree totally, Dr Fidge. In any other situation it would be regarded as an abusive relationship. The AMA is slowly recognising this, but historically has left its young out on a cliff to survive or not.

  18. Rob the Physician says:

    Well…! this situation, to those who have been ‘in the system’ long-enough, was totally predictable. And that being due to too many medical schools, too few training positions and those training working a “ridiculous” 40-hour week…… get-real boys and girls – “you work ’til it’s done”!!
    No wonder it is taking 50% longer to train our professionals!!!

  19. daman langguth says:

    Universities have created this problem, and should be seeking to address it. Of course they will not as they do not respond to the laws if supply and demand.
    Foreign full fee paying garduates should of course be returning to their home country as this is what was intended, otherwise they will displace Australian graduates.

    Only when it comes back to bite them (when O/S students stop coming) will the unis reverse their policies. Although the attempts to create “MD” medical degress will continue I shoud suspect. Government needs to make clear if these students will be ever given internships.

    On the bright side, perhaps like Germany we can use these medical students who have had thousands of taxpayers’ dollars spent on them as taxi drivers with medical advice.

  20. Brisbane GP says:

    I am intrigued that this has suddenly become a “crisis”.

    Many of us looked years ago when the Commonwealth started dramatically increasing medical school placements, in response to trendy vocal minorities, and asked where these increased numbers would find internships. The glib Cwlth comment was that this was a State function. And so with head-in-the-sand aplomb, it was left there, without consultation with the States. Numbers went up dramatically, and now we reap what we sow. The Commonwealth offered increased funding for places without planning internship and training places. But this has been known forever. It was sticking out a mile at the start. The blame should be sheeted where it lies – with the Commonwealth and with those who for their own reasons have offered the increased places.

    There is a further factor. University funding was altered and the Universities threw the door open to full fee paying students – basically to get money. This adds to the clogup.

    It is not the job of the States to bail out either the Commonwealth or the Universities who have both acted with poor advance planning and from their own motives.

    My own personal view is that the time is long overdue for health (as well as education, BTW) to become a Commonwealth responsibility, and thereby establishing some uniformity of standard and performance, and also the taking of the responsibility for the situation they have created.

    The crisis is only for those involved and their own future careers (it is tremedously sad that governments have toyed with the future of the young for such political reasons) – otherwise we reap what we have sown.

  21. Dr Julian Fidge says:

    The hospitals can easily accommodate about 125% of their existing interns, and should do so.
    Most of us will remember trying to care for 50 patients, and the danger and stupidity of the rostering. Completely pointless, as no-one learns anything more after about 6 hours at the pace an intern or resident works.
    In Wangaratta, Victoria, residents are STILL rostered on from Friday morning to Monday afternoon, despite my frequent protests.
    The patients and junior doctors will do much better if we reduce the workload of interns and spread the work around.
    Morally, ethically, professionally or whatever criteria you wish to apply, the correct course of action is to increase the number of junior doctors and decrease their workload.

  22. Michael Coglin says:

    If fee-paying undergraduates from both Australia and overseas are prepared to pay $45-50k in fees to a University, what is wrong with a fee-paying internship? Hospitals could be paid $50k by fee-paying interns to create supernumary internships which met accreditation requirements.

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