Aniello Iannuzzi: What happened to merit?

INTERN allocations and the oversupply of doctors for training places will continue to be headline news for years to come.

Not only do we have the tsunami of graduates from Australia to accommodate, we also have the large number of international students graduating in Australia and overseas-trained doctors awaiting placement.

In the latest MJA a model was put forward that attempts to make the allocation process simpler.

The whole discussion over intern allocation is way too narrow and fails to take into account so many fundamental aspects of education, employment and workforce.

As we’re still in an Olympic mindset with the Paralympics under way in London, let’s use elite sport as an example.

To qualify as an Olympian, an athlete trains hard, competes for a place and gets picked if they are one of the best. In the arts the same principle applies, as it does in business.

Unless one is a rare breed of billionaire stock, in Australia we generally pride ourselves on hard work and a fair go to get us places.

Employers and Olympic selectors do not want a “schlep in booties” — to use a term borrowed from US humorist and doctor, Arlan Cohn, whose alter ego Dr Oscar London describes himself as the world’s best doctor — someone with talent, a good work ethic and some runs on the board.

So why do medical students and junior doctors feel so entitled to be treated differently?

All the discussions about intern allocation and training positions are about “fairness”, “rights” and, if I am not mistaken, a very strong sense of entitlement and self-declared excellence on the part of the graduands and recent graduates.

Nowhere do I see any discussion of merit. Why?

It is time that medical students and the profession get real about this issue. Law firms are selective about who they employ, dental practices and vets select the best graduates, and pharmacies also try to get their hands on the best young pharmacists to employ.

If you talk to any graduates from these disciplines, there is no assumption of entitlement to employment, let alone good employment — you prove yourself or miss out.

As politicians have scattered medical schools all over Australia, often with little thought given to availability of academics, infrastructure and job opportunities, the number of medical students has swollen. Twenty years ago, it was safely assumed that medical students came from the tip of the academic bell curve; however, once the numbers are doubled, mathematics dictates that this is no longer the case.

In the past 10–20 years most medical schools have abandoned a graded marking system in favour of nebulous notions of satisfactory/unsatisfactory or pass/fail. Over the years many students have told me they would prefer more exams and some “real marks” so they can better gauge their progress.

Say a student is diligent, intelligent and achieves a very high level of clinical practice at medical school. I fail to see the “fairness” of a system that allocates such a student to a lottery for an intern position, on equal standing with a student who fumbles and bumbles through university.

A common counterargument is that all the best graduates will congregate at a small number of hospitals. So what? Such competition is necessary among hospitals to genuinely establish cultures of excellence.

When you fast-forward 1–2 years after internship — to registrar allocations and specialist hospital appointments — the merit principle well and truly applies.

Given the number of medical schools and foreign doctors, a merit-based system would require a board-style exam such as the US Medical Licensing Examination. A simple system would be to modify the Australian Medical Council exams to achieve this.

Applicants would then be ranked on merit and employers could more confidently assume a minimum level of knowledge.

But, but, but … all the purveyors of political correctness will cry foul while many doctors will quietly cheer a return to some standards.

Dr Aniello Iannuzzi is a GP practising in Coonabarabran, NSW.

Posted 27 August 2012