Issue 33 / 27 August 2012

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

16 thoughts on “Aniello Iannuzzi: What happened to merit?

  1. Anonymous says:

    Appointment to a position is based on merit or “something else”. Whilst it is true that not all that counts can be measured – and certainly not all that can be measured counts – assessment by examination using objective criteria is as good a proxy as any. It may not assess attitude, personality, social consciousness or social “connections”; but these are, more often than not, subjective prejudices. With responsibility for the care of others attitudes change personality improves and the other two come to be seen for what they are. In 1956 Ludwig on Mises published “The Anti-Capitalist Mentality” which explains why so many hate merit in its objective assessment.

  2. Dr Julian Fidge says:

    A very disappointing, baseless article with non-specific, vague criticisms of the new vs the old.

    For the article to have any validity means the medical educators, who have pretty much universally done what Australia is doing now, have all got it completely wrong. Which is unlikely.

    What is more likely is that an older doctor, selected on the single value of an academic score, at one point in their very young life, feels threatened by the more comprehensive thought behind the selection and training of new doctors.

    Don’t forget, nobody has any idea of how to quantify a good doctor. So to advocate one group over another is nonsense.

    Dr Julian Fidge

  3. Anonymous says:

    If internships are critical to medical education, then students should pay for these in the same way they do for medical education. International students should fund their own internships if they want to be registered in Australia. Graduates should also be required to provide a return of service to underserved populations such as those in rural, urban fringe, lower socio economic areas following completion of all postgraduate training (after achievement of Fellowship of a specialist medical college). If you want the tax payer to fund your training, then you need to give something back to the public health system when you are fully qualified.

  4. Sue Ieraci says:

    Jonathan makes a good point: no medical graduate is able to be registered to practise medicine without an internship. The US system administers a licensing exam at the end of internship, but the Australian system administers ongoing assessment instead. Which is better – an exam, or twelve months’ continuous assessment by a range of supervisors? I would argue for the latter – there is no better assessment of both competence and performance than directly supervising someone on the shop floor.

  5. Jonathan says:

    Internship is a LEGAL REQUIREMENT to qualify as a doctor. Denying graduates an internship is the same as kicking dental students out of their course in their final year for no reason. How can the author not see the implied contract that exists between medical students and universities/hospitals/society to allow them to become a doctor if they pass the assessments?

  6. Current intern says:

    All discussions of merit based systems inevitably fail for political reasons when international students are brought into the equation.

    Who should get an internship spot: an excellent international student, or an above-average local student?

  7. R. Spencer says:

    I agree that our current system of medical training needs attention. With large increases in junior staff we are going to have a large imbalance between the number “teachers” and “students”. But I do not agree that graduands and recent graduates have a “very strong sense of entitlement and self-declared excellence.”

    “Why do medical students and junior doctors feel so entitled to be treated differently?”
    Dr Aniello Iannuzzi compares medicine to law, dentistry, vetrinary science and pharmacy. But medicine is clearly different. It is illegal to practice medicine in Australia without completing an Internship, in any capacity. A medical degree without an internship is useless, unlike a law degree, or any other degree you care to mention. Current medical students ask for nothing more than to be able to complete their training and obtain general registration. Merit systems do apply during university (and after); with students passing or failing, just like other degrees.

    And who’s to say the “tip of the academic bell curve” made the best doctors anyway?

  8. Anonymous says:

    As a current medical student I can say that most student would support a merit based employment system if it weren’t for two things: 1) Medicine is notoriously corrupt as a profession (even if everyone pretends it isn’t), a merit based system wouldn’t select the best it would select those with the most contacts and prettiest CVs, 2) A MBBS without an internship is absolutely worthless, without an internship we can’t even get registration. Unlike the US, Australia’s medical education system is an expensive tax payer funded enterprise, unless this investment is to be wasted we need to guarantee common-wealth funded domestic graduates an internship. As for international students, well maybe if they had a bit more merit they would have gotten into medical schools in their own country!

  9. Eddie says:

    I agree that with the increase in the number of universities in the country, it’s about time the AMC adopt the US style of one standard exam for all graduates and IMG’s.

  10. Sue Ieraci says:

    Dr Aniello says “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.” I recall the time when the highest university achievers went to the best-resourced inner city hospitals, while the underresouced outer urban and rural hospitals were seen as “second class” workplaces, despite their draining populations being more needy. It’s true that lawyers and accountants don’t have government sponsored guaranteed internships, but nor does our population have universal access to government-funded law or accountancy. I have supervised many hundreds, if not thousands, of junior doctors over thirty years – they are just as good and bad as ever – some academic, some practical, most a combination of the two.

  11. Anonymous says:

    Two hundred years ago, the Australian population was mostly convicts. We’re not so closely descended from them anymore. Times have changed.

  12. shaun says:

    “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.” This is not true.

    Twenty years ago the population of Australia was smaller. If the population increases, so does the absolute number of students 2 standard deviations above the mean.

  13. Anonymous says:

    A summary of the article with which I agree is that recent changes simply breed mediocrity which is counterproductive

  14. David says:

    As a profession, medicine in Australia has an enormous advantage over other professions because the intern and early hospital years facilitate the difficult transition from the largely theoretical activity of medical school to the practical activity of medical practice. It is apparent that medical students find the translation of theoretical knowledge to practice to be very difficult, a phenomenon that is not widely understood or acknowledged. Such a transition is not provided in other professions, such as the law, where placement may be on the basis of patronage, a phenomenon that is largely, but not entirely, absent from medicine.
    Intern and trainee years are therefore very important and they need to be spent in situations where quality training can be provided, which does not necessarily mean in a tertiary teaching hospital.
    Furthermore, comparison of (most) Australian junior doctors, with (many) overseas trained doctors confirm the value of the amount of clinical content in Australian medical schools and the system of hospital training and supervision. international medical graduates also benefit considerably from supervised hospital practice.
    These factors confirm the social value of intern and resident training and the value of provision of intern places for all graduates and if possible for IMGs.
    By all means, make allocation competitive, but do not make it an option before registration. We also need to avoid systems that reward factors other than merit and open the way for advancement by privilege and patronage, which lead to corruption and which therefore have a high social cost.

  15. Anonymous says:

    Some people are just lucky to be born in a different generation where universities did not try to get ahead by pumping out medical graduates. We were encouraged to enter a profession “in demand” but were not foretold that the job supply would be vastly unavailable. Many clinicians now reflect on how easy it was to secure a specialty training position. A bachelor degree qualified you to be a general practitioner. Colleges were begging residents to join their ranks. Now we just might have to content ourselves with half a decade more of residency. Less strain on the government that way!

  16. Anonymous says:

    I completely agree with you Aniello. Our current system has evolved and not been planned. We would not design the current system with medical schools and postgraduate training unlinked; funding for medical schools that has no relationship to the actual workforce requirements for doctors able to practice independently; the colleges making completely independent declarations of standards for training without coordination or evidence; the persistence of the “intern year” leading to general regaitration and the historical but ludicrous notion that this means that a general registered doctor can practice independently; and, as you say, the idea that all medical graduates are some how “entitled” to a job. Without a market for intern places there are no incentives for medical schools to improve their graduands. The support for the notion of full emnployment for medical graduands from the AMA is clearly about driving their membership up, and support from the universities is clearly about selling more medical student places, especially to overseas full-fee-paying students and the soon to come unregulated “MDs”. No where is there any consideration of what the nation and the community actually needs in terms of overall health service delivery and care. We need a complete overhaul of the the medical training pathway that produces doctors able to practice independently, including determining what a “doctor” should do versus what can be done by lower qualified and cheaper practitioners under medical supervision, the funding drivers for training and service delivery, and the roles of medical schools/colleges/the public sector/the private sector in these. But this won’t happen because no government has the courage to do it. Only a financial crisis of the scale of Greece could provide the need for such a review. In the mean time, while we can afford to pay for an increasing proportion of GDP going to illness care, the medical lobby groups (AMA/colleges/medical schools) will continue to shroud wave so as to retain the status quo, and governments will continue to shy away from any truly difficult and reforming decisions.

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