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EXPERTS have warned that rural areas and lower paid specialties such as general practice are likely to find it harder to attract medical graduates if tertiary education costs soar, after Australian research found that domestic full-fee paying graduates have a preference to pursue urban-based, higher-paid specialties.
A study reported in the MJA found that domestic full-fee paying (FFP) medical graduates were more likely to prefer urban locations (odds ratio [OR], 5.58; 95% CI, 2.04–15.26; P<0.001) and higher income specialties (OR, 1.37; 95% CI, 1.07–1.75; P<0.05) and less likely to nominate in-need specialties like general practice than Commonwealth-supported place (CSP) graduates. (1)
Professor Richard Murray, dean of medicine and dentistry at James Cook University, said the finding of an association between high tuition fees and interest in urban, high-pay career choices among Australian graduates was “worrying, but not surprising”.
“This highlights the need for governments and universities to consider how unintended consequences of the proposed deregulation of university fees are to be managed”, he told MJA InSight.
The researchers analysed exit questionnaires of more than 4000 students who graduated from 2008 to 2011. Respondents included 408 domestic FFP and 3398 CSP students. The data were collected as part of the Medical Schools Outcomes Database and Longitudinal Tracking (MSOD) Project, an initiative of the Medical Deans Australia and New Zealand and funded by Health Workforce Australia.
Domestic FFP students comprise only a small minority of the medical student population at present, the researchers said, so the impact of these findings was likely to be minimal. However, the findings highlighted the potential workforce consequences of tertiary policy changes.
“If the number of FFP places is increased through changes in government policy or establishment of more private medical schools, strategies to increase the focus on rural and other underserved populations might be needed”, they wrote.
They also warned of the possibility that increased fees for CSP students could drive these graduates towards higher-paid, metropolitan-based specialties. “Such an effect might, however, be mitigated by continuing the apparently successful rural medical education initiatives that, although costly, are effective in promoting rural recruitment.”
Professor Murray said he was not necessarily opposed to students making a greater contribution to their medical education, particularly when urban-based, high-earning specialties currently attracted the most graduates. “Those folk have benefited from a publicly funded education.”
However, he believed targeted investment would be needed to achieve desired workforce outcomes, such as primary care and rural practice.
“Among other things, we are going to need investment in scholarships and debt remission in return for work in underserved areas”, he said. “Rural and regionally based medical education and specialty training pathways are going to be critical in efforts to address the geographic maldistribution of doctors. We can’t rely on ‘trickle out’ of graduates to areas of need."
James Lawler, president of the Australian Medical Students’ Association (AMSA), said the MJA findings emphasised the need to limit the number of domestic full-fee paying medical student places and consider the workforce consequences of university fee deregulation.
“Australia needs to train a medical workforce which emphasises rural practice and general practice; full-fee paying places for domestic students would be detrimental to this goal.”
Mr Lawler said the current federal government has not repeated a 2012 commitment to AMSA by the then Labor government to limit the number of domestic full-fee paying medical student places.
The findings also signal the likely workforce outcomes of the federal government’s proposed deregulation of university fees, adding to evidence from around the world that upfront education costs and student debt were determinants of graduates’ specialty choice and practice location, Mr Lawler said.
However, he disagreed with calls to mitigate the impact of higher education costs by expanding rural practice initiatives. “We welcome greater investment and focus on measures to expand rural practice initiatives; however, doing so in order to fix policies which draw graduates away from underserved areas is not logical.”
A spokesperson for Department of Health said the department provided a range of incentives to encourage GPs to work in rural areas including the HECS Reimbursement Scheme and the General Practice Rural Incentives Program.
If GP rebates are to be cut then shouldn’t every health provider using Medicare rebates also take a pro rata hit.
That means specialists would take over $10 reduction in their patient rebate.
I started medicine at age 26, after completing a combined economics/science degree & working for NT Treasury for 4years. I feel I have a fairly good understanding of the financial effects of being a mature aged medical student trying to support myself through medical school. I was fortunate enough to have only paid $2 500 per year in HECS for my first degree, and during my 4yrs employment premedical school paid off my $10, 000 HECS and started medicine with a clean financial slate. I had extremely supportive family, but they were not in a position to support me financially, hence I got through medicine on austudy and whatever work I could fit around medical school hours. I moved to Brisbane for medical school (previously having lived in Alice springs and Darwin) and found that I had to build at least 2-3hrs travel into my day being reliant on public transport & living in whatever accommodation I could afford (generally some distance from the university/medical school). I lived in over 6 different places in the 4 years & met some amazing people. I came out of medical school with a medical degree, an intern position in WA, a $10,000 personal loan, and a $36,000 HELP debt. I currently work in a remote/rural town where I have committed to living & am currently awaiting GP fellowship. On the whole i am glad I did medicine, have had amazing experiences (good & bad) and finally at age 38 i am starting to be in an ok financial position. My point is that we need to spare a thought for the people who have a passion for medicine, but limited financial support. I was lucky to do medicine when I did and am grateful to the taxpayers for subsidising it, however, the same decision in current circumstances would be financial suicide.
As a teacher and examiner for the University of Melbourne, Monash University and Deakin University, I have become hardened to the notion that the medical students have only a passing curious interest in Primary Care.
The first week of a six week block rotation is spent orientating the student to the structure and importance of Primary Care. Unfortunately, very few students consider General Practice as an option.
The feedback at the end of their rotation is mostly very positive, however one student failed to achieve a pass purely because of a lack of engagement at every level of the process. This student spent the time studying for the USMLE !
Late last year I was the mentor of a potential Fellow whom was approaching the FRACGP examination in March 2015. Soon after the Government’s fee announcement, he resigned from the program citing “there is no future in General Practice” and he has since decided to seek specialist training.
The writing is not just on the wall, it’s being written every day by the changes wrought by those whom have little understanding of the impact of their decisions.
Or perhaps, in my naivety, the intention actually IS to unravel one of the best Primary Care systems in the modern world.
But that would be too cynical.