more_vert
PRIVATE fee medical school placements have become common for Australian students, with costs of several hundred thousand dollars by the end of training not unusual. With large and increasing disparity of remuneration between GP and non-GP specialists, it is likely the resulting educational debt contributes to the current concerning decline in graduates choosing GP training. Additionally, the probable negative effect of such fees on the diversity of students and a meritocracy-based medical practitioner system is deeply concerning.
I was recently flabbergasted when a friend of one of my children was offered a postgraduate medical school place at a Victorian university at a cost of approximately $350 000. Over 4 years this was about $50 000 each year with a $150 000 residual in a Higher Education Contribution Scheme (HECS) type arrangement. Calculations based on a 5% interest rate loan paid monthly, mean that at the end of 4 years this would add up to about $400 000.
This young person is an Australian citizen, lives in Victoria, achieved an Australian Tertiary Admission Rank (ATAR) of over 99, a Graduate Medical Schools Admission Test (GAMSAT) of over 95 and excelled in a relevant undergraduate course at the same university. Of note, they come from a migrant, blue-collar family.
On exploration, I discovered this university now offers over one-third of its positions under the private fee-paying arrangements described above and mainly to Australians. Examination of several other Australian medical schools revealed similar practices and fees are now commonplace. Until now, I was under the illusion that such places were for full fee-paying international students who are not eligible for Commonwealth supported places, or in Australia’s few private universities.
I’m old enough to be one of the fortunate doctors who went through medical school in the post-Whitlam, pre-HECS years of no university fees. A number of us were children of blue-collar workers or single parents or lived in social housing. We chose our specialties because we were interested in them, good at them and they suited us. The philosophical platform of reasonable HECS for Commonwealth supported places, where the lifetime financial advantage of a university education is paid later when earnings meet a threshold, seems sound and hopefully not an impediment to student diversity and fairness.
However, such private fee-paying places absolutely distort a meritocracy-based system, the entrants we get and their subsequent specialty choices. I contend it’s also likely to affect the social obligation doctors feel towards their community, and their propensity and ability to undertake pro bono work and provide care to people and communities that are less able to pay.
The decline in GP training over the past two decades has been profound, with less than 15% of graduates now choosing GP training (here and here). This is of great concern, as for an effective sustainable and accessible health care system it is considered that at least half of medical practitioners should be GPs. Well established factors that influence this are the disparity of remuneration between GP registrars and other registrars, the declining real income of GPs and the rising disparity between GP specialists and non-GP specialists, with non-GP specialists now earning about twice as much as GPs, with this gap widening With future earnings having been found to be more important for the 33% of junior doctors reporting any educational debt, the influence of private fee-paying medical places on the decline in graduates choosing general practice as their specialty is likely to be significant.
The Australian Medical Association is advocating strongly for GP registrar equity in remuneration and conditions with non-GP registrar colleagues. It seems to me we also urgently need to go back to “the well” and address the obvious problem with private medical school places and the resulting educational debt on subsequent specialty choices. Additionally, as a profession and society, we should urgently reflect and act on the deeply concerning negative impacts this is likely to have on achieving diversity in medical school students and medical practitioners and in fostering a meritocracy-based training system.
Dr Ines Rio is a GP at North Richmond Community Health, and Senior Medical Staff at the Royal Women’s Hospital. She is Chair of North Western Melbourne PHN.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.
Yes I am from a public high school and would not likely have been a Doctor if not for Gough Whitlam. As it was I was from an outer urban area I had to live away from home and put myself through a University. Working weekends and all term holidays. Medicine would not have been considered if I had also to repay course tuition fees. I remember being down to my last 50 cents every Friday lunchtime.
1. Meritocracy disappeared long time ago in med school selection when rural quota was introduced 20 years ago. Those from rural areas need far lower scores to get in. Where is the justice in that? Its injustice to the students in metro areas.
2. Number of doctors per capita in Australia is higher than in most developed countries, yet we seem to be graduating and importing more doctors. This only means higher tax rates.
3. It doesn’t make any sense for GPs to complain of ‘low pay’ and that abhorrent phrase ‘workforce shortage’ in the same breath. Economics 101: its all supply and demand. Forget about MBS fees. If there were half as many GPs, GPs would be able to charge a private fees exceeding that of specialists’ fees. What GPs need more than anything is a lesson in Economics 101.
It’s important to note that such fee-paying courses were briefly banned (circa 2007), but the legislation only covered undergraduate courses. The solution to this legislation from universities such as Melbourne was to rebrand their degrees as MDs, thereby shifting the classification of the degree to graduate courses, which the legislation didn’t cover. All the better, they could charge students for two degrees!
The universities have a lot of explaining to do. That is where the real rot began.
The problem is even bigger: as a country we have become too dependent on migration of doctors and other health professionals to Australia, especially in rural and regional areas. As a developed nation we should be self-sufficient/migration-neutral. Surely the supply chain disruptions and closed borders has made this clear?
There are many children who would make good doctors (and nurses and allied health professionals) who cannot get a place in tertiary education because of costs and/or lack of places, or they did not get a high enough score to get a place but are bright enough to make good doctors and nurses. What happened to work force planning?
I am not against migration of health practioners, only against being dependent on migration to keep our health care afloat and the negative effect it has on low and middle income countries when large numbers of their health professionals migrate. Migration is great when it is balanced.
I am the child of a Holocaust survivor, driven to be a GP after Whitlam era uni support to pay back into the community. I wonder if the refugee children and those of migrants of our current era will have any such impulse, given their lack of welcome and the costs outlined here. Who will look after the 15% of us who will have diabetes in the future, those with OA, those with moderate mental health trouble, when I finally retire? I recoil from the picture of these moderate medical conditions being managed by expensive specialists, who over investigate compared to GP and who will drive the cost of our medical system into American spheres
Any time I complain about the poor remuneration of GPs, my retired physician father tells me ‘well you should have specialised’
Ines,
These figures are truly shocking. The scale of the private fees and the disparity in expected incomes between GPs and other specialist is certain to cause distortions in the choices that young medical graduates make.
Apart from causing a mal-distribution in choice of GP vs other Specialty, the risk is that a bunch of kids will end up doing work they really don’t enjoy just for the income. We know that doesn’t end well.
Good on you for raising this and hope you can taker it further.
Here here! We need to maintain the meritocracy. Kids from social housing, rural/remote areas and other disadvantaged groups know and understand their community – they have that ingrained sense of commitment to give back. Positive discrimination works to address workforce shortages – this is doing the exact opposite!
“Calculations based on a 5% interest rate loan paid monthly, mean that at the end of 4 years this would add up to about $400 000”
…but Ines, wouldn’t a large part of the interest ie the bit not covered by HECs, be compounding all the time and lead to a figure well Northwards of $400k?
I’m not sure exactly how it works
I commenced the Medical Course in Adelaide in 1965, my tuition paid by a Commonwealth Scholarship which was awarded from examination results in the Leaving Year ( matriculation ) . My parents were “ten pound Poms” who emigrated from Britain mid -1950s and would not have been able to afford to finance the course for me. Perhaps these types of scholarships could be re-introduced for deserving candidates, a kind of compromise between the free tuition of the Whitlam years ( ultimately unsustainable) and todays crippling HECS/HELP debts. I am immensely grateful for the foresight of the Menzies Govt in bringing in the Commonwealth scholarships which of course became redundant in the Whitlam years and were never ( to my knowledge) reintroduced.
1. This is the experience in the the US, not a system to emulate 2. If you pay for your education you feel less obligation to your community 3. the amount of money seems a lot to a student but defrayed over a 30year career it may not be much more than insurance however behavioral economics doesnt work that way 3.the changing ideology-driven structure of University funding has encouraged this situation to develop and is the root cause of the problem 4. The impact of this will always fall hardest on rural and poor urban areas , already lacking doctors.5. GPs should be paid more , I am a specialist and my wife is a GP !