*Medical Student, ANU
Professor Frank Bowden wrote in the Sydney Morning Herald on the 11th of September 2009 about the balance between appropriate working hours for junior doctors in order for them to acquire sufficient training and experience, and the potential safety and quality of care issues surrounding junior doctors working increased hours while inexperienced, fatigued and stressed. In the latter part of his article, Professor Bowden rounded onto the real crux of the situation facing junior doctors leaving medical school in the coming years; that there is in fact going to be a glut of graduates released into the workforce with too few senior practitioners to provide training and too few hospital positions to accommodate graduate numbers.
To members of the public, there is no cause for alarm here. The quality of education Australian medical students receive in 2010 is as strong and all-encompassing as it ever has been. There is arguably more content being taught to students in their medical degrees than in previous decades if you consider the additional medico-legal, population health, psychological and evidence-based-medicine aspects of our training.
To upcoming graduates of medical programs, there is cause for alarm here. Without adequate training and hours spent in hospitals in the early and crucially formative years post-graduation, there can be no guarantee that what qualified as a resident 20 years ago will parallel what qualifies as a resident in 2010. Here are the facts; there are 3400 medical students who will finish their university education in 2012 seeking internships in 2013, whilst at present there are 2030 internship places currently available in Australia1. The reason for this disparity is the huge increases in medical school intake quotas and the opening of new medical schools around Australia since 2004. Tiffany Fulde, the former president of the Australian Medical Students Association (AMSA) announced in October 2009 that unless the urgent issues surrounding placements for medical graduates are addressed expeditiously “this medical student tsunami will strike us unprepared”1.
In order for Australian medical schools to increase student numbers a major source of funding has been sourced from a growing body of international students. Currently 19% of Australia’s medical students are international, increased from 10% in 19992. It would seem that the primary purpose served by international students is to prop up universities who are unable to attain adequate levels of funding from state and federal education budgets3. The annual fees of an international student to attend medical school in Australia may exceed $40 0003. This may seem like a lucrative solution for under-funded medical schools if it were not for the problem of finding internship places in Australia for these students after they graduate. In 2010, not a single international student was granted an internship position in NSW4. This hardly seems fair given the amount of time, energy and money these students have contributed. However, this is most likely a portentous sign of things to come. First it will be the international students who miss out on intern places, and then it will be the local students.
The years of studentship in medicine do not pass by breezily amid a constant process of examination, evaluation and re-evaluation. One important difference with today’s medical students that separates us from our senior clinicians is that we pay more for our degree today as do all other non-scholarship students in Australian university courses since the introduction of the Higher Education Contribution Scheme (HECS). This is pertinent to the profession of medicine which asks of its members to act altruistically at all times; that is, to put the priority of the person under your care ahead of your own. If you combine this with the fact that most medical courses are post-graduate entry programs, requiring that every student must achieve a bachelor degree or higher qualification before commencing medicine, the present day medical student must have a firmly focused desire to enter into a medical career before they embark on this very long unpaid journey. As the pressures of starting a family, buying a home, funding your studies and living costs (many students often move inter-state to attend hotly contested university placements) begin to mount before a cent has been earned in your chosen career, there is a lot of time to consider the possible ways to circumvent the debts and rectify the lifestyle sacrifices that have accumulated over the years. A backlash may occur in the behavioural trends of doctors as the incentive to repay the community and government that supported them is replaced with a desire to self-serve. New doctors will be more conscious of the need to earn as much money in as little time to off-set their debts. This will cause under-staffing and under-resourcing in areas of need.
The most recent estimates from the National Health Workforce Taskforce are that Australia has a shortage of 4500 doctors5. Whilst the rationale behind increasing medical student numbers to amend the shortage of doctors observed in Australia is sound, there must now be execution of strategies to increase post graduation training places to preclude a situation in which we are left with medical graduates who are unable to practice despite the clear requirement for more doctors in Australia. Dr Andrew Pesce, president of the Australian Medical Association (AMA) recently expressed his fears that Australian graduates will be forced to travel overseas to complete their training5. This is the direct opposite outcome of what the government originally set out to achieve.
Former Prime Minister Kevin Rudd labelled the Australian healthcare system to be “universally bleak”6, which may be for a host of reasons. However, was it beneficial for Kevin Rudd to label this huge section of the workforce a wasteland? This is not going to attract potential nurses, technicians, orderlies, laboratory staff, administrative personnel or any individual considering a career in healthcare. With a large proportion of the population approaching retirement age and carrying the associated health issues this period of life brings, the priority of federal and state politicians should be to rally the workers of the healthcare system. This would reinforce the value of being a healthcare worker in the community.
The 2010 federal election failed to address the internship crisis in any direct way. In fact, on the combined web pages of the Australian Institute of Health and Welfare (AIHW), Australian Labour Party (ALP) and ‘yourHealth’, a website setup for people to share their ideas on health reform with the government, the word ‘intern’ is not mentioned once7-9. The government’s focus is on increased training positions for General Practitioners and Emergency Medicine staff, which occurs one to two years after internship. This reflects the government’s band-aid attitude to health policy, failing to see the training process in full.
The combined Deans of Australia’s medical schools have supported a move towards a capping on medical student numbers, such that they remain frozen until an adequate number of internship places have been established10. Australian universities have undertaken massive reforms to increase the intake of medical students receiving training around Australia in order to address the dire shortage of doctors in the current health system. Now it is the turn of the hospitals’ to undergo reforms to complete the next step in the process.
Private hospitals represent a significant potential resource for graduate positions. As it stands, private hospitals account for more than 40% of hospital admitted patients and perform 64% of elective surgeries in Australia11. This affects junior medical staff as they effectively miss out on the benefits of observing and assisting in the treatment of a huge portion of patients. Furthermore, based on the anecdotal experience of my colleagues, the patients within private hospitals are often just as willing to assist in the learning process of medical students and junior doctors. Tapping into the private hospital patient and clinician pool must become a viable option to aid students and junior doctors in their learning.
Another possible solution to the increased number of medical graduates and the potential limited exposure to clinical learning would be to make use of patient simulators. The use of these for students and recent graduates may be a viable tool for education and gaining experience in many clinical situations. Simulators may be more cost-effective than other alternatives and allow inexperienced doctors to make ‘mistakes’ without the weight of real-world consequences befalling them.
In any event, the prospects of medical students in Australia as they move into the workforce are justifiably comparable to a natural disaster. The waves of graduates about to leave universities around Australia are keen to contribute to the health system to the full potential of their ability, it is only appropriate that the hospital systems accommodate and reciprocate this feeling.