Should medical intern policy just be about numbers of places?

Worrying about the number of medical intern places means we have lost sight of health priorities. Al Power

The issue of training places for new medical graduates was again in the news last week when Health Minister Tanya Plibersek announced A$8 million to expand medical intern places in rural private hospitals. The measure is targeted at overseas students completing medical degrees at Australian universities.

This is just the latest in a long, sorry saga of patch-ups for the disjunctions in responsibility for various elements of the medical training pathway.

Episode by sorry episode

It all started with perceived shortages of medical graduates (especially in rural and remote Australia), which led to the creation of new medical schools and dramatic increases in enrolments.

After a decade of increasing enrolments of domestic students (a commonwealth government responsibility) and international fee-paying students (a university choice), graduations have grown faster than medical intern positions (a state government decision).

This bulge of graduates has created an employment-graduation imbalance in medicine for the first time in Australian history.

Last year’s story was medical graduates’ inability to find internships. After years with outstanding intern vacancies, the crunch had come and not enough internships were available for all graduates.

The internship year is officially called PGY1, post-graduate year one, signalling that it is but the first year of a longer period of post-graduate training.

And the next instalment in the saga will take place later this year as the bulge in the medical pipeline makes its way through the system.

Although only one year of internship is required for full medical registration, in the past most medical graduates have undertaken a second year of hospital-based experience (PGY2) as a prelude to specialist training (PGY3+).

So the 2014 claim will likely be that there are not enough training places for the interns to get specialty training.

Stephen Duckett

Wrong direction

The recent claim from the president of the Australian Medical Association that full fee-paying international students are being given priority in some states over interstate, but nevertheless still dinky-di, Aussies is true.

But it begs the question of why states should choose interns based on their country or state of origin in the first place. Does a state health system “owe” its medical graduates jobs?

Very few fields of study or work come with such an expectation of entitlement. Perhaps the hospital intern process should prioritise interns who would best serve the health of their population.

Assuming that many international graduates will seek work in Australia, it seems arbitrary to put them in second or fourth place if they are better candidates than domestic students.

A better way

Surely, there are better criteria as far as health system needs are concerned. These include:

  1. Academic merit, as measured by marks in academic subjects.
  2. Clinical skills, as measured by marks in clinical subjects.
  3. Patient empathy, as measured by marks where this dimension of performance is assessed.
  4. Likelihood of remaining in the state or territory, as measured by where the student graduated or where she went to school, or both.
  5. Likelihood of working in an area of workforce shortage. This could also be measured by where the student went to school, or in an interview, although it can be difficult to ascertain a graduate’s true intentions in a competitive selection process.
  6. Finally, full fee-paying students should be given preference as a way of encouraging the development of an international medical education industry, and pulling together enough funds to continue subsidising domestic students.

The first five criteria are likely to be more relevant to patients and population health than the place of birth of the doctor. The final one is relevant to universities struggling to fill funding shortages and to states that need more doctors.

It’s clear that, in some states, international students who graduated from the local universities are considered before graduates from interstate universities. Minister Plibersek’s announcement about extra intern positions was welcomed by medical deans but it leaves the bigger questions about intern selection unaddressed.

Surely, the more important issues are less about which (potential) doctors to put first, and more about how to prioritise patients in the selection process.

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