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Why international medical students deserve a place in Australian hospitals

Amid Australia’s ongoing doctor shortage, the health system risks losing dozens of Australian-trained, foreign-born doctors because of a shortage of intern places. The Australian Medical Students Association…

Medical graduates need to complete a hospital-based intern year before they gain full registration. UoNottingham

Amid Australia’s ongoing doctor shortage, the health system risks losing dozens of Australian-trained, foreign-born doctors because of a shortage of intern places. The Australian Medical Students Association estimates the system needs 182 intern places to ensure all international students can finish their medical training and gain full registration as doctors.

These intern, (or post-graduate year one) places, are based in hospitals, which are run by the states. But the Commonwealth also bears some funding responsibility for medical training. The Commonwealth, state and territory health ministers are expected to discuss who should pay and potential solutions to the problem when they meet tomorrow in Perth.

Rise of international student migration

Over the past decade, international students have emerged as a prized and contested human capital resource. OECD and select Asian countries are expanding their international student flows, through global promotion strategies and regional migration programs, aligned with lower entry requirements, including for medical degrees.

International students have been immensely responsive to these migration options. In 1975, 600,000 international students were enrolled abroad, compared with 3.4 million in 2009. By 2025, it is predicted there will be 7.2 million international students studying globally.

A recent British Council survey of 153,000 international students confirmed opportunities for migration exert an extraordinary impact on the choice of study destination. While students sought a high quality, internationally recognised education, the scope to remain and work was found to “massively impact” both decisions and expectations.

In 1999, following the removal of a three-year eligibility bar, international students became immediately eligible to migrate to Australia. Within six years of the policy change, 52% of skilled migrants were selected onshore.

International medical students have funded their own studies to meet Australian requirements. PhotoDu de CreativeDomainPhotography com

By 2010, 630,000 international students were enrolled in Australian courses (all fields and sectors). Of these, 18,487 were undertaking health degrees, including over 3,000 medical and 10,000 nursing students. International medical student graduates grew 223% from 1999 to 2009, compared with 52% growth in Australian domestic graduates.

International medical students

In 2009, the majority of international medical students were enrolled at Monash, Melbourne, Queensland, New South Wales and Sydney universities. Their source countries were highly diverse – most notably Malaysia (1,134 students), Singapore (577), Canada (437), the United States (84) and Botswana (74), followed by South Korea, Brunei, Hong Kong, Indonesia and Sri Lanka.

These international students achieve stellar rates of immediate employment and are highly attractive to local employers. As demonstrated by yet-to-be-published research conducted for the Medical Deans of Australia, 45% of international students plan to remain in Australia when they commence their studies. By their final year, 78% accept intern places (virtually all those who are not scholarship students sponsored by their home governments).

Australia’s Graduate Destination Survey from 2009-2011 reveals their employment outcomes to be near identical to those achieved by domestic students (99.6% working full-time at four months compared with 99.7%). The source country was almost irrelevant, with 100% of Canadian, US, Malaysian, Indonesian, Taiwanese, Norwegian and Botswanan students fully employed, compared with 97% from Singapore and 89% from China.

International medical graduates

As affirmed by the OECD, Australia has developed extraordinary reliance on international medical graduates (IMGs), who gain their qualifications overseas.

By 2006, 45% of Australian residents holding medical qualifications were overseas-born, including an estimated 25% who were overseas-qualified. The United Kingdom/Ireland, China, India, North Africa/ Middle East, Sri Lanka, Bangladesh, South Africa and the Philippines were major sources of migration.

This diversification of supply has proven extremely challenging for Australia. The 2006 census shows just 53% of IMGs secured medical employment in Australia in their first five years of residence (across all immigration categories).

Doctors from English-speaking background countries moved seamlessly into work, while Commonwealth-Asian doctors fared reasonably. Outcomes were poor, by contrast, for many birthplace groups. Just 6% of doctors from China found medical employment within five years, along with 23% from Vietnam and 31% from Eastern Europe.

Australia is short 182 intern places. SydneyUni

Employment access is significantly better for IMGs selected through the 457 visa temporary sponsored pathway. From 2005-06 to 2010-11 17,910 doctors were sponsored as temporary 457 visa migrants to pre-arranged jobs, with a 99% immediate employment rate.

From 2004-05 to 2010-11, an additional 2,790 IMGs were admitted through the permanent General Skilled Migration category. But not all passed the Australian Medical Council examinations, which are a requirement for unconditional registration in Australia. From 1978 to 2010, 82% of candidates passed the MCQ (the standard theoretical examination), typically on their first or second attempt, along with 85% of clinical candidates. But overall AMC completion rates were just 43%, since many choose not to persist with the process.

Large numbers of IMGs face significant barriers to securing professional registration. By contrast, international medical students face no impediments: they’re of prime workforce age (far younger than IMGs) and have self-funded to meet Australian domestic requirements.

Medical students' future

We know that large numbers of international medical students wish to migrate to Australia – and access to intern places is critical for them to secure permanent resident status.

If Australia fails to retain these graduates, other countries will. Singapore, for instance, actively recruits in Australia, in a context where the nation’s fertility rate is incredibly low. New Zealand annually registers over 1,200 IMGs per year, but two-thirds will have left within two years. So there is major interest in attracting Australian-trained graduates.

If Australia is serious about retaining international medical students in the future, it’s vital to provide access to intern training places. While the students’ long-term intentions are unknown, it’s clear they have great potential to address Australian workforce shortages in the future.

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19 Comments sorted by

  1. Sue Ieraci

    Public hospital clinician

    Thanks for the article, Prof Hawthorne.

    You have covered the motivation for universities to seek fee-paying students, and their later career outcomes, but have not mentioned the impact of these learners on health care delivery.

    In industry circles, the current situation is know, perhaps unkindly, as the "medical student tsunami" - progressing to the "intern tsunami".

    Yes, there is a shortage (and maldistribution) of senior, capable medical staff. To get to that level, though, junior doctors…

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    1. Stephen Duckett

      Director, Health Program at Grattan Institute

      In reply to Sue Ieraci

      Thanks Lesleyanne. This is an important debate with much previous discussion very muddled.

      I think an important issue not so far covered is about the balance of benefits: to what extent is there a public benefit in providing these graduates with a salary and training for another one or more years and to what extent is there a private benefit. Framed in these terms, the policy question becomes about how to ensure the public benefit (and the public costs) are appropriately sized against the private benefits.

      Incidentally, the Commonwealth offer to meet 50% of the costs is not particularly generous or startling. They are already committed to meet 45% of the costs from 1 July 2014 anyway so the incremental cost for them is trivial.

      Stephen Duckett

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  2. Dale Bloom

    Analyst

    “Amid Australia’s ongoing doctor shortage”

    Hey?

    It appears there are enough doctors in Australia, it’s just that most are concentrated in urban areas, and have forsaken the rural areas.

    “At the moment the average rural GP earns considerably more than the average city MP so it’s not the lack of money or earning capacity that’s the problem, in fact they’d rather earn less and not have to work so hard,” Professor Dwyer said.

    https://theconversation.edu.au/money-not-enough-to-entice-doctors-to-the-bush-8740

    But why should rural people have to have foreign intern doctors?

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    1. Ulf Steinvorth

      Doctor

      In reply to Dale Bloom

      Thank you for calling a spade a spade Dale, your question illustrates rather succinctly the real issue in this discussion: It's not whether Australia has enough doctors, enough Intern places or whether they are trained well enough - it's whether they are Australian-born or not and to what extent foreign-born doctors working here are given the same rights and opportunities as Australian-born docs.

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    2. Sue Ieraci

      Public hospital clinician

      In reply to Dale Bloom

      Dale - you are confusing International Medical Graduates with fee-paying students becoming interns.

      Interns are in their first post-graduate year, having passed an Australian exam. That year is a pre-requisite to general medical registration, and has to be adequately supervised. Many interns go to large rural hospitals, but there is not enough supervision for them in small rural sites. Some of these interns might be fee-paying students from Canada, US or Malaysia (three currently common sources…

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    3. Andrew Smith

      Education Consultant at Australian & International Education Centre

      In reply to Dale Bloom

      Simple solution, penalise Australian born doctors (nurses etc.) educated in Australia who choose to work abroad as opposed to rural and remote communities.

      But that's not the point is it?

      In my experience almost everybody in a rural or regional community is happy to have an international or local fee paying graduate, though some do complain about communication skills of international trained doctors (dropped in deep end and appears IELTS not sufficient to assess workplace communication skills as it was designed for academic language purposes?).

      As my uncle in town observed, those who do not like or want to use international doctors (who are not white) are simply racist.

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    4. Dale Bloom

      Analyst

      In reply to Sue Ieraci

      Getting more government money to go to rural areas instead of it being so often squandered in the cities would help make rural towns more attractive to live in.

      The claim was made that Australia has an “ongoing doctor shortage”. However, according to WHO data, Australia seems to have slightly above average physicians per 1000 people compared to OECD countries, and very much above average when compared to poorer countries.

      http://apps.who.int/gho/data/?vid=92100

      The problem appears to be…

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    5. Ulf Steinvorth

      Doctor

      In reply to Sue Ieraci

      The Australian Medical Association seems to have considered Overseas Trained Doctors as the most promising strategy to fix the rural doctor shortage:

      'The influx of overseas trained doctors is the only reason that medical workforce numbers in rural areas are not in complete free fall.
      Up to 50% of doctors in some parts of rural Australia are now overseas trained - well above the 25% average across the country.'
      https://ama.com.au/amardaa-rural-workforce-rescue-package-fact-sheet

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    6. Sue Ieraci

      Public hospital clinician

      In reply to Dale Bloom

      Dale says "Getting more government money to go to rural areas instead of it being so often squandered in the cities would help make rural towns more attractive to live in."

      Did you read this one, Dale?

      https://theconversation.edu.au/money-not-enough-to-entice-doctors-to-the-bush-8740

      All professionals are scarcer in rural and outer metro areas - for reasons that are much more complex than money.

      The most successful strategy for medicine so far seems to be the rural medical schools, taking students from rural areas and also introducing urban students to rural life. Are any other professions trying this strategy?

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  3. Jane O'Sullivan

    Agricultural Scientist at University of Queensland

    This article sheds little light on the debate due to its omissions. Some of these seem contrived to bias the case for foreign students.

    It fails to recognize any connection between Australia’s immigration rate and its apparent shortage of doctors. There is no mention of the failure for hospital capacity in general to expand to keep up with population growth, let alone the hospital system’s capacity to take and supervise interns (as commented on by Sue Laraci above).

    If the population is growing…

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    1. Andrew Smith

      Education Consultant at Australian & International Education Centre

      In reply to Jane O'Sullivan

      Yes the "runaway population growth" bogeyman and immigration.

      Firstly population growth has a significantly component of temporary residents i.e. international students, temp workers and dependents (12/16 month rule), immigrants or new permanent residents are only part of that.

      The headline or quantitative figures have been used in the media to create alarm to the extent that the present government has become paranoid about perceptions of "big Australia", although the real estate industry does…

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    2. Jane O'Sullivan

      Agricultural Scientist at University of Queensland

      In reply to Jane O'Sullivan

      Dear Andrew,
      It's getting a bit off-topic to talk about population growth generally, but the cost of population growth is far greater than the cost of the small extent of ageing it can off-set. The case for ageing being a major economic burden is weak - although of course it means more demand on the health system (but less on several other sectors, and plenty of time to adjust). What's more, unless you think population growth can continue for ever, there must be a time when it stops and ageing…

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    3. Andrew Smith

      Education Consultant at Australian & International Education Centre

      In reply to Jane O'Sullivan

      You cited population growth in your original comment? I disagree with your opinion that the cost of ageing is or will be small? The cost of ageing will not just be in the health system but affect the work force, real estate, communities, baby boomers with dependents and (both) parents in care etc.

      Population growth internationally will stabilise by 2050 except Sub Sahran Africa, but again the definition of population (growth) does not include just immigrants but temps and Australian citizens…

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    4. Mark O'Connor

      Author

      In reply to Jane O'Sullivan

      Thanks Jane.
      You hit the nail on the head when you say:
      "No evidence is given of a shortage of equally qualified and motivated Australian school leavers. The government may think it is cheaper to fill medical schools with self-funded overseas students, but they fail to factor in the cost of providing the extra infrastructure that every extra Australian resident entails - around $200,000 per added person."

      I assembled the evidence on this issue in the book Big Australia? Yes/No, by Mark O'Connor…

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  4. Mark O'Connor

    Author

    Andrew Smith I must again object to your failure to identity your own vested interests when making comments on the supposed benefits of high migration rates. You should identify yourself as a migration agent. (The "AIEC" in front of your name does not do this for most people.) Your business interests are relevant information, which should never be suppressed on this forum.

    You were recently denounced as a troll, for this and other tricks, on The Conversation; and while your recent comments have been more cautious, they still show the same habits of "talking for victory", declining to modify your claims in the light of evidence, and maligning those whose arguments you can't disprove.

    (For Smith's prior history, see https://theconversation.edu.au/new-migration-council-to-fight-for-a-bigger-australia-7895 ).

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    1. Andrew Smith

      Education Consultant at Australian & International Education Centre

      In reply to Mark O'Connor

      I have never attacked anyone personally but have been attacked constantly by the "usual suspects" who cannot discriminate between arguments based on evidence versus what they perceive as attacks on their personal opinions and beliefs, much like a religion.

      I am open about my occupation and for your interest most Europeans are not interested in Australia, except for a visit for study or travel.

      For an explanation of the anti immigration and population growth alarmist lobbies, who obviously only…

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    2. Jane O'Sullivan

      Agricultural Scientist at University of Queensland

      In reply to Mark O'Connor

      (sorry about the reverse-chronology posts - this is a response to Andrew Smith's comments below. I do hope the editors restore the reply buttons on each post, as they have now said they will.)
      Dear Andrew,
      If the article to which you referred us for the 'facts' is your standard of evidence, you are evidently not applying the same level of scrutiny to the claims that support your view as you do to those that oppose it. Apart from being full of unwarranted attacks such as "the miserable anti-life…

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    3. Andrew Smith

      Education Consultant at Australian & International Education Centre

      In reply to Mark O'Connor

      Hello Jane, These are merely related general background for others who read these forums, and not specific data (that can be provided).

      You can also be more specific but you claim "its arguments are so full of factual errors and outrageous misrepresentations it's not worth responding to them." For example? It should be easy to counter?

      Where does evidence e.g. $200K per resident infrastructure come from? For example, an Australian using motor car, large house, frequent breaks/holidays etc…

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