Australian Doctor: Storm Warning – A lack of intern places is clouding the future

Australian Doctor: Storm Warning – A lack of intern places is clouding the future

A lack of intern places is clouding the future of medical students and graduates, but what’s the solution?

Two very different disasters dominated my Twitter feed last week.

One was Hurricane Sandy, dubbed “Frankenstorm”, as it battered the east coast of the US. The other was the intern crisis affecting Australian-trained medical graduates, which is whipping up fears among medical students across the country.

About 155 international students are set to miss out on an internship in 2013, and there are warnings it is just the tip of the iceberg.

Domestic students whose graduation is still years off fear there will not be enough intern places for them when the time comes.

In Sydney last month, students hit the street in protest, wearing scrubs and waving placards saying: “Keep Australian-trained doctors in Australia”.

But weathering this particular storm is not going to be easy. The number of graduating medical students has doubled from about 1500 a decade ago to more than 3000 this year. By 2016, the figure is expected to reach almost 4000 annually.

The squeeze on training places is also likely to be felt further down the training pipeline, with future shortages of post-internship and even specialist training places predicted.

A failure to plan for clinical training in the past is now haunting the present and the future.

Robbing Peter
It seemed like a breakthrough had been reached in late September when Federal Health Minister Tanya Plibersek offered $10 million to create 100 new intern places in private hospitals. But then the fine print emerged.

The money was to be taken out of the budget for the Prevocational General Practice Placements Program (PGPPP) — a highly successful, growing initiative already providing placements for interns in general practice. Robbing Peter to pay Paul was the way many GP leaders saw it.

The money was a one-off deal, not to be provided in subsequent years. The promise was also conditional on the states providing the remaining positions — something they are refusing to do, saying public hospitals are already at training capacity.

For Rob Thompson, a third-year federally supported medical student at the University of Western Sydney (pictured above), the stand-off between the states and the Federal Government does not bode well.

“I don’t graduate until 2014 so there’s still time for something to be done, but if governments can’t take the first steps now to secure places for those international students, it doesn’t pose much hope for the future,” he says.

Solutions in sight?
If public hospitals are already at training capacity, what other solutions might there be? Here are a few possibilities:

1. Make a general practice rotation mandatory for all interns
Professor Simon Willcock, formerly the chair of General Practice Education and Training, put forward this proposal more than a decade ago and remains strongly in favour of it.

Also supportive is Professor John Dwyer, emeritus professor of medicine at the University of NSW.
“We are far too hospital-centric in our training and in our health system … I’d be calling for three months in a community environment,” Professor Dwyer says.

If mandatory rotations in general practice make such good sense, then why is the government considering stripping $10 million out of the budget for the one national program training interns in general practice, the PGPPP?

Ms Plibersek has justified the cuts by saying the program was under-subscribed last year, but RACGP president Dr Liz Marles remains critical.

Dr Marles says — and the Department of Health and Ageing’s own annual report acknowledges — that all 975 PGPPP places are expected to be filled next year. This year was an anomaly as the program had to rapidly train up new supervisors to meet demand, according to Dr Marles.

Dr Rashmi Sharma, whose Canberra practice takes on five PGPPP interns each year, says the program has been a huge success.

“When PGPPP first started, the hierarchy said ‘What will they learn in general practice? Just coughs and colds’.

“But the interns I speak to now say they are managing patients for the first time. They’ll say: ‘I managed my first case of diabetic ketoacidosis and saw that patient every week for 10 weeks.’

“In the hospitals they were left to fill out forms, not doing any critical thinking.”

Not everyone is excited about the prospect of more general practice-based training.

Mr Thompson says he’s got his heart set on being a proceduralist when his studies are completed. Expanding training into general practice doesn’t help him. But Dr Sharma disagrees.

“For those who don’t become GPs, they still get that appreciation of life on the other side.”

She says governments needs to invest more in helping practices take on interns — through both infrastructure grants and greater incentives for supervising, which are presently insufficient.

2. Put interns in private hospitals
The Federal Government has already announced its intentions to go down this road for next year — a move applauded by students and the AMA.

Catholic Health Australia says its large private hospitals could provide sufficient experience in emergency medicine and intensive care.

But Professor Dwyer is concerned.

“An internship in a private hospital where there isn’t complete registrar coverage 24/7 is going to be far inferior to working in a public hospital where there’s either specialists or registrars you can talk to all day, every day,” he says.

Professor Willcock is more optimistic. “Absolutely, the private hospitals must be part of the solution — so long as they can be accredited to the same standards as the other hospitals.”

Mr Thompson is also supportive. “It’s definitely a sound idea. My one concern is because private hospitals often have a lot more elective procedures it skews what you get exposed to. It should be one attachment, not your whole internship.”

3. Send them to the bush
The picture of rural Australia opening wide its arms to interns has gained warm support on Twitter.

“Rural docs and rural patients have the capacity,” one GP tweeted. Another wrote: “Plenty of rural training sites but no money for salaries.”

The success of programs such as Queensland’s Rural Generalist Training Pathway and Victoria’s Murray to the Mountains Initiative, where interns complete 20 weeks’ training in a rural general practice, have been held out as leading lights.

But Professor Willcock says while the bush has to be part of the answer, it’s not going to be “the overarching solution to the numbers”.

4. Federal takeover of all medical training?
If the current internship problems are largely the result of a blame game between the states and the Federal Government, what if the Feds just took all the responsibility? After all, the Federal Government controls the purse strings.

Many would like it, but it’s unrealistic, says Professor Willcock.

“While it’s tempting to think you could organise everything centrally, if you don’t have a regional understanding of what’s happening you’re too far removed from it.”

5. Cut the number of hours interns work in the hospitals to make more places available
This option is one Professor Dwyer thinks is worth considering. “There would be plenty of work for additional interns to get experience if we reduced overtime and employed more doctors — a more reasonable spread of the workload,” he says.

But Professor Willcock says a study showed this wouldn’t create many more places or save much money.
“Most [interns] only worked 10 hours overtime on average. And there was a real risk of it interfering with the amount of training and exposure they got,” Professor Willcock says.

“It would also significantly affect their income.”

Political will
In the end, the answer to the internship problems may depend less on finding the right solutions than on finding the political will.

Ms Plibersek is, in essence, urging everyone to stay calm and carry on. She says she is working with the states through the Standing Council on Health and with Health Workforce Australia to plan for future training needs.

Health Workforce Australia says its work is still in early stages, though it aims to set up a national medical training network to plan and organise the medical training pipeline.

Professor Willcock is also feeling confident about these evolving plans.

“I see nothing to suggest that locally trained domestic students will miss out on internships. I don’t have any concern that people won’t be able to get jobs,” he says.

Mr Thompson hopes the optimism is well founded.

“The intern crisis is in its acute phase. But I fear there’s very much a chance it could become a chronic disease,” he says.

By Sarah Collyer, 5/11/2012 Australian Doctor. Reproduced with permission.
Original here: http://www.australiandoctor.com.au/in-depth/news-review/storm-warning

This post was written by
Medical Student Action on Training (MSAT) is a grassroots movement by Medical Students Australia wide who have united to raise awareness and demand political action be taken to solve the #interncrisis
  • notoptimistic

    why don’t nurses and doctors, who know the ridiculous-ness of this government’s priorities simply go on strike? Because they are committed to their position as health care providers above and beyond politicking. In any other industry, if the government stopped training enough future workers through TAFE or the equivalent, and filled the shortages with poorly equipped international imports, there would be riots on the streets. Never mind that those imports are being poached from countries in much more dire need of their services, making the practise morally bankrupt. The fact that this government spends 29 Bill annually keeping criminals well fed, air conditioned and with access to the internet and TV, while not all public schools are fully air-conditioned, and they cant even bring themselves to spend money on junior, Australian trained doctors, would be laughable if it weren’t so frightening. Again, never mind that all evidence shows the prison system creates a criminal underclass rather than solves crime, they still commit more money to the practise every year. As far as I know there isn’t much research supporting the abandonment of medical training and improved healthcare, That wouldn’t be an ethical study. But seemingly the government has a hunch that this may in fact be the case. All jokes aside, looking from the government’s perspective, why spend money on something which will only bear fruit after their term in office? Pampering prisoners, who are of voting age, ensures votes in your favour, properly funded state institutions take a back seat when no politicians or their families stray from the private institutions they so eagerly encourage… Am I too cynical? I hope so, but it isn’t as if this is an isolated piece of poor policy, the Australian political system as large and expensive as it is, fails to produce the one thing we hire them for, strong policy which can be voted on, instead we are led to vote based on gender, hairstyle or family life… And we call ourselves adults…