Issue 44 / 12 November 2012

THE role of intern places in the grander scheme of our medical workforce has dominated the medical media in recent weeks.

On one side are the potential interns themselves, including many fee-paying overseas students who no longer have a guaranteed intern place. On the other are state and federal governments repeating the usual tussle about who is responsible for funding intern places in our public hospitals.

But what about the many other nuances in this debate, and is the general public aware of all these aspects?

Medical internship in Australia is a paid job, combining service and training, as well as a prerequisite for medical registration. With rising expectations in the community, which has also become more safety-conscious, there are increasing demands on senior staff to increase the supervision and teaching of interns.

So, while medical student places have expanded in response to a medical workforce shortage, the contribution interns make to patient care is, by necessity, limited.

And post-internship, what then? It has been a long time since a completed internship was considered sufficient training and experience to enter any form of independent clinical practice.

The result is hospitals need sufficient places for a large number of residents, senior residents and registrars, and many more general practices need to train GP registrars. Do we have the infrastructure, or even the planning, to cope with those requirements?

These are some of the immediate practical issues yet to be resolved in this debate — but what of the ethical and philosophical ones?

While most doctors accept as given that a paid internship should automatically follow graduation, many other professions do not benefit from this arrangement. Does the community hold the same assumptions about public funding of internship as doctors do?

Perhaps it’s time to revisit the concept of the 2-year internship — the same model as the UK Foundation Programme.

When the prerequisites for general medical registration (medicine, surgery and emergency medicine) are spread across 2 years, the burden of supervising those terms is halved, while trainees can continue to accumulate experience.

It may be easier to convince the community that a compulsory, paid internship is a right for every graduate if their second year of hospital service is also compulsory. The reality of contemporary medical training means that the practical changes would be minimal.

And what of the role of universities? Are university medical courses and training linked to the requirements of clinical practice? Can a graduate with a medical degree be assumed to be “work ready”, or even safe to practise?

If paid internship is considered to be an automatic entitlement, then shouldn’t a medical degree certify suitability for that internship?

In these times of workforce flux, it is more crucial than ever that university medical student intake and training is intricately linked to community workforce needs.

We know that full fee-paying overseas students are an important source of revenue for universities, but recruitment must be transparently linked to an ongoing pathway into the medical workforce. This must include the areas of workforce need — not just rural and remote areas but also outer metropolitan areas.

Without linking all these issues, what is the point of this debate?

Dr Sue Ieraci is a specialist emergency physician with 30 years’ experience in the public hospital system. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management.

Posted 12 November 2012

9 thoughts on “Sue Ieraci: Internship dilemma

  1. Peter Arnold says:

    In addition to the points Sue has made, there is a further dimension to this debate: some countries regard internship as the completion of undergraduate training, and insist that the internship be completed in the same country as the one where the MBBS was obtained.

    This is not unreasonable, as the work interns are allowed to do is predicated on the assumption that they have received a certain standard of undergraduate training.

    Some new graduates might well find themselves in a “Catch-22” situation – unable to find a position in Australia AND not acceptable for a position overseas.

    In my view, there is no point in offering the undergrad course to local or overseas students without guaranteeing an internship opportunity.

    Peter Arnold, former Deputy President, NSW Medical Board and Chair of its Registration Committee.

  2. Gerry FitzGerald says:

    There is another dimension to this issue related to the responsibilities of the taxpayer to fund postgraduate education.
    It is recognised that interns fulfill service delivery roles to some extent but also are financially supported through the educative element of their formative postgraduate education. For example, in some rotations, interns are taken “off line” for periods of time to undertake additional education. The taxpayers have accepted this as part of the investment in Austrlaia’s future doctors. However with the rapid expansion of student numbers, there has been major increases in intern numbers, far in excess of reasonable service delivery requirements, the taxpayer is funding more of the postgraduate education. The current question regarding overseas students is should the Australian taxpayer fund the postgraduate education of people who have funded their own university education?

  3. Eleanor Dawson says:

    I note Dr Arnold’s comment with interest. I have been concerned to read elsewhere,that the encouragement of overseas students to study medicine at Australian universities had not apparently clarified for them, how they would be able to gain formal accreditation here or elsewhere. It is unacceptable for them not to have a path to use their knowledge and experience todate in the further interest of their own career development and the health care of patients. Some may well feel that they have been conned and then betrayed.

    60 years ago the 1945/1946 influx of ex-servicemen under a reconstruction training scheme (CRTS) presented a similar problem of numbers. Extern positions were therefore provided. Some granduands applied specifically for them, favouring teaching hospital experience, at RPAH Sydney for example. Externs had similar opportunities for training apart from place of residence which could be arranged autonomously. For such a provision to be made now would serve Australia’s needs and those of the current granduates.

  4. Benjamin Andiyar says:

    While Mr Fitzgerald is correct in stating that there is an educational component to the intern year, perhaps he missed the statement in the article above: that medical internship is a paid job. Yes, a job that combines work with education, like many positions do (on-the-job training and the like). With the actual proper educational component of an internship taking up at most several hours of the week – hours which are claimed to be protected but are often violated by patient-care – and with interns, even with the current glut in the system not uncommonly working 60 hour + weeks, I fail to see how this job, which includes the vast-majority of time as *work*, is considered an ‘educative element’, rather than a job with incorporated education/training.

    The suggestion therefore that international graduates should pay their own salary, and yes, it is a *salary*, in order to attain accreditation here is a a little less than egalitarian. As to the statement that there are interns entering the system “far in excess of service delivery requirement”, Australia still imports more than two thousand doctors each year to make up our workforce shortages and will continue to do so for some time – indeed, there are still marked workforce shortages to come over the next few decades. Do we have more interns than we require? That’s a possibility. Without them however, we will not have enough GPs and consultant specialists in the years to come, and as such we would be jeopardising the future of the workforce by removing the opportunity of Australian-trained and residing doctors to work within our system.

    We already did that once, when the Howard government capped medical school intakes in the late 1990s. That’s why we’re in the situation we are today, let’s not do it again.

  5. mycosis says:

    workforce shortages are a myth perpetuated by universities to egregiously increase the number of full fee paying students for their financial benefit without taking responsibility for the gross distortion they are causing to the entire system…we have plenty of doctors,but they all work in cosmetic,skin cancer,weight loss or a million and one other special interest clinics,looking after the worried well ,9 to 5,….anything but genuine general practice,which is demanding and under-rewarded…until”clinics” are excised from medicare and rebates for real general practitioners rise substantially,nothing will change…the universities must start reducing their numbers and show some social responsibility…U.Q is the worst….

  6. Dr Harry Haber says:

    I wish to propose at this late time the allocation of RMO positions, the division of the work load for a three and a half day working week so that all graduates could share. It would mean a halving of salaries but all graduates would receive training, the other three and half days would be as unpaid services with training made available in private hospitals, psychiatric hospitals, public hospital clinics, nursing homes, general practices and other medical services where doctors can gain experience such as histopathology, haematology, child care clinics, the state coroners pathology and autopsy. Assistance with preparing better medical reports and discharge summaries, an area sadly lacking, more time allocated to communication with GPs . Retired GP Harry Haber

  7. mycosis says:

    Nice romantic idea Harry,but what you describe is semi-retirement for new grads….At this time of their career they need to be constantly challenged and under the hammer if they are to become decent doctors…the reality is that we have far too many graduates(universities fault)…giving them “mickey mouse” training positions will lead to complete dumbing down of many already dumb graduates….the government & the AMA must come down on the universities…mycosis

  8. Ninan Mathew says:

    I started my medical training in 2001 and we had heard fairly loud “whispers” of a huge influx of medical training positions to fill the “short-fall” of doctors in the community. The questions every 1st year medical student asked back then were “Where are they all going to go?” and “Can hospitals afford to employ them all?”. These were not “perceptive” questions to ask back then. It just seemed to naturally follow on from the news.

    However it seems that the people who decided to “solve” the doctor shortage didn’t really consider this at all. Their last-minute scramble produced some interesting results: We saw the advent of GP rotations, which was refreshing and educational, but we also saw Radiology Internships, where your job was to simply stand in the background, while others reported on the images… oh, and you had to collect xrays, let’s not forget about that. Patient contact? Nil. Now there are Medical Administration Internship positions for those of us who got into medicine and never actually wanted to see a patient. Now don’t get me wrong. I think Medical Administration is invaluable, but this is a joke.

    In addition to this, we now have rotational rosters on ward jobs, such that there will be 3 interns on a team, but only 1 will be rostered on for the morning, 1 for the afternoon and another for after hours. Of course, the first intern will be doing the job of all three due to time pressures. The other 2 interns will generally not do much and have next to nil ownership over the patients they’re supposed to care about. They say that this rostering scheme is about eliminating fatigue and overtime, but I say it’s medicine gone mad.

    So it was quite a surprise when people were suddenly up in arms, claiming “We just realised that there is an Intern Crisis!”. No, we didn’t just realise. It was just ignored until it became a collosal embarrassment. Who’s responsible? The people who decided to flood the nation with idealistic and expectant medical graduates. These are medical graduates who through no fault of their own, expected to get a fair go by at the very least attaining general registration. Now we’re hearing talk that “not all professions give guaranteed internships, so why should we?”. This smacks of a cop-out and nothing more: “We messed up, but you shouldn’t have expected anything more in the first place”. Not a new argument. Not a helpful argument.

    So what about the universities? Surely they would have said no to increasing numbers if they thought it would result in a crisis, right? Idealistic thinking to say the least. No university in their right mind would refuse the “Prestige” and extra income that comes with having a Medical School. So in the end, it’s the poor, idealistic medical graduate (who more than likely said at their entrance interviews that they wanted to cure cancer or build a charity hospital or be like Patch Adams) who just has to suck it up and face the harsh reality of this medical game: You’re on your own.

    Universities no longer have to train people to become GPs (this now requires a specialty training course), they only need to train Interns. Hence is it surprising that the level of compentency in graduates is dropping? The style of learning is interesting too: You need a degree before-hand (so that someone else can teach you how to learn) and then you use self-directed learning throughout the course. Doesn’t that just mean: “We want to produce medical graduates… but we don’t really want to be involved in the process”?

    Furthermore, there has been no respective increase in specialty training positions. Hence even if the “Intern” crisis was quelled, we would then have a glut of doctors stuck in the public health system, trying to get into specialty training programs. We are bound to public health, because we cannot open up private practices, as EVERYTHING needs a specialty qualification. Hence our only avenue of “escape” is to get onto a training program, ANY training program, to complete it and then leave this miserable existance far behind us.

    But even that is not possible. The bottle neck will shortly be at the pre-registrar (accredited) level, effectively creating an underclass of senior RMOs and unaccredited registrars, who will do anything and go anywhere (eg. Rural – Surprise, surprise) to try and get onto a program, all the while colleges are spouting “You need to have a balanced lifestyle”. What rubbish. We sacrifice enough already only to be asked to sacrifice more later on. However if the end result is pure chaos, then I say get out. Medicine is no longer a vocation that inspires. All who enter into it at this stage have been duped… or have nepotism on their side.

    In the end, the real issue is NOT about servicing Australia’s needs. That unfortunately should be secondary. These graduates/junior doctors are real human beings, with goals, aspirations, families and personal responsibilities. They have a right to all of these things. They also represent the more altruistic part of the Australian population, having dedicated their lives to the sacrifice that is Medicine. They sacrificed time/health to get in. They sacrificed time/health/family to get through the basic degrees and then some sacrificed even more to simply work the ungodly hours that come with the job. On top of that, they ask themselves everyday, do they have anything more to sacrifice to get onto a program? Often times, the last blow is that they finally sacrifice the altruistic spirit that got them into medicine in the first place: “Bugger everything else, I’m going to get onto a program at all costs, get through it and then go private. We owe this public health system nothing”. A sad state, but unfortunately I don’t think doctors view this as “selling out” anymore. I think we just want some semblance of a life.

  9. Ali Sharif Smko says:

    Regarding the issue of internship. I am one of the victim of all the Medical Boards in Australia. I graduated in 1989 (overseas) and came to Australia in 1998, I passed M.C.Q test in 1999 and clinical part in 2003… and I have done tons of C.M.E. on line over those years to improve my knowledge…I never got a chance to get full registration because of bearuracy within the Medical Board system and I had no choice but to go back to my country in 2009 , recently I updated my English test (O.E.T) and I applied for internship in several N.S.W Hospital through the net for year 2013, but I wasn’t sucessful. I think internship in no longer easy to get and previous experience makes you no better than a new graduate….I need all the help from you guys ..to get me a position….I am currently working overseas and ant to go back to Australia ( I have Australian citizenship)…..

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