Issue 8 / 11 March 2013

THE current priority system of allocating internships in Australia is unconstitutional and needs reform, according to the authors of an article published online today by the MJA. (1)

The article said that the system allows the states to give preference to Australian students graduating from medical schools in their state “over all other applicants, including interstate Australian graduates”.

Dr Dev Kevat, of Monash University’s School of Public Health, who has an interest in human rights law, and coauthor Dr Fiona Lander, a medical intern and lawyer , wrote that the priority system violates Section 117 of the Commonwealth of Australia Constitution Act 1900.

Section 117 states that: “A subject of the Queen, resident in any state, shall not be subject in any other state to any disability or discrimination which would not be equally applicable to him if he were a subject of the Queen resident in such other state.”

The authors wrote that this section of the act could “prevent, for example, an applicant for internship in Queensland who was trained in Tasmania from being treated differently to a candidate trained and residing in Queensland”.

“The departure from the principle of equality access of citizens in competing for jobs promulgates more than mere ‘academic’ concern. Erosion of rights may start with seemingly minor irregularities, tolerated on pragmatic grounds, before further changes increase the differences in treatment between citizens”, they wrote.

The authors highlighted recent changes to the priority system in Victoria as a predictable next step in the process, where international students graduating from Victorian medical campuses were now the second highest priority category.

The Victorian Department of Health (VDOH), and its agency, the Postgraduate Medical Council of Victoria (PMCV), which administers the allocation of interns on its behalf, changed its policy last year to give higher priority to international graduates than to Australian citizens who have done their medical training interstate, even if those graduates were Victorian secondary or undergraduate students.

Dr Will Milford, chair of the AMA’s Council of Doctors-In-Training, said the MJA article highlighted why it was time for decisive intervention from the federal government in the ongoing intern crisis in Australia.

“At the end of the day, there needs to be a high-level decision made about whether international students are offered internships”, Dr Milford told MJA InSight.

He said the Victorian decision on interns was a bellwether.

“We agree with the supposition that what Victoria has done is very good for Victorian interests, but it is not good for everyone else”, Dr Milford said.

“The question now is whether the other states will adopt a similar system to Victoria. Self-interest will likely dictate that they will”, he said.

Medical director of the PMCV, Dr Susannah Ahern, declined an offer to comment on the MJA article, saying only that “Victorian policy is determined by the Victorian Department of Health, which PMCV implements”.

The VDOH was also asked to comment on the article but had not responded before publication.

Dr Milford said although he would welcome a decision from the federal government about international students, if the decision was to stop offering them internships that would also have consequences.

“The trouble is, every one of those students is required”, he said. “A bottleneck has been created at the state level because of funding issues.

“If graduates are forced to go offshore for their internships that’s inefficient and counterproductive.”

The knock-on effect of not giving international students internships would be that they would stop coming to Australia to train, which impacts the budgets of medical schools relying on full-fee-paying internationals, he said.

“And that means closing medical schools, or the quality of the training drops, and that’s probably worse.”

AMA Queensland president, Dr Alex Markwell, said she believed there was enough “political will” to reform the system by the end of the year.

“We have a poorly coordinated intern allocation system”, she told MJA InSight.

“We’ve been calling for a national merit-based system for some time. It’s about finding a way for the different jurisdictions to be comfortable with and accepting of sharing information and a single website that is coordinated nationally.”

– Cate Swannell

1. MJA 2013; Online 11 March

Posted 11 March 2013

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21 thoughts on “Intern system “unconstitutional”

  1. Anonymous says:

    The case for a National Intern Allocation system published last year by the MJA highlights that this is one of many issues with parochial state run systems:

  2. Joan Benjamin says:

    Changing to a merit based system of allocation for intern positions whilst preferable to the “Victorian” solution is still a short term solution. What is needed is an examination of the training/educational requirements to assist in the transition of graduates from limited participation in the medical workforce to full and effective participation. Followed by a rational consideration of the funding responsibilities between the state and federal jurisdictions to support the transition. Clearly the decisions enemating from such considerations be done so in the context of the Australian medical workforce, present and future.

  3. Pavel Jancik says:

    It shocks me that such important and global areas as education and health are governed at state level. The relatively recent abolition of state health professional boards and the introduction of AHPRA seems to be the first step in the right direction: national standard with national governance.
    Pavel Jancik
    Registered Nurse and Paramedic

  4. barrister says:

    obviously the authors must be referring to the constitution of another country – there does not appear to anything unconstitutional in the administrative arrangements of the states regarding their medical allocations needs and allocations.
    The Universities selling their medical degree as a commercial product as income for the university cannot expect the States to comply or assist with the universities commercial arrangements. The students foreign or local are merely buying the degree course. The State makes the arrangements which it requires.

  5. Peter Kennedy says:

    Mr Jancik, it shocks me that you think that anything which is considered important all over the globe, must be governed by a single massive monolithic continent-wide authority. I think that in general the more important an issue is, the MORE it is necessary that it be governed at the most local practicable level that’s as close as possible to the people.
    The people democratically voted for our Constitution under which the States allow the Commonwealth power to make laws about a certain limited number of matters, all other matters including education and health being the responsibility of the States. The people have repeatedly democratically voted against expansion of the Commonwealth’s power into these areas. I’m shocked that you have a problem with that.

    By the way the registration of health professionals is still governed at State level. It’s just that the States have unanimously agreed to keep a common register and to pass similar legislation governing AHPRA and the national Boards. Any State could pull out of this mutually agreed arrangement at any time. The Commonwealth government has no role in it.

  6. Pavel Jancik says:

    Mr. Kenedy, there is no suggestion of “massive monolithic” authority here, if that’s what you inferred from my post then I am shocked by that. Now after we were both “shocked” enough I suggest you start thinking about the duplication and triplication and quadruplication of efforts at state government levels, incompatibilities of IT systems, tracking of patient care, list goes on. Now that’s what I call massive.

  7. Owen Lewis says:

    Two points
    As a rural practitioner my feeling is that our needs “out here” would be better served if health was fully a national responsibility with a stronger regional system than at present.

    We could supervise an intern in our general practice/rural hospital as a suitable pre-registration experience. Of course some more tertiary hospital experience is necessary but it does not have to happen first.

    Hence I say create more internship opportunities and limit the states’/teaching hospital’s vested interests.
    Owen Lewis, Roxby Downs

  8. Health servicces manager says:

    Why have an allocation system?

    This whole argument is founded on the premise that medical graduates are entitled to employment in the hospital system immediately upon graduation. Why should they? Non-medical graduates are not allocated jobs upon completion of their degree. Medical graduates should have to compete in the ‘marketplace’ for a job just like everyone else. There is no entitlement to employment just because you have a medical degree.

    The argument that they must be given a job because government funds supported the training is not valid as most university places are tax payer supported. It is only the matter of total cost and proportion funded by tax payers that is different.

    It is also argued they will not get registration without this initial employment. The argument is untrue. Every graduate from an Australian medical school is entitled to Provisional registration with the Medical Board of Australia. They must get a job and demonstrate a level of competency to apply for general registration. This is not too unlike others in the workforce who must demonstrate competency before they can progress in their careers.

    It is time to put an end to treating medical graduates differently from other graduates. They really are not special.

  9. Sue says:

    “They must get a job and demonstrate a level of competency to apply for general registration. This is not too unlike others in the workforce who must demonstrate competency before they can progress in their careers.” So how, HSM, are they being treated “differently”? I have lived through the time of merit-based allocation, based on university results. IF you want all the best graduates at the biggest city hospitals, that’s how you get it.

  10. Jonathan says:

    “Barrister” clearly didn’t even bother to look up the section of the Constitution referenced in the first paragraph: s117: “A subject of the Queen, resident in any State, shall not be subject in any other State to any disability or discrimination which would not be equally applicable to him if he were a subject of the Queen resident in such other State.” Hence, preferentially hiring local graduates is unconstitutional.

  11. Enlightened says:

    If this is the case, surely then the way all (so-called) “non-VR” GPs are treated is non-constitutional?
    They only receive (so-called) “VR” GP Medicare rebates if they work in “areas of need” and get 1/12 working in cities.

    We’ve had “non-constitutional” – and certainly corrupt – practices in medicine in Australia for years.

    Australian born and trained “non-VR” GPs; exact same work, exact same responsibility, exact same qualifications – and only HALF the Medicare rebate…

    It’s been a long time since medicine in Australia was working according to the law.

  12. barrister says:

    Amazing – didn’t know the medical profession had a hidden cache of constitutional law expertise. We lawyers must read up on coronary artery bypass grafting, no doubt it is an easy read and the description no doubt is detailed , after that we probably could perform some in our chambers- in between court appearances.

  13. Blackstone says:

    Dear Barrister, I’d urge you to read the academic article in the MJA. The authors have included citations to relevant case law, both supporting and against (which they distinguish). They also acknowledge the input of a Professor of Constitutional Law. I do hope you use more accurate analogies in court – if you studied a medical degree(rather than read up on a medical topic like bypass), it would be quite reasonable for you to write something about a medical topic and submit it a journal. Its highly unlikely the MJA would publish dross – legal experts peer review their ethics and law section. Sincerely, Blackstone

  14. Sue Ieraci says:

    barrister – you really MUST read up – coronary bypass grafting is so passe’ these days!

  15. Rose says:

    The fact remains that people who have lived their lives in urban capitals such as Sydney and Melbourne do not wish to work permanently in remote areas, let alone work long-term in states like Queensland, WA, nor in a Northern Territory . So if these far-flung locations select their own graduates hoping that they will continue a career in unfashionable hick locations with extreme climate, saltwater crocs , then I respect their choice.
    Intern places for overseas graduates is a political question-supported places in areas of need is logical. I will support any intern who wishes to work in a remote area.

  16. Guy says:

    This is an important point. We have not heard any actual arguments from the states as to why preferential discrimination IS constitutional under s117 of the Commonwealth Constitution.
    Do they have some solid legal argument, or did they just not think of this before implementing the scheme?

  17. rick says:

    “It’s the vibe of the thing …”

  18. JohnB Myers says:

    HSM suffers from Dr “envy”, and is not alone. Whatever non-medico’s think is irrelevant. Internship is part of graduate training and every person who is admitted to Medical School does so on the basis that they will receive adequate, and not less than the best training.
    Managers do not need to be tested in the field, although obviously they could do with a trial period too, to remove the sour grapes.
    Doctors are the best, perform to our best and therefore like a super model need to be groomed and up to the test that faces us. Thank G-d for well trained doctors.

  19. Peter Kennedy says:

    Mr Jancik, I have been not only thinking about but working on real solutions to the problems you mentioned for a long time. These solutions do not and must not include your simplistic and anti-democratic proposed solution of simply abolishing State governance of education and health by some overriding dictatorial fiat.

  20. Pavel Jancik says:

    Mr. Kenedy, thank you for the effort you say you put into fixing problems in our current system. My point was not to put down genuine efforts to improve the existing status quo, but to point out the waste of it. The fact that you and others need to exert thoughts and work to fix the chasm between the states point to a problem. The words simplistic, anti-democratic and dictatorial are all of your own production, I would like to use words like simple, streamlined, consultative, democratic and federally run system. By the way the federal government is a democratic one, as we might soon witness.

  21. Dr JP Moloney says:

    Sorting medical students on the basis of academic results will disadvantage potentially some of the best doctors in the year. There are groups of well-supported students from the city, who are fed and watered and don’t have to work to get through, and there are multiple others who scrape by in shared accommodation, with rural backgrounds; who have to work long hours at part-time jobs to support themselves. This was classically demonstrated when rural scholarships were first begun. Many (including my son) suddenly didn’t need to work, and started topping subjects in the year. I have seen several such students plough throughout specialty training suddenly blitzing the field when it becomes “level”.

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