On Friday, the NSW Health Minister, Jillian Skinner, hosted a summit in Sydney to address concerns about the shortages in medical intern placements (details of the program are here).
The meeting was closed to the media but – in an example of how social media is transforming the way we all work – there were plenty of citizen journalists in action in the room. To get a sense of who was tweeting what, check this compilation from Australian Doctor magazine.
Steve Hurwitz, a medical student at Newcastle University and the public relations officer for the Australian Medical Students’ Association, was busily taking notes to compile the report below for Croakey readers.
I asked him to provide a straight summary of the presentations and discussions. If any speakers or other participants in the event would like to add to this report in the comments section, please do so.
Reporting on the National Medical Intern Summit
Steve Hurwitz reports:
The NSW Minister for Health, Jillian Skinner
Jillian Skinner opened by emphasising the positives of the current situation, and the moves the Government has made to increase training in NSW. She highlighted that NSW Health has invested $100 million to create 927 internships in 2013.
She wants to “prevent the heart ache being repeated” and solve this issue “once and for all”, with projections suggesting we’ll need approximately 800 more internships in 2016. There could be extra capacity found in services outside of hospitals since they are still largely under-utilised for training.
Workforce planning shows a shortage of doctors in 2025 if the status quo is maintained. If, however, productivity increases, we could have a surplus of doctors.
She noted the importance of trying to address this for international students because they are “vital to the Australian economy”.
The Federal Health Minister, Tanya Plibersek
Tanya Plibersek spoke for much longer than Mrs Skinner and encouraged the attendees to look at a broader picture – the whole system of medical training (the training “pipeline”) – so that we don’t just push this training problem down stream.
We also have a big problem approaching with an increasing number of doctors in the middle of their training (after internship and before specialist training).
Last year we faced a confusing situation where the Government couldn’t get a straight number on how many internships they needed to supply.
At the moment, the health system relies on too many short-term fixes, like paying ‘exorbitant’ fees for locums and flying doctors in from overseas. It’s not possible to run a health system like this. The interns coming through can help address this. She described the situation as a “good problem to have”.
Training places have significantly increased in medicine and nursing over the last 10 years and specialty training positions are continuing to increase. These increases have been for an important reason – we need these health professionals now and in the future.
The training in rural, regional and remote areas needs to increase. Over 70% of the new Commonwealth-funded training posts include at least one rural rotation. We need to work with the Specialist Colleges to move more training posts to rural and regional areas.
Ms Plibersek mentioned clinical placement charges, which is a change from the status quo of hospitals providing teaching pro-bono, but called for changes to be deferred until after the Independent Hospital Pricing Authority had properly considered the issue. She’s asked all health ministers to look at streamlining the funding of medical training.
Professor John Dwyer AO, Emeritus Professor of Medicine, UNSW
Professor Dwyer opened by recognising that the “right people are in the room” to address this problem. He stated that we can’t look at the internship problem without looking at medical education more broadly.
However, this education model needs to be cost efficient and enable the next generation of practitioners to deliver a different model of care.
He made some proposals, including:
1. Reduce medical programs that are six years to five years to help shorten the length of training (note, however that there are only three 6-year medical programs in Australia);
2. Include a ‘sub-internship’ within medical school, where students do the work of an intern and are paid a ‘student wage’ of $25,000 so that they graduate with general registration; and
3. Allow early streaming into specialties during medical school.
Summary of panel discussion
It was highlighted again that internships are just one of many years of postgraduate medical training.
The mandatory/core terms of internships were discussed, e.g. medicine, surgery and emergency. It was questioned whether these core terms limit expansion of the number of internships available to medical school graduates. Dr Joanna Flynn, the Chair of the Medical Board of Australia (MBA), said the board’s role is to protect the public. The MBA doesn’t want to create barriers, and there is lots of scope for increasing jobs.
It was pointed out that Emergency Department rotations are more effective than other rotations at identifying at-risk junior doctors.
Dr Michael Bonning, representing the AMA Council of Doctors in Training, said he believed early streaming of medical students should not be mandated, because not all students know what they want to do for the rest of their careers. He also said that countries with early streaming, such as the United States, haven’t found that it decreases healthcare costs. This could also lead to students failing to have a good understanding of the roles of GPs and other specialties, which would be detrimental to the healthcare system.
There was uncertainty about conscripting doctors into rural areas to meet rural workforce needs, as punitive measures don’t provide long-term solutions. The MBA said that emergency terms don’t necessarily need to be in emergency departments, just have experience somewhere (like a general practice) with emergencies/acute care.
Australia still lacks coordination of the training pipeline between medical school and the production of fully qualified graduates. This is both in terms of the numbers but also the Colleges often don’t recognise prior training and work of applicants.
Final messages from the panelists
1. We need to focus on the current internship issue without forgetting the whole training pipeline;
2. We need to link undergraduate training and planning with the specialist training Colleges;
3. Remove the gap created by unaccredited years between completing internship and starting specialist training, which aren’t recognised by the Colleges; and
4. The federal and state governments need to cooperate for long-term solutions.
Professor Stephen Duckett, Grattan Institute, Melbourne
Professor Duckett explored some of the economic arguments around interns. He said that they aren’t the only way to address healthcare needs.
He suggested that at the current “effective price”, the supply of interns is greater than demand and if there are productivity gains within the health system we could have an oversupply of doctors.
Purely relying on the output of doctors from medical school is an inefficient way to achieve our health system objectives.
Currently we pay a lot for the training of medical students. The private hospitals received a good deal from the government to take on interns – they got a 100% subsidy. It’s difficult to define what costs are attributable to clinical work and what are attributable to training.
Some panelists were wary of taking a pure market based approach to healthcare because those forces can lead to perverse results.
Prof Justin Beilby, from Medical Deans Australia and NZ, said we need to match up education and workforce planning, including service models, so we are training the correct number of students in the correct way.
It was questioned why we only guarantee internships (for domestic, Commonwealth-supported medical students) when we actually need adequate numbers of training positions all along the training pathway.
Private hospitals’ roles in training were discussed. The additional internships that were funded by the Federal Government last year had a poor take up. Reasons for this were thought to include: the lateness of the offers (approximately one week prior to Christmas), the lack of public rotations, the bonds attached to them, and the locations of the internships.
While some private hospitals can provide opportunities through the whole training pipeline, it was thought preferable for interns to rotate through private hospitals as part of a larger network, so interns work in both public and private settings (including the community, e.g. general practices). While it is important to increase the quantity, we have to be careful not to decrease the quality of these places.
It was discussed that employers in all sectors have a responsibility for training and developing their employees.
Martin Laverty, the CEO of Catholic Hospitals Australia, said he would love to increase the number of available internships in his hospitals, having been able to find 70 internship places this year, at quite short notice.
We need to expand the rural training opportunities for vocational training so that people who want to work and live rural don’t have to return to the city to complete their training.
The panel considered whether interns are primarily training or providing a service. An academic in the audience cited submitted but unpublished data that interns spend 6.2% of their time in education.
It was highlighted that a short window of opportunity exists now to solve the internships problem for 2013.
If governments and the private sector don’t start working together early, at the end of the year, we’ll find ourselves with potentially hundreds of unemployed medical graduates.
The whole training pipeline needs to be considered and Colleges need to improve their recognition of prior learning. Assessment at the end of internship was considered; however, it is unclear how an effective system could be implemented.
The concept of a training wage for students doing a ‘sub-internship’ was contentious. However, the concept that interns are paid too much was strongly challenged. One attendee said that any new graduate in the public service is supervised heavily and still paid an appropriate income.
Obtaining general registration before graduating from medical school would require students to have prescribing rights, and workplace-based assessment would have to be improved. If students are providing a service, then they would require a wage. A well-defined set of responsibilities and a supervision framework would need to be developed.
The closing message from Jillian Skinner
This has been a good opportunity to make a start, and it shouldn’t be wasted. The discussions will be distilled into a paper that will be presented to the Standing Council on Health.