Kunal Luthra is AMSA Vice President (External) in 2014
This post was written to serve as a brief primer for medical students on this issue.
One of the forgotten casualties of the Federal Budget this year was the abolition of the Prevocational General Practice Placements Program (PGPPP, usually referred to in speech as ‘PG triple P’), for reasons of expense.
That’s a bit of a mouthful.
But it’s a cut that alarmed AMSA, and has had flow-on effects that have subsequently alarmed medical students around the country. Since the announcement, AMSA has consistently been speaking to Government, Opposition and the Department of Health about this particular program.
So what is PGPPP? It provided rotations in general practice for prevocational trainee doctors. In some states, these were largely PGY2+ trainees, or graduates who were two or more years out from medical school. In South Australia and Victoria, however, approximately half the PGPPP rotations were for PGY1 trainees – interns. For many interns, the PGPPP placement in a community general practice would make up one of the five rotations they would undertake over the course of their internship. Removing PGPPP removed this rotation.
Broadly speaking, this has had two major consequences:
- PGPPP was one of the few ways medical graduates could actually gain exposure to general practice, and particularly rural general practice, before entering specialty training. We know already that one of the keys to resolving Australia’s rural doctor maldistribution is getting more interested young doctors out into rural communities after graduation. Removing PGPPP creates a gap in the ‘rural training pathway’ the government should be hoping to engineer. We also know that we should be encouraging more graduates to take up general practice, and so removing exposure to general practice for trainees is a backwards step.
- In the short-term, there has been a cut in the number of internships offered in states that used PGPPP to fund internships. In late May, following the Budget, the following announcement was placed on the SA MET (South Australian Medical Education and Training) website:
“In 2014 the PGPPP funded 23 intern positions in South Australia for a total of 278 intern positions, plus 16 PGY2+ positions. With the loss of this funding, the number of intern positions in South Australia for 2015 will be reduced proportionately. Final numbers are still being determined, and will be dependent on the accreditation of additional emergency medicine terms in public hospitals”
Without the rotations provided and funded by the Commonwealth-run PGPPP program, the onus was on state-funded public hospitals to make up for the resultant gaps in the intern year. The funding and capacity at a state-level in South Australia is limited. If the hospitals could not add more rotations, the number of internships would have to be cut. And that is what has happened.
This is a difficult environment to advocate for more funding, but AMSA, and particularly a group of committed and passionate medical student advocates in South Australia, are continuing to lobby all levels of Government, as well as state health departments, about this important issue.
AMSA has opened applications for the IFMSA General Assembly in Turkey, August.
The IFMSA (International Federation of Medical Students’ Associations) represents over 1.2 million medical students worldwide, and is the world’s largest student-run organisation. The IFMSA unites medical students worldwide to lead initiatives that positively impact the communities which we will one day serve.
AMSA is looking for students to form part of the delegation (both general delegates and in leadership positions). For more information on applying for the conference, please click here. For further questions about the IFMSA not covered in the above documents, check out “Understanding the IFMSA” or “About the IFMSA.” Due date for all positions is November 30th, 2014. However bid documents for organising a pre-GA workshop are due on the 24th Nov, 2014 and any interested applicants are highly encouraged to contact Francis Ha (firstname.lastname@example.org) ASAP.
Anna Szubert is a medical student at ANU
Earlier this year, Silicon Valley giants Apple and Facebook were in the news for following their already top notch insurance benefits for women employees with another corporate benefit: cryopreservation, or egg freezing (1).
On first consideration, this can only be a good thing. It would allow female employees the opportunity to continue their careers well into their 30s and 40s without the inevitable loss of productivity and progress that comes with childrearing. However, there are a few problems with the promotion of cryopreservation as a benefit to career-oriented women.
There are potential problems with the efficacy (and ethics) of cryopreservation itself. However, a larger issue that arises is the idea that having children is incompatible with career progression such that career-oriented women are expected to go to extreme lengths to postpone childbearing.
This idea is incredibly pervasive and rarely questioned. After all, corporations and modern wage systems were invented in the age of the stay-at-home spouse. Employees with other responsibilities taking up their time only hurts the bottom line. Reserving promotions for those whose only responsibility is to the workplace makes good business sense, apparently.
As a result of this, there is a great presence of pregnancy bias in Australian workplaces, and medical workplaces are not exempt from this. A recent report by the Australian Human Rights Commission (2) showed that women were consistently passed over for promotions when they were expected to become pregnant in the next few years (even if they had not mentioned the intention to do so). Additionally, women who took time off to care for children were penalised for that time off with wage decreases disproportionate to time off and hours worked, and fewer opportunities for promotion. Indeed these effects lasted as far as 30 years after taking time off. The report also demonstrated that men wanted to take time off to care for children, but were consistently discouraged from doing so.
The gender wage gap for medical practitioners is, as of August 2014, 30.7%. This is larger than the national average of 18% (3). Data show that while first year medical graduates received the same yearly wage, a wage gap between men and women steadily widens after internship. 30-60% of this wage gap is due to differences in hours worked (which in itself is mostly due to the increased load of unpaid domestic work for women). 40-70% of the wage gap in medicine has been ascribed to fewer offers for promotion, performing fewer procedures on average than men, and an “unknown factor” (4). Similar problems plague the path to medical leadership, where some 80% of the presidents of medical colleges are men.
Even AMSA is not immune to this inequality. Of the past 16 AMSA presidents, only 3 have been female, including this year’s AMSA president, Ms Jessica Dean. If AMSA is to serve its role as an advocacy body for the equal rights of all medical students, it must be aware of the impact of gender inequality on the lives of its representatives, and to reflect critically on the nuances of its own internal gender dynamics.
As you can probably guess, this is a big problem for the future of medicine. The workplace is no longer filled with career men with stay-at-home wives. The medical workplace will reach a 1:1 women to men ratio in 2020 (5), and the number of men who intend to share childrearing responsibility with their partners is steadily increasing. Additionally, increasing acceptance means more same-sex couples are raising children of their own.
As the medical field constantly changes with new innovations for the conditions we treat, we should no longer keep to outdated modes of practice. Women should not be expected to cryogenically postpone family life for a fulfilling career, and men should not be discouraged from having greater childrearing responsibilities. As you move throughout your career in medicine remember that change begins first with awareness, and a willingness to stand against the status quo.
You can read AMSA’s policy on gender equity, adopted at AMSA’s Third Council meeting in 2014, here.
1. Who Benefits When Companies Pay for Egg Freezing? [Internet]. [cited 2014 Nov 5]. Available from: http://www.newyorker.com/news/daily-comment/facebook-apple-egg-freezing-benefits
2. Australian Human Rights Commission. Supporting Working Parents: Pregnancy and return to work national review report 2014. 2014;
3. Workplace gender equality agency. Gender pay gap statistics [Internet]. 2014 p. 1–12. Available from: https://www.wgea.gov.au/sites/default/files/Gender_Pay_Gap_factsheet.pdf
4. Workplace Gender Equality Agency. Behind the gender pay gap [Internet]. 2012 p. 1–5. Available from: www.wgea.gov.au
5. Schurer S, Kuehnle D, Scott A, Chai Cheng T. One man’s blessing, another woman’s curse? Family factors and the gender earnings gap of doctors. Melbourne institute of applied economic and social research. 2012.
Nicky Betts, University of Western Sydney
In Australia, we enjoy an excellent healthcare system, despite current issues of contention like the $7 GP co-payment. We have what is essentially universal access to free, high quality healthcare, and heavily subsidised essential medicines through the PBS. Of course, there are still many issues with health in Australia, and many groups, particularly the Indigenous population, face significant systemic challenges to their health. But overall, on an international scale, we are exceedingly fortunate.
Many people in developing countries are unable to access life-saving, cheap generic medications due to patent monopolies maintained by faceless, developed-world corporations. Patents are a form of intellectual property rights which give inventors exclusive access over their ideas or products in order to incentivise novel solutions. The minimum worldwide patent standard is 20 years. Even though there are not only companies willing and capable of producing these drugs and distributing them at low cost, as well as a huge market for their purchase in places like India, China and across Africa, the rich and powerful pharmaceutical lobby obstructs this in order to maximise their own profits with a complete disregard for human life and suffering.
The Trans-Pacific Partnership Agreement (TPPA) is central to this issue. The TPPA is a regional free trade agreement (FTA) currently being negotiated by 12 countries in the Pacific Rim, including Australia, the United States, New Zealand and Japan, encompassing 40% of the world’s GDP. It includes chapters on a whole range of things, such as Environment, Customs, Market Access, and of course, Intellectual Property (IP). Provisions within the IP chapter of the TPPA released by Wikileaks in 2013 include several key issues:
- patent term extensions (lengthening the duration of patents by five years, delaying the introduction of generics)
- lowered requirements for patentability (such that molecular alterations to drug structures that do not provide clinical benefit can allow the drug to be re-patented)
- restriction of pre-grant opposition (so that inappropriate patents cannot be challenged before they are approved, only after, needlessly complicating the procedure)
- patenting of diagnostic, therapeutic and surgical methods
- expansion of data exclusivity (meaning that generic drug companies would need to repeat clinical trials for drugs that have already been proven effective, which is costly, time-consuming and unethical)
Furthermore, ISDS provisions are also included. These would allow foreign corporations to sue a member Government (e.g. Australia) over measures that affect their financial interests, including public health policy. Currently, the Australian Government is being sued by Philip Morris Asia, a tobacco company, over plain-packaging legislation due to ISDS provisions in our FTA with Hong Kong.
However, these negotiations, which began in 2005, have been shrouded in secrecy. Shady back-room discussions are being held out of the public eye, allowing Governments to escape attention being drawn to unscrupulous behaviour. Despite the lack of public representation at the negotiating table, there is somehow nonetheless the presence of pharmaceutical industry executives, which flies in the face of common sense considering their blatant conflict of interest. Even the Australian Parliament lacks access to the text. We only know the limited amount we do because of the aforementioned partial release of documentation in 2013 by Wikileaks, as well as a very recent leak this October. The recent leak reflects the unpredictable nature of negotiations – advocacy by medical groups has lead to the removal of the provision for patenting of surgical methods from the working document, but on the other hand, most concerning aspects remain.
As our knowledge and understanding of the TPPA grows, the Australian people, medical students included, must not remain silent on this issue. Our ignorance and apathy regarding this alarming development in the world of global health serves as tacit permission for the continued march towards excessively restrictive, and globally irresponsible, intellectual property law. Advocacy on access to essential medicines is, quite simply, essential; to ensure that the disenfranchised, the voiceless, of the developing world can achieve the access to life-changing medications they deserve.
Leadership is something that has always interested me so when I saw the AMSA National Leadership Development Seminar (NLDS) advertised I thought why not, this could be for me.
As a mature age student I’ve worked in management roles before and have had opportunities to develop my leadership skills but feel it is an area where there is always something new to learn. The theme of the seminar , “How do you lead in a profession of leaders” interested me as I have for some time realised that leadership is more about the actions one takes than the role one is in and that everyone has the potential to be a leader. I have also felt that leadership in the medical profession is important as we are in a great position to be advocating for better healthcare for the community, particularly those more vulnerable.
As a first year at Flinders University, the NLDS was the first AMSA event I’ve attended. I had a reasonable idea of the activities that AMSA is involved in, particularly the advocacy work, but was interested to hear more about the broad range of activities.
Speakers at the seminar came from diverse backgrounds (medical and otherwise) and shared inspirational personal anecdotes of their journeys towards being leaders and advocates. Although all speakers were of great quality, Sally Cockburn (Dr Feelgood) talking about her advocacy work in an extremely engaging and humorous way was a highlight as was hearing from the AMA President, Brian Owler about the road safety campaign ‘Don’t Rush’ he has championed.
One of the opportunities at the seminar was the NLDS Meet your MP program. Delegates were supported to contact their local MP to arrange a meeting while in Canberra to discuss issues AMSA has identified that were important to us including refugee mental health, mental health in medical students, the internship crisis and proposed deregulation of university fees. I had contacted my local MP but hadn’t heard back. However at Adelaide airport I happened to spot Nick Xenophon, SA Senator and managed to have a short conversation with him (ok, I ran after him and caught him before he disappeared into the QANTAS lounge!). He raised his concerns about deregulation of university fees and offered to meet with me and some other delegates in Canberra. A couple of chance encounters later that day (on the plane and at Hudson’s at Sydney airport….. no, I was not stalking him) and a meeting was arranged. He was generous enough to invite a number of people to attend. A delegation including medical students from SA and AMSA President Jess Dean attended Parliament House (a thrill in itself). Although Senator X only had a short time available he was interested to hear more about the impact of fee deregulation on students. The internship crisis was an issue he was not previously aware of but Jess managed to raise this in the meeting and he was concerned enough to seek more data. He also raised the impact of fee deregulation in media conferences that week. Experiencing the power of advocacy first hand like this was eye-opening and very motivational.
NLDS was a great introduction to AMSA events with many highlights, not least of which was meeting wonderful medical students from other universities across Australia. The organisation of the event was terrific with a good balance between academic and social functions. It has certainly inspired me to become more involved in AMSA and to be a progressive leader that acts, and not just to sit back and wait for change to happen.
The two-day AMA National Alcohol Summit commences at the National Convention Centre in Canberra today.
The Summit features political, medical, public health, and community leaders; police; families of victims; and other stakeholders who have come together to discuss the range of harms that alcohol brings to the Australian community, and develop practical solutions to produce a safer, more responsible drinking culture.
AMSA President Jessica Dean said she is looking forward to representing the views of medical students and young Australian at the Summit.
“We know that there are issues; we need to raise the profile of this issue and start working towards solutions,” Ms Dean said.
“Young people are bombarded with alcohol advertising in sport. We need to create a divide, create spaces where alcohol advertising cannot pervade.”
According to the AMA, 40% of young people were not aware of the harms of drinking when pregnant.
Currently, limited evidence exists regarding the efficacy of regulatory strategies to mitigate alcohol-related harms. It is important, therefore, that any future policy frameworks are formed only following collaboration with stakeholders, including young people.
“AMSA wants to ensure that young people aren’t left out of the conversation. Ask us what we think and listen to us. Only through working with young people will we be able to find an effective solution.”
The Australian Institute of Health and Welfare found that many young people between the ages of 14 to 18 report admit to behaviours that reflect a poor knowledge of the real risks of alcohol-related injury.
“It is about empowering young people to make better choices as individuals.
“Imposing limitations on individual’s personal freedoms are not steps that should be taken lightly. Rather, any solutions that do impose such limitations must be justified, well-considered, and evidence-based.”
“AMSA is calling upon universities and Government to focus on the dissemination of information and education of young people. Moreover, we are calling for adequate access to counselling and referral services for students affected by alcohol misuse.”
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24 October 2014
The Australian Medical Students’ Association (AMSA) today reiterated its concerns that burgeoning medical school fees will dramatically skew the medical workforce.
AMSA President, Jessica Dean, argues that governments should be working towards resolving the rural workforce maldistribution, not making it worse.
“The Bradley Review into higher education revealed that there were significant barriers to accessing higher education among students from rural and remote areas,” Ms Dean said.
“We also know from the Mason review that one of the most effective strategies to resolve the rural workforce maldistribution is to recruit students from rural and remote areas.
“The Government appears to want to implement the recommendations of the Mason review, and has invested in rural clinical training accordingly. It is unfortunate that the significant impact that fee deregulation will have is not being considered.”
Medical school places are capped for reasons of clinical training capacity and workforce need. The demand for these places is high. This has led some, including projections from the Grattan Institute, to suggest that fees could rise in excess of $37,000 per student per year in medicine.
“Needless to say, pricing medicine at over $200,000 for a degree would only further weaken our ability to recruit students from rural and remote backgrounds,” Ms Dean said.
“It seems only logical that if the supply of medical school places is capped, the amount that fees are allowed to rise in a deregulated environment should also be capped, to minimise negative public health and workforce consequences.
“If fees are deregulated, AMSA is calling for an independent monitoring authority to be included in the legislation to report on fee increases to the Departments of Education and Health, and the Senate.”
AMSA has expressed its concerns to two Senate hearings – including the Inquiry into the Higher Education Bill – in recent weeks. The suggestion to cap medical school fees in response to capped supply was noted in the Bill’s regulatory impact statement.
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Hok Lim is a fourth year medical student at the University of Melbourne
As medical students we dream large. We enter the profession to make a difference or create a change so that we can live in a better, healthier society. I have attended a number of global health conferences during my medical course. I had been inspired by great leaders in global health: an injection of much needed motivation and context for my medical career. But there is sometimes a feeling of being overwhelmed and dwarfed by their greatness and impact. I felt I had ideas, but lacked a road map on how to create, build and complete a global health oriented project.
AMSA’s GlobalEx conference did just that. GlobalEx sets itself apart from other conferences by creating a learning environment where there are no spectators, only participants. People came from various universities around Australia. Held over three days, GlobalEx was grueling, challenging and satisfying.
Day One provided a platform for students to explore and put forward ideas and form teams. Day Two is where groups developed their projects. Day Three was the day for consolidation and the pitch to a panel of social entrepreneurs and public health professionals.
GlobalEx fostered an exchange of ideas between people in a fun and safe environment. I felt ideas flow from people – which humbled me and showed me how much talent there is in medicine. Each day was interlaced with productive workshops lead by leaders in project development, social entrepreneurship and project management. The projects that were developed were far beyond the expectations I would have had for teams of medical students. The pitches were equally impressive. Several teams caught the eyes of the judges and were given the chance to collaborate with panel members.
The highlight from the social program was the salsa dance lesson at the Provincial bar in Fitzroy. We all got to strut our stuff. Even those who are not usually dancers looked like pros at the end of the night. ‘Salsa Sally’ [Logistics Co-coordinator Sally Gordon] showed she was Salsa Queen with a surprise Salsa display end the dance lesson. The night was topped off with a trip to Messina.
Towards the end of the conference there was a time to reflect. For some it was a great learning experience, for others, GlobalEx stirred deep emotions. Maybe it was a sense of achievement, or a sense of fluid teamwork and solidarity or a discovery of new potentials. I was amazed to see tears in a fellow delegate’s face as she expressed the profound impact the conference had on her.
If you are looking for a global health conference that will challenge you, inspire you and provide you with practical tools; GlobalEx is a must.
Transcript of AMSA’s contribution to the Inquiry into the Higher Education and Research Reform Amendment Bill 2014 (10/10/2014)
Ms Dean : Thank you very much for the opportunity to come here today and share the concerns of Australia’s medical students. We share the concerns of the other students groups about the impact that this is going to have on medical students. Furthermore, we have quite specific concerns regarding the impact of this on medical education and the consequent impact on public health. Those public health concerns are not only shared by our members, the medical students, but echoed by the council of junior doctors and the Australian Medical Association.
To provide some context, medical student places are capped. That means we have a capped supply. We know that the demand for medical student places is incredibly high, so essentially what we are looking at is not a free market. Projections from the Grattan Institute suggest that the cost of a medical education will be around $37,000 per year per student. That is for a four to six year degree. If we look at the current market, the University of Sydney is already charging over $66,000 per student per year. So what we are really looking at is a debt of up to $250,000 for a medical education but considering the lack of true market forces applying in this area our students are concerned that there is no reason that this debt will not skyrocket, given that there is capped supply and unlimited demand.
On the impacts specifically on the students themselves, as already suggested, debt itself acts as a deterrent, regardless of repayment schemes, particularly for those from lower socioeconomic backgrounds. We know from the Bradley review that rural and remote students already suffer significant obstacles to accessing education. Our students are particularly concerned that the interest rate and the impact that that will have on their life choices, particularly on their ability to have children. The nature of medical education is such that training occurs at the prime fertile age for women—more than half of medical students in Australia are female—and your salary does not plateau until after you have specialised. Most specialty training in Australia is not part-time, so most women have to wait until after their training to have children. If they are looking down the barrel of a significant debt with significant interest rates that is going to impact that choice significantly. Further, we know from a beyondblue survey of medical student and doctors’ mental health that financial stresses have a significant deleterious impact on medical students’ mental health and we know that students generally are in the most affected age demographic regarding mental health outcomes.
Turning to the public health issues, we are really concerned about the impact this is going to have on workforce maldistribution. We already have a shortage of rural doctors. We know from the Mason review that the best way to fix this is to take students from rural and remote backgrounds, who will then end up being rural and remote doctors. If this is going to deter individuals from that background it is going to have a significant effect on something we are already trying to battle. We know from studies out of North America that debt drives medical graduates away from primary care. It drives them, potentially, to more lucrative specialties. We do not need more anaesthetists. The impact that this is going to have on our distribution within the workforce is also considerable.
Lastly, where is the money going to come from? Medical students are looking at a $250,000 debt when they graduate. A large proportion of medical graduates—doctors—work in private practice. They have significant discretion not only over what they charge in fees but also over whom they bulkbill. Our concern is that if medical graduates complete medical school and go into practice with such a significant debt the people who are going to end up repaying that debt are the patients. We have significant concerns for the students themselves but also public health concerns for the future patients of Australia.
Senator KIM CARR: I ask you all: what is your view about the level or the adequacy of consultation with student groups?
Ms Dean : We have been to Canberra quite a few times this year but we have not had the opportunity to meet with Minister Pyne. We found the consultation to be quite effective in airing our concerns, but we are quite concerned that they are not being recognised appropriately. The regulation impact statement directly acknowledged the concerns of medical students and the potential impact on medical education, but negated it on the basis that doctors earn a lot of money, which is not really the primary basis of our concerns.
Mr Luthra : The regulation impact statement did not really address any of the public health concerns that we had raised with the minister’s office or with any other members that we have met.
CHAIR: Who else from the government did you meet with if you did not meet with the minister?
Mr Luthra : We have met with the minister’s office, the Treasurer’s office, the Prime Minister’s office and a number of other Liberal and National MPs.
Senator KIM CARR: We heard yesterday from Universities Australia that seeking greater public investment in universities was like flogging a dead horse. What is your view of that evidence?
Mr Luthra : In our view the issue of public funding is a matter of priorities. We have repeatedly identified in that in the past—for example, in their submission to the Lomax-Smith review on base funding, the Medical Deans Australia and New Zealand identified that medical education was underfunded by approximately $20,000 per student per year. Again, the public funding for medical education is well below the OECD average. The way see that is that those other OECD countries are prioritising medical education, the education of students and the health of their populace over politics.
Senator RHIANNON: I was going to ask the same question that Senator Carr has asked…because it is such a contrast. This is the fourth day of our inquiry and, with all the submissions and evidence, and the evidence we have had this morning from vice chancellors, it is such a different message. You all go to universities: it is where your life is at the moment What are your reflections on why there is such a difference, where you have vice-chancellors who have really signed off with a government that has said they are going to take $5 billion off higher education—it is breathtaking? The question is: why?
Ms Dean : In terms of medical education, we are often on the same page on a number of issues with the medical deans and the vice-chancellors regarding the quality of medical education. However, on this particular issue our biggest concerns are the public health impacts and, on that specifically, we found ourselves divided.
Senator XENOPHON: I will direct this to Ms Dean, and I am happy for other members of the panel to chip in. Ms Dean, you made reference to what has been occurring in North America, where there has been workforce maldistribution in terms of the way things work in the US, and your fears that this could happen here with the deregulation proposed. Are there any ways, in the context of the government’s proposals that that could be ameliorated? We heard evidence earlier from the Vice-Chancellor of Flinders University that, in terms of their programs and medical students in the Northern Territory, if you provide further assistance you can keep people working in regions and not become an exodus—not that I have anything against an exodus. Do you see ways in which what you consider to be a bad package could be ameliorated or improved?
Ms Dean : I am going to split that question into two components—maldistribution in terms of geographical location and specialty distribution. In terms of specialty distribution, the studies that we referenced are out of North America and—
Senator XENOPHON: Could you provide the committee with copies of those?
Ms Dean : Yes. The concern there is basically relating to the significance of the debt—that upon graduation the size of that debt is such that individuals are pushed into training pathways that mean they are going to be able to repay that debt sooner. I am not really aware—I will ask Kunal to add to this—of any system that would do anything to ameliorate the size of the debt, other than fixing the system itself.
In terms of maldistribution, as we have said, that is an issue of deterrence. If individuals are deterred from studying medicine that means we are not going to be able to get those individuals back into the areas of need from which they came. That is the basis of our concerns.
Mr Luthra : Thank you for your question, Senator Xenophon. The Mason review regarding rural workforce maldistribution suggested that incentive payments are not an effective workforce strategy to correct that maldistribution. We suggest that, hypothetically, if you provided debt relief to students who were willing to work in rural areas that would not be the most effective strategy to get those students working as rural general practitioners.
Rather, the effective strategies are getting students from those rural backgrounds initially—which this legislation obviously works against—and providing rural training pathways after graduation, which is probably a separate discussion. So we are suggesting a solution in a deregulated environment for medical education. Obviously, we think that deregulation in general is not a good idea, but if there was a deregulated environment, given there is a cap on the supply of medical school places, we think there should be a cap on the fees that universities are allowed to set for medical schools to prevent them from skyrocketing infinitely.
Senator XENOPHON: I understand your opposition to the deregulation model. You are saying that there ought to be an exemption to what the government is proposing by virtue of the capped medical places.
Mr Luthra : Essentially, because it is not a free market.
Senator RUSTON: Discussion about funding in this space is not new. This is not the first time that we have suggested reform in the higher education space around funding. I just wonder whether the organisations that you represent have made submissions to previous proposed changes or budgetary recommendations from previous governments. For example, have any of your organisations responded to the $6 billion worth of savings and funding changes that were proposed by the previous government?
Mr Luthra : The Medical Students Association has made submissions over the years regarding base funding. Whenever there are cuts to university education we believe that that is going to have a negative effect on medical education and on health care.
CHAIR: We are incredibly under the pinch and…it would be useful if we could actually get their stuff on the record. I have a question about internationally fabulous research. Ms Dean, which university are you from?
Ms Dean : Monash University.
CHAIR: So you are all attending incredibly successful Go8 universities. You are in a very privileged position to be at those institutions and you are all arguing on behalf of low-socioeconomic status students. I would like to hear from each of you why you did not go to your local university and yet expect—
Senator LINES: Should we all answer that?
CHAIR: Excuse me, I have listened quietly for an hour.
Senator LINES: For what purpose?
CHAIR: Because it is important. When we argue on behalf of regional students, we need to ensure that regional kids get to go wherever their brains can take them and that we have a system that supports that. I want to go to the NUS submission. The vice-chancellor of CQU, the university that has the highest proportion of low-SES students, is also the most positive advocate. We had him before the committee yesterday. I am interested in that nexus. We are out of time so I would ask each of you to take that question on notice and provide an answer in writing. I would really appreciate that. Medical students, I would also like to put to you the challenge of the maldistribution of the workforce, particularly in the context of regional areas and why we are not uncapping medical places. I would ask you to take that question on notice. Thank you very much for your evidence. It has been great.
Transcript of AMSA’s contribution to a Public Hearing of the Senate Select Committee into the Abbott Government’s Budget Cuts (16/10/2014)
CHAIR: Welcome. We have been talking a lot about the impact of this budget on young people. It is nice to have the voices of some younger people for evidence today. I understand that information on parliamentary privilege and the protection of witnesses and giving evidence to Senate committees has been provided to you. Do you have an opening statement? I invite you to give that now.
Ms Dean: Yes. Firstly, I would just like to say thank you on behalf of Australia’s medical students for the opportunity to voice some quite serious concerns that our members have regarding the budget. These concerns are in three main areas; the higher education impacts, the impact on medical training and the GP co-payment.
In terms of higher education the 20 per cent cut in base funding is devastating to the medical students of Australia. Medical deans in the base funding review showed that medical education was already underfunded by more than $20,000 per student per year. The amount that the government contributes to medical education is lower than other OECD countries. Simply, if we want to produce quality doctors in Australia then we need adequate funding. It is as simple as that.
In terms of the student impact of the debt, medical education is quite unique in that the number of medical student places around Australia is capped. That means we are functioning in an environment with limited supply. The demand on medical education is obviously very high, so the impact of market forces on this area is very dangerous. There is no reason why, with limited supply and a significant demand, the cost of medical education is not going to skyrocket. Already in Australia full-fee students pay more than $60,000 per year and a medical course cost $250,000.
The impact of such a significant debt can be seen both on the students themselves but also on the community. There are significant public health impacts of students and medical graduates carrying such a significant debt. We know that debt aversion is real. Those from lower socioeconomic backgrounds are deterred from studying irrelevant of repayment schemes. We know this from studies from the UK. Furthermore, from the Bradley review we know that there already exist significant obstacles to accessing tertiary education for those from rural and remote backgrounds.
In terms of the public health impacts, the Mason reviews shows that one of the best ways to overcome the rural doctor shortage is to take students from rural backgrounds. Therefore, in order to overcome this rural doctor shortage that we are suffering, we really need to try to ameliorate the obstacles for rural students to access medical education. We know that a significant debt pushes doctors away from primary care. We know this from studies from the US and New Zealand. If medical graduates finish medical school with a $250,000 debt looming over their shoulders, they are going to be more drawn to lucrative specialties and away from primary care, which is where we need them.
Lastly, who is going to pay the debt? A large proportion of medical practitioners practice in private practice. That means they have discretion over what they charge and who they bulk-bill. That means that ultimately this $250,000 debt may end up being paid by the patients themselves, which is not what we want to see in the future.
In terms of impact on medical training, the Prevocational General Practice Placements Program was removed in the budget. It provided GP placement opportunities for junior doctors, including medical interns. The consequence of this cut was that the number of internships were reduced around the country proportionate to this loss of funding. South Australia was particularly hard hit, with the number of internships falling by 23 from 278.
That is almost a 10 per cent cut in the number of internships offered in South Australia. We have to remember that this is occurring in a year when the number of medical graduates has increased. So rather than increasing the number of internships proportionate to workforce need and the increasing number of medical graduates we have seen a cut. This also all occurred in the week of internships applications, leaving final year medical students around Australia in a state of distress.
The abolition of HWA is concerning to our members because what it shows is that workforce planning is not being considered a priority. This is in a climate of a concerning training bottleneck, a rural doctor shortage and workforce maldistribution, where workforce planning is really quite imperative. In terms of the GP co-payment, our members support universal health care as the most equitable and efficient way to deliver health care. We believe any obligatory co-payment to be irreversible step away from this ideal. Furthermore, there is no such thing as a wasteful consult. Non-communicable diseases are our biggest health threat into the future. Prevention is imperative and deterring the community from these consults that provide an opportunity for lifestyle change is a huge backward step, as is the abolition of ANPHA. These budget cuts are going to have deleterious consequences on young people, students and households.
CHAIR: Thank you, Ms Dean.
Senator LINES: Thank you for appearing once again and thank you for your ongoing submissions and presentations. It is very much appreciated. I am sure it comes on top of already very tight work schedules. I just want to go to evidence that Ms Jenny Lambert gave—this is to the three of you—at the Senate inquiry into higher education last week. Ms Lambert said:
I understand the Senate—
and I presume by that she meant the Senate inquiry last week—
has been presented with a range of evidence and it is already in the public domain that a number of private higher education institutions have definitely committed to reducing the fees.
When Open University gave evidence about fees being reduced, the best they could say was that they had a deep hope that fees would come down. Are you aware of any of those comments being made by any institution?
Ms Dean: As I said before, medical education is already so significantly underfunded that we see no possibility that the fees will ever go down. The projections from the Grattan Institute suggest $37,000 per student per year, which is a significant increase from what they are already paying. Like I said, full-fee students already pay over $60,000, so if you are looking for a price signal that may be where it is.
Mr Luthra: If we are placing faith in market forces to reduce fees, the impact of market forces in medicine—as Jessica has already outlined—would be that, with such excessive demand and a capped number of CSP places, it would make sense for all universities to consider an increase are willing to pay as much as it takes to get into medicine.
Senator URQUHART: Thank you. I just wanted to touch on something that you said in your opening statement. It was about the cut in terms of funding to medicine courses. Will that be a disincentive for students to study in medicine courses? Do you think the extra costs, obviously, but also the cuts to the HWA and all that sort of stuff, will have some effect on people thinking, ‘I’d really like to go down that path and study medicine but with all these obstacles there now plus the bigger debt and the cost cuts, I’m not going to do it.’ Do you think that will enter into some students’ minds?
Ms Dean: Definitely. In terms of the impact of the cut to medical education I do not think it is the students themselves who should be concerned; it is the community.
We really should be concerned for the community, and the quality of the doctors that are being produced. If you are cutting corners on medical education it is the community that will suffer. In terms of the students, as I suggested, anyone would be deterred by a $250,000 debt.
That, in itself, is petrifying. Even if you are in medicine as a career, where you can make a good income and where job security exists, it is a significant debt for anyone, and it does have consequences for the individual but also for the community.
Mr Luthra: I was just going to add that, with reference to you point about Health Workforce Australia, and some of the later impacts on the training pipeline, I think that does potentially have relevance in terms of medicine as an international export. We hear a lot from the minister about making Australia’s higher education system an international export. Where we are right now, a number of international students who are currently studying medicine, and who are paying up to $60,000 a year to study medicine, are not able to secure internships and postgraduate training places in Australia. If that continues, and if the government does not address that we will see that situation worsen in future years.
CHAIR: Why is an internship important for medical student?
Mr Luthra: An internship is required for any student scheme to gain full registration as a doctor in this country.
CHAIR: Without it, the degree is pretty much useless, isn’t it?
Ms Dean: Exactly.
Mr Luthra: They would not be able to practice.
Senator URQUHART: You talked a little bit about the $7 copayment. What do you see as the ramifications of that if it is implemented?
Ms Dean: The end of universal health care, put simply.
Senator URQUHART: Describe what that means. What does it mean for the community?
Ms Dean: That means accessing health care. It is pretty simple, in its basic terms. Universal health care is one of Australia’s most prized possessions. To obliterate it in one fell swoop is incredibly disappointing and signifies a significant step backwards in terms of the evolution and development of health care in Australia.
Senator URQUHART: If people are discouraged from going to GPs, for one reason or another, and they are unable to afford the $7, what does that mean for the health system?
Ms Dean: I think the more important question is: what does that mean for the individual as well as the health system? If people are deterred from accessing health care early, particularly their GPs, generally it means you lose the opportunity for preventative interventions, which is what I touched on. Lifestyle change is one of the most effective interventions we can make in terms of non-communicable diseases and long-term, chronic, complex-care conditions. In terms of the healthcare system it means later presentations and more complex presentations.
That means longer hospital stays and, ultimately, more-costly care. Prevention is really the cornerstone of a good healthcare system, and anything that deters presentations to the GP clinic is going to be deleterious.
Senator URQUHART: Certainly it means a huge impact on the health of the individual but it means a bigger impost on the health system, because we will have sicker people presenting to hospitals. They may not have done had they sought interventionist assistance earlier on.
Ms Dean: Yes.
Senator URQUHART: There is even the lifestyle stuff that can generate people requiring hospitalisation when they may not have if they had changed their lifestyle earlier.
Ms Dean: Exactly. We are losing the opportunity for prevention, which is the most cost-effective measure.
Senator URQUHART: We have also heard from witnesses today about the possible restriction of social mobility as a result of the proposed higher education changes. Do you have a view on that?
Mr Luthra: We do. As Jessica mentioned, we think there is evidence out of the UK that suggests that people from lower socioeconomic backgrounds are deterred from higher education purely by the fact that a large debt may exist. Let’s be honest, the majority of medical students—particularly in the Group of Eight universities—are from relatively wealthy backgrounds. They would probably be in the higher SES segment of the community. We think the medical workforce should be representative, as Jessica mentioned.
If we want people to go out and be GPs in outer metropolitan suburbs or in rural and remote areas, we need to recruit people from those areas. We think that, with the higher education reforms, if there is a $250,000 debt facing you and no-one in your family has ever been to university before, that will be a deterrent.
Senator URQUHART: Do we see that now? Do we see where more rural GPs are from rural areas? I know there is a push to get GPs to go out into rural areas because of the lack of GPs particularly in those areas. Would that then become an impediment?
Ms Dean: We know from the Mason review that there are two very effective strategies. One is taking students from rural backgrounds to enter medicine. The other one is rural and regional training pathways, which we are seeing good investment in at the moment. We know that those are the two most effective strategies for increasing doctors working in rural and regional areas and overcoming the shortage.
Senator URQUHART: I know we have a fantastic rural clinical school in Burnie, in my part of north-west Tasmania, that goes out to areas like the west coast, which is very isolated. It gives medical students the feel of that sort of community and what it is like. It is so important to try to get students down into those areas so that that is where they go at the end of the day.
CHAIR: Are you having any conversations within your student bodies and so on about what they see as the consequences of these changes—in particular, I think you mentioned fee deregulation—and whether people are going to make decisions on the basis of the cost of a degree? People make statements about it influencing their choice of degree but we do not yet have any hard evidence. I am looking now for anecdotal evidence among your student cohort.
Ms Dean: I can identify four areas of choice that I think are going to be significantly affected. The first is the decision to enter medicine. A postgraduate woman who will probably be a fantastic doctor told me she already has a mortgage on her house. She has two adult children and made the decision that she wanted to become a doctor. She has very clearly said that she could not take a second mortgage for her university debt. So she is an individual who would not have become a doctor if there had been a $250,000 debt on the other side.
CHAIR: On that point: many medical degrees are now postgraduate degrees, so the intake of new graduates is older. We are talking about older cohorts. People in their thirties, after having had a career and a primary degree and so on, will often come to do degrees at Deakin University. So what you are saying is that that situation—
Ms Dean: Yes. We are essentially deterring those people from studying.
Mr Luthra: And many of those people, having completed a previous degree, would have the opportunity to enter the workforce and start repaying the debt they have already accumulated.
Ms Dean: I will talk about the other three choices that I think are significant. I have already spoken about specialty choice. That is already very significant. Already individuals who are graduating are talking about what a debt would mean. They are considering general practice or any of the other perceived lower paying specialties within medicine. They are reconsidering choosing things like anaesthetics or surgery, which they think yield a higher income potential, because of the consequences of significant debt. I have already suggested that, when they are considering what they can afford in running a GP practice, the fees they are going to charge are going to be contingent on the debt they have to pay. These are all considerations. Lastly, there are life choices. More than half of the medical students in Australia are female. The time they choose to have kids is after that they specialise, which happens to be in their thirties, which is at the latter end of their child-bearing years. The decision to take time off from medicine when you are accruing interest of up to six per cent per year on a $250,000 debt is not a small decision, and I think it is going to have a significant impact on the ability of these individuals to take time off to have kids. I know that there are already significant concerns within the medical student community about how they are going to manage that.
CHAIR: How many medical interns are going to miss out on a place this year? Do we know the total number?
Ms Dean: It is very difficult for us to speculate on those numbers, because they take into account the number that will preferentially go overseas and the number that will not graduate or satisfy the academic requirements or the English language requirements. Based on the number of applicants this year against the number of internship positions, taking into account all those caveats, there was a shortfall of 240 positions. We are optimistic that as the year goes on we will be able to better identify the exact number of those who will miss out this year. It is also difficult because every final year medical student knows the climate. They know that those numbers are what they are, and so there are a significant number of students who are preferentially taking job opportunities overseas, and that we are losing from the Australian medical workforce because the climate is what it is.
CHAIR: What should a student contribute? Obviously there are people who would like to see an entirely user-pays system, and there are other people who would say we should go back to the situation we had when students did not have to pay anything. Is the private-public notion a fair model—that if the private benefit is 30 per cent and the public benefit is 70 per cent, then it is one third-two thirds, which is private contribution versus government contribution? Does AMSA have a position on what a fair fee structure looks like for university students?
Mr Luthra: We have not got an official position on whether the private contribution should be $10,000 or $15,000. We do acknowledge that medical education is significantly underfunded, but we do consider that that underfunding should be corrected through increased public funding, as other OECD countries have approached it.
The current level of private contribution, where a medical student can graduate with somewhere from $40,000 to $60,000 of debt seems reasonable to us, but we have not speculated on a variation at AMSA.
Senator CANAVAN: Do you think that all degrees are created equal, so to speak—do some disciplines provide greater public benefits than others? I did philosophy and economics and I love discussing whether this table exists, but I do not know how much public benefit it has actually delivered to the world. What are your views on that matter?
Ms Dean: I think it is both an issue of public benefit and private benefit and also one of equity. Fairness should underpin a lot of these discussions, and I think that that should really be a priority as well.