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Ranking the league tables

University league tables are becoming something of an obsession. Their appeal is testament to the ‘at a glance’ approach used to convey a university’s standing, either nationally or internationally. League tables attract public attention and shape the behaviour of universities and policy makers. Their demand is a product of the increasing globalisation of higher education, tighter allocation of funding, and ultimately the recruitment of foreign students. Medical schools are not immune to this phenomenon, and are banished to a rung on a ladder year after year according to a formula that aggregates subjectively chosen indicators. While governments and other stakeholders are placing growing importance on the role of league tables, it is necessary to scrutinise the flaws in their methodology and reliability in measuring the quality of medical schools.

Academic league tables, the brainchild of Bob Morse, were developed for the US News and World Report 30 years ago. [1] They were pioneered to meet a perceived market need for more transparent, comparative data about educational institutions. [1-3] Despite being vilified by critics, several similar ranking systems emerged in other countries in response to the introduction of, or rise in, tertiary education tuition fees. [1-3] League tables have since garnered mass appeal and now feature as a staple component of the education media cycle. They often take on the form of ‘consumer guides’ produced by commercial publishing firms who seek a return for their product. [1]

Although in existence for less than a decade, the Times Higher Education (THE) World University Rankings, along with the Quacquarelli (QS) World University Rankings and Shanghai Jiao Tong University Academic Ranking of World Universities are considered the behemoths of international university rankings. They provide a snapshot of the top universities overall and by discipline. From 2004 to 2009 THE, a British publication, in association with QS, published the annual THE–QS World University Rankings, however, the two companies then parted ways due to differences over methodology. The following year, QS assumed sole publication of rankings produced with the original methodology, while THE developed a novel rankings approach in partnership with Thomson Reuters. Many countries also generate national rankings by pitting their universities against each other – Australia’s answer being the Good Universities Guide.

League tables employ various methodologies to rank universities. Most involve a three stage process: first, data is collected on indicators; second, the data for each indicator is scored; and third, the scores from each indicator are weighted and aggregated. [3] The THE rankings use thirteen performance indicators, grouped into five areas including teaching, research, citations, industry income and international outlook. [4] Teaching has a 30% weighting and constitutes a reputational survey (15%), PhD awards per academic (6%), undergraduates admitted per academic (4.5%), income per academic (2.25%) and PhD/Bachelor awards (2.25%). [4,5] QS also uses a similar construct to render their final rankings. In contrast, the Shanghai rankings are established solely on research credentials such as the number of Nobel- and Fields-winning alumni/faculty and highly cited researchers, and the number of non-review articles published in Nature and Science. [6]

The influence of ranking tables has grown to such an extent that various vested interests indulge in rankings for different reasons. [1-3,7-9] A 2006 international survey revealed that 63% of higher education leaders made strategic, organisational, managerial or academic decisions based on rankings. [7] This is not always for the benefit of students or staff, and sometimes simply reflects the desire of a senior team to appear to have had an easily-identifiable impact. It is claimed that rankings have also influenced national governments, particularly in the allocation of funding, quality assessment and efforts to create ‘world class’ universities. [8] Furthermore, there is limited evidence that employers use ranking lists as part of the selection of graduate recruits. [8]

Academic league tables are no strangers to criticism, reflecting methodological, pragmatic, moral and philosophical concerns. Critics argue that ranking lists have applied the metaphor of league tables from the world of sport; a simplistic and incapable tool for evaluating the complex systems of higher education. [3] Rankings are guided by ‘what sells in the market’ rather than the rigorous quality assurance practices of academic bodies.

The world’s main ranking systems bear little resemblance to each other, owing to the fact that they use different indicators and weightings to arrive at a measure of quality. [1-3,8,9,11] According to a study by Ioannidis et al., [10] the concordance between the 2006 rankings by Shanghai and the Times is modest at best, with only 133 universities holding positions in both of the top 200 lists. The publishers of these tables impose a specific definition of quality onto the institutions being ranked, by arbitrarily establishing a set of indicators and assigning each a weight with little theoretical basis. [1-3,8] Readers are left oblivious to the fact that many other legitimate indicators could have been adopted. To the reader, the author’s judgement is, in effect, final. Many academics are of the view that rankings do not take into account the important qualities of an educational institution that cannot be measured by weightings and numbers. [8]

Statistical discrepancies also compound the tenuous nature of league tables. Often institutions are ranked even when differences in the data are not statistically significant. [1-3,8] There have been many instances where data to be used in compiling ranking scores are missing or unavailable, especially in international comparisons. [1-3,8] Moreover, data availability is a source of bias, whereby publishers opt for convenient and readily-available date, at the expense of accuracy and relevancy. [1-3,8]

Another cause for concern is that rankings place a significant emphasis on research while minimising the role of education in universities. [5] Most educators would recognise that the indicators for quality teaching and learning are limited. [1-3,8] Various proxies for teaching ‘quality’ are used, including average student-staff ratios. [1-3,8,11] The lack of robust data relating to teaching quality is attributed to its difficult, expensive and time-consuming nature. [2] When considering that teaching quality is one of the key dimensions of medical education, its neglected importance severely compromises the meaning of any data produced by these tables.

The main mechanism for quality assurance and evaluation amongst medical schools at present is regular accreditation by national or regional accreditation bodies. [5] The Australian Medical Council (AMC) is responsible for setting out the principles and standards of Australian medical education, including assessment. The ‘one-size-fits-all’ approach of ranking tables is a futile means to effectively measure the quality of medical schools. Medical education is characterised by a range of unique indicators, for example, clinical teaching hours and global/rural health exposure. As a direct consequence of accreditation bodies, most medical schools deliver a consistent level of education and yield competent interns to practice in the Australian healthcare system. By contrast, league tables are over-simplified assessment tools for evaluating the quality of medical education, and even have the potential to harm the standards of education. [10]

Although league tables are not exalted and revered to the same degree as in the US or Europe, Australia is inadvertently heeding this imperious trend. League tables are nothing more than ‘popularity polls’, and should not become an instrument for measuring the quality of universities and medical education.

References

[1] Usher A, Savino M. A world of difference: a global survey of university league tables. Toronto (ON): Education Policy Institute; 2006 Jan. 63 p.

[2] Stella A, Woodhouse D. Ranking of higher education institutions. Melbourne: Australian Universities Quality Agency; 2006 Aug. 30 p.

[3] Marginson S. Global university rankings: where to from here. Asia Pacific Association for International Education. 2007 Mar 7-9; Singapore. Melbourne: Centre for the Study of Higher Education; 2007 Mar.

[4] Baty P. Rankings methodology. Times Higher Education; 2011 Oct 6. [updated 2012; cited 2012 Apr 7]. Available from: http://www.timeshighereducation.co.uk/world-university-rankings/2011-2012/analysis-rankings-methodology.html

[5] Harden RM, Wilkinson D. Excellence in teaching and learning in medical education. Med Teach. 2011;33:95-6.

[6] Liu NC, Cheng Y. The academic rankings of world universities. Higher Education in Europe. 2005 Jul;30(2);127-36.

[7] Hazelkorn E. Handle with care [Internet]. Time Higher Education; 2010 Jul 8. [updated 2010 Jul 8; cited 2012 Apr 7]. Available from: http://www.timeshighereducation.co.uk/story. asp?storycode=412342.

[8] Lee H. Rankings of higher education institutions: a critical review. Qual High Educ. 2008 Nov;14(3):187-207.

[9] Saisana M, D’Hombres B. Higher education rankings: robustness issues and critical assessment. Luxembourg: Office for Official Publications of the European Communities; 2008. 106 p.

[10] Ioannidis JPA, Patsopoulos NA, Kavvoura FK, Tatsioni A, Evangelou E, Kouri I, Contopoulos-Ioannidis DG, Liberopoulos G. International ranking systems for universities and institutions: a critical appraisal. BMC Med. 2007 Oct 25; 5(30).

[11] McGaphie WC, Thompson, JA. America’s best medical schools: a critique of the U.S. news and world report rankings. Acad Med. 2001 Oct; 76(10):985-92

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Humble beginnings to life changing discoveries

Welcome to Volume 3, Issue 1 of the Australian Medical Student Journal. As always, we hope this issue offers excellent food for thought for budding doctors and researchers.

From our deputy editor, Hasib Ahmadzai, comes an editorial reflecting on the role of medical students in medical discoveries in the past. It goes to show that when medical students get to work, it is amazing just what we can achieve!

Australian of the Year and plastic surgeon Prof Fiona Woods entertains us with stories of how her early experiences stretched her mind and informed her later discoveries. Our other guest author, Sir Gustav Nossal, uses his decades of research experience in immunology to provide an insightful discussion on the serious inequalities present in global health.

The award for best article for Volume 3, Issue 1 of the AMSJ goes to Matthew Bray and Daniel Keating for their original research on ‘Immunisation and informed decision making amongst Islamic primary school parents and staff’. Their research was considered by editorial staff to be robust in methods and offering a unique perspective on an issue that is not often considered by practitioners in Australia.

As a young journal, we host many changes each time we go through the publication process as we strive to continually innovate and bring readers the highest quality of student research publication.

The editorial department has undertaken many of these changes. One of our aims has been to make the AMSJ a truly Australia-wide medical journal. This issue is the first for which we have recruited editorial and production staff from almost every state. Our team has welcomed seven new editors and now represents ten different Australian universities. With both rural and urban students on board, we believe that the AMSJ is well equipped to encourage research across a wide range of medical practice settings.

This is also the first time that the publication process has primarily taken place through email and teleconference, rather than face-to-face meetings. We have particularly benefited through the adaptation of cloud technology. With this change, remote collaboration has been made easier and more efficient.

While we have engaged Australia on an organisational level, this issue sees further efforts to bring equal readership and access to the journal for all Australian students, regardless of location. This has culminated in distribution to not just every medical school in Australia, but also their 50 rural clinical schools and campuses.

Furthermore, the AMSJ website has seen many advances to keep pace with current technology, including a touch-friendly mobile website (which can be found on your smartphone at www.amsj.org).

Other upcoming events include the next round of recruitment for the AMSJ team in August this year. We would strongly encourage enthusiastic and dedicated medical students to apply for one of the many roles available. This is a unique opportunity to become part of a growing national organisation which encourages development of critical thinking, teamwork and research publication skills.

We would like to extend our thanks to all of the voluntary AMSJ staff and external peer reviewers for their invaluable efforts in the production of this issue. To our readers: thank you for your continued support and we hope you will share our passion for medical student research.

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The great wall of medical school: A comparison of barrier examinations across Australian medical schools

Figure 1: Miller’s Pyramid of Clinical Competence with Associated Assessment Methods. Adapted from [2], with permission.

Figure 1: Miller’s Pyramid of Clinical Competence with Associated Assessment Methods. Adapted from 2, with permission.
From the moment that a medical student receives their university offer until the moment they take the Hippocratic Oath in front of proud family and friends, they will tread a path only taken by a select number before them. However, with medical schools now in every state and territory of Australia, the journey will not be identical for all students. For some, this will be a marathon, with continuous assessment peppering the entire journey, while others will encounter multiple large hurdles, interspaced with periods of calm. Despite this very different experience of medical school, all will ultimately compete for an increasingly competitive pool of internship positions, which represent the key to unlocking their future medical careers…

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In and out in four hours: The effects of the four-hour emergency department target on patients, hospitals and junior doctors

Introduction

In the eyes of the general public, a hospital’s Emergency Department (ED) is synonymous with overcrowding and tedious waiting. Keen to change this, last year, at the meeting of the Council of Australian Governments, the states ratified a National Partnership Agreement on health reform. One controversial outcome of this agreement was the four-hour National Access Target (NAT), which requires that all patients that present to EDs will need to be admitted, discharged or referred within four hours, if clinically appropriate. [1-3]

The new targets are currently being phased in, beginning with life-threatening triage 1 cases, but the true impact of the plan is unlikely to be felt until 2015, when non-urgent triage 5 cases will also be required to meet the target. Under the terms of the agreement, if 95% of patients within a particular Australian state are seen within the four hour target, that state will be awarded extra funding out of a national pool of $250 million over the next four years. [2]

The introduction of the NAT has been met with several questions. Does putting a time limit on patients in the ED jeopardise their safety due to rushed management decisions? Is it realistic that this target can be met when there are so many factors impeding efficient patient assessment? How will you be affected when you work against the clock in the coming years?

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Crossing boundaries – the expansion of the AMSJ

Some staff of the AMSJ. Clockwise from left: Patrick Teo, Timothy Yang, Matthew Schiller, Chris Mulligan, Praveen Indraratna, Aaron Tan, Alexander Murphy, Grace Leo, Veronica Lim and Helena Jang.
Some staff of the AMSJ. Clockwise from left: Patrick Teo, Timothy Yang, Matthew Schiller, Chris Mulligan, Praveen Indraratna, Aaron Tan, Alexander Murphy, Grace Leo, Veronica Lim and Helena Jang.

From treating acute blood loss in children to palliative care barriers for the elderly, this issue truly showcases the enormous potential and diverse interests of Australian medical students. Our authors have not been afraid to address controversial issues such as emergency department waiting times, healthcare financing and comparisons between barrier exams across Australian medical universities. We are also privileged to be sharing the insights of four remarkable professorial guest authors. Former Australian of the Year recipients Fiona Stanley and Ian Frazer shed light on future directions of research; the IVF and stem cell research pioneer Alan Trounson reflects on progress in his field and Alden Harken, Professor of Surgery at the University of California San Francisco reminds us how fortunate we are to be in medicine.

 

A core focus of the AMSJ is to become a national journal, that is, one which represents fairly and equally the academic and research achievements of students Australia-wide, without ties to a particular university. The journal has expanded widely in recent months, our current editorial team now spans four states, and we are moving towards full nationalisation of our staff for future issues. Meeting our readers is also a key priority in shaping a national journal, and we were very pleased to hear many positive comments and suggestions from those who attended the AMSA National Convention and Global Health Conference in July.

One of our exciting new initiatives is the AMSJ Blog, updated regularly at our website: www.amsj.org/blog. Authored by staff members, it provides personal perspectives on medical student life, with articles ranging from practical educational posts to lessons learnt outside the hospital, and tackling the bigger questions we all ask ourselves from time to time (‘So you don’t want to be a doctor anymore?’). We hope you take a look at this terrific new forum for student participation.

As always, support for the AMSJ across Australia’s medical schools has been extraordinary, with the free print copies being in huge demand. Remember that you can download the entire journal for free from our website. Articles from the AMSJ will soon be available on the EBSCOhost database and have gained interest from other major academic research databases and indexing systems. We have also had the pleasant ‘problem’ of reaching our friend limit on Facebook and are switching to a new AMSJ Facebook page: www.facebook.com/amsj.org so please make sure you visit and click ‘Like’ to stay up-to-date!

The journal is a massive undertaking, and we are grateful to have a wonderful and dedicated volunteer staff of medical students and peer-reviewers who work very hard to make this journal a success. Of course we also thank you, our readers, for welcoming and supporting us as the AMSJ continues to display the research abilities of Australia’s medical students.

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Telemedicine: The possibilities, practicalities and pitfalls

The internet has woven itself into the fabric of society, by offering a plethora of services which have evolved from luxuries to necessities.

Telemedicine – the use of the internet to transmit information for diagnosis and management – has garnered recent attention because of the Federal Government’s promise to provide AU$392million for its development, and the proposed national broadband network which may increase the efficiency of telemedical services. [1,2] Telemedicine, endorsed by the Australian Medical Association, [3] has a number of applications; however, the most highly publicised of these is the concept of online interactive consultations with a specialist practitioner in real-time, potentially using a Skype™-like platform.

In the coming years, telemedicine will likely play a significant role in our careers and as such, we must have an understanding of both its benefits and limitations. Despite the obvious potential of telemedicine, several questions remain in the minds of the public, doctors and also medical students. The first is: do we really require telemedicine? The costs are significant, but so is the need for the 12% of Australia’s population inhabiting outer regional and remote locales – data travels significantly faster over hundreds of kilometres than patients and their families. For example, geriatric patients even in the relatively large Queensland town of Rockhampton may need to travel over 600 kilometres to their nearest geriatrician. [4] For frail elderly patients, this is hardly practical. To help address this, the University of Queensland’s Centre for Online Health currently provides approximately 2,200 inpatient and outpatient consultations annually, primarily for geriatric and paediatric patients. A designated outpatient clinic exists at the Royal Children’s Hospital, Brisbane, and the transmission of video, radiological images, laboratory data and medical records allow distant consultants to conduct ‘video ward rounds’ for their inpatients. [4,5]

Nonetheless, even if there is a need for telemedicine, is it effective? Can doctors really diagnose and treat patients they are not in the physical presence of? Although telemedicine has been studied in several ways, two particular studies investigated these questions. A Canadian randomised controlled trial found that telepsychiatry and face-to-face psychiatry produced equivalent clinical outcomes [n = 495]. Further, when comparing the travel and accommodation costs of patients versus the cost of videoconferencing technology, the authors found the costs of the latter to be 10% cheaper. [6] Similarly, a Scottish study which compared 44 outpatient diagnoses and management plans made by a neurologist in a face-to-face…

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National standards in medical education

Since 1999, the number of Australian medical schools has doubled.

While this has brought about diversity, it has arguably also created a worrying lack of standardisation in the skills of graduates. National curricula are currently a hot topic, with the development of a standardised Australian curriculum for Kindergarten to Year 12 well underway. Is it time to rekindle a similar debate within Australia’s medical education sector?

Presently, the only force acting to maintain a degree of standardisation between Australian medical curricula is the Australian Medical Council (AMC) and its accreditation processes. The AMC accreditation standards guide, while laudable, does not direct the specific structure or content of curricula, leaving the door open for the veritable potpourri of programs that we now have across the country. For example, the guideline for curriculum content of the basic biomedical sciences, which occupies one line of the document, does not even mention the names of the various biomedical disciplines: “[t]he course provides a comprehensive coverage of … basic biomedical sciences, sufficient to underpin clinical studies.” [1] Either the AMC is not prepared to put more specific guidelines in the public domain, or little guidance exists to direct curriculum development. The open-ended regulatory framework has seemingly acted for more than a decade to feed a process of medical schools constantly reinventing the wheel with ‘revolutionary’ medical programs.

Of all the medical science disciplines, the teaching of anatomy has been the most criticised in recent times. Anatomy provides a case study in teaching disparities between universities. In a recent national survey, striking differences were demonstrated between medical schools in several areas, including the amount of hours dedicated to formalised anatomy teaching, the delivery of lessons, the use of cadavers, and the manner of assessment of anatomy knowledge. [2] For example, eleven of the nineteen medical schools surveyed have no specific requirement that student demonstrate sufficient anatomical knowledge at examination. Most medical schools pool anatomy questions with those of other disciplines, and calculate an overall passing grade. Thus, a student could be considered competent in basic clinical sciences without passing anatomy. These and other findings have prompted recent calls for a national curriculum for anatomy. [3] However, despite being extremely topical of late, anatomy is but one example of the heterogeneity in teaching across Australia. It would be difficult to make a strong case for having a standard curriculum for one subject and not others.

The suggestion…

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Forging Ahead

The first copies being distributed at the launch

It is a pleasure to welcome you to this issue of the Australian Medical Student Journal (AMSJ).

After the very successful launch of the AMSJ’s inaugural issue in 2010, it has been decided that the journal will now operate on a biannual basis from this year.

It has been almost a year since the AMSJ’s launch function, which was held on the 29th of April 2010 at the new Lowy Cancer Research Centre in Sydney. A sizeable crowd of medical students, clinicians and academics from across Australia were present for the event, including many of the authors published in the inaugural issue. Among the guests was AMA President, Dr. Andrew Pesce, who cut the ribbon from the first box of copies. Also present were many of the generous sponsors of the inaugural issue.

Following the launch, 2,500 hard copies of the journal were distributed to students Australia-wide via the twenty university medical societies. In early July, through a partnership with the Australian Medical Students’ Association (AMSA) Global Health Conference (GHC) in Hobart, copies were distributed to all 500 delegates. The new AMSJ website also proved to be a huge success, receiving around several thousand visits in the week after the launch, and over 15,000 visits in the months that followed.

The second half of 2010 saw the roll-out of the first major phase in expanding the AMSJ’s staff structure. A national recruitment campaign has seen the AMSJ take on staff from all twenty Australian medical schools, giving the journal a tremendous presence in the student community within a short period of time. Check our staff list to find out who is the AMSJ Representative at your university.

Continuing in the footsteps of the inaugural issue, this issue contains a broad range of high-quality student research, reviews and opinion pieces. Women’s and children’s health are particularly well represented in this issue, with articles covering the acute abdomen in pregnancy, causes of neonatal death, ovarian conditions, vertical Hepatitis B transmission, and the confidentiality rights of minors. Medical hygiene also comes under the spotlight with articles on alcohol-based hand rubs, and stethoscopes as vectors of infection. We have also published articles from an interesting range of guest authors, this time with a little more of an educational slant. Among others, John Murtagh (author of Murtagh’s General Practice) offers some advice on how to deal with baffling patient presentations, while Murray Longmore (author of the Oxford Handbook of Clinical Medicine) shares some tips on how to enjoy one’s patients more! Nobel Laureate, Peter Doherty, and outgoing editor of the Medical Journal of Australia, Martin Van Der Weyden, offer some reflections on their interesting career paths.

We are also pleased to announce that we will be partnering with the AMSA Convention 2011 to present the 2011 NHMRC Student Research Competitions (see page 14). If you are in Sydney in July for the Convention, look out for us there.

Once again, I offer a huge thank you to everyone who has made this publication possible, including the authors, staff, sponsors, and most importantly, our readers.

I would encourage you to think of how you may like to contribute to the next issue of the AMSJ. Submissions are already open for the next issue, which is due to come out in September. Also, stay tuned for updates about our next round of national recruitment.

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International medical students: Interned by degrees

The progression from university to the workforce in medicine is not comparable to any other discipline or profession.

An internship is essentially an extension of a medical degree, and the degree is redundant without one. The issue of the burgeoning numbers of Australian medical graduates, and the associated ‘crisis’ in intern placement availability, is currently the preeminent political issue for medical students. Increasingly, international students have been caught in the middle of the storm.

To put this situation in the proper context, one needs to look back to the late-1980s and 1990s. At this time, Australia was seen as being oversupplied with doctors in general. There was a strong policy reaction to this sentiment, which capped student numbers, and levied heavy restrictions on overseas-trained doctors. The turn of the century saw an abrupt turnaround in this attitude, as a different picture was painted about the country’s long-term health workforce requirements. Temporary resident visas for overseas doctors grew from 664 in 1993-1994 to 1923 in 2001-2002. [1] On the graduate front, from around 2003, government policy has allowed international medical graduates to remain in Australia. [2] Given worsening projections for future workforce shortages, one could be forgiven for thinking that this was seen as the start of a norm that would continue indefinitely. While incoming international students were never given a guarantee of placement after graduation, until recently, it was often implied that this would never be an issue.

Australia only had ten medical schools in 1999, whereas today we have twice this number. [3] International places have increased as a proportion over this time. In 2002, 161 international students graduated from Australian medical schools, representing 11% of total graduates. This year, the number is predicted to be 423 students, or 16% of the total. This is as high as 34% at one institution. [4] Unfortunately, while governments eagerly and justifiably expanded the numbers of medical places at universities, this was not matched by sufficient planning for long-term doctor training. Consequently, last year, many graduates had genuine cause for concern about receiving an intern placement. However, just because we have a bottleneck of medical graduates does not mean that we have an oversupply. Make no mistake; the future of our health system needs every single graduate we are producing. Although we are dealing with unprecedented numbers, the training system needs to come to terms with this reality as soon as possible.

Even domestic Commonwealth-supported students have had reason to worry until the Australian Health Ministers’ Conference this February, when they were given a guarantee of training places for the foreseeable future. This is to be achieved by doubling the undergraduate clinical training subsidy across all states for 2010-2011, with the annual commitment totalling $140m nationally. [5] While this is a very positive and encouraging step forward, it excludes many potential future doctors.

For international students, there are no guarantees. Worse still, some international graduates from certain Australian medical schools would not even be able to gain an internship-equivalent in their home country. One cannot underestimate the perspective of our international colleagues – after spending a fortune on living expenses and university fees, being told that they will not be able to continue their training in the country where they graduate. For some, continuing their training anywhere may be extremely difficult. This is the frightening scenario that many are now facing.

It is not a well-kept secret that many medical faculties around the country are heavily reliant on international students and their fees to fund medical programs. Can we justify milking international students for their dollars, followed by abandonment at graduation in favour of the colleagues whose degrees they subsidised? Furthermore, there is the possibility that the international student funding source could deplete if recent developments discourage new students from coming here.

Currently, governments spend enormous sums of money attracting and retraining foreign health workers. Admittedly, overseas-trained doctors are filling a more immediate gap in the system that is considerably further down the line of training than internships. This is no doubt necessary for the time being. Nonetheless, it seems senseless that we are prepared to spend such amounts bringing overseas-trained doctors into the country, but cannot bring ourselves to adequately train and retain doctors reared in our own top-class medical schools.

The ramifications extend beyond just international students. Local full-fee-paying students, who make up further 6% of medical graduates, are also excluded from the recent guarantee of training places. [6]

The challenge, of course, is not just to make places for more students, but to ensure that this does not affect the quality of teaching that all trainees receive. It is also critical that we do not simply replicate the mistakes of the past: we need to ensure that there is adequate downstream planning, not just more intern places. Recent government announcements about General Practice and specialist training places are encouraging in this regard. [7]

If governments consider international and domestic full-fee-paying students not worth retaining, then they should perhaps reconsider the approval of such medical places in the first instance. But for those already in our programs, this line of reasoning simply is not good enough. There is no adequate justification for any Australian-trained medical student being denied an intern placement. It is nonsensical to on one hand have a workforce shortage, and on the other hand be turning away the best long-term solution to that shortage. If someone is good enough to be trained in an Australian medical school, then they should be good enough to practice here.

References

[1] Hawthorne L, Birrell B. Doctor shortages and their impact on the quality of medical care in Australia. People Place 2002;10(3):55-67.

[2] Joyce CM, Stoelwinder JU, McNeil JJ, Piterman L. Riding the wave: current and emerging trends in graduates from Australian university medical schools. Med J Aust 2007; 186(6):309-12.

[3] Prideaux D. Medical education in Australia: Much has changed by what remains? Med Teach 2009;31:96-100.

[4] Medical Deans Australia and New Zealand. National Clinical Training Review: Report to the Medical Training Review Panel Clinical Training Sub-committee [Online]. 2008 Mar 26 [cited 2010 Mar 12]. Available from: URL: http://www.medicaldeans.org.au/pdf/Medical%20Deans%20National%20Clinical%20Training%20Review%20March.pdf

[5] Department of Health and Ageing. Australian Health Ministers’ Conference Communiqué [Online]. 2010 Feb 12 [cited 2010 Mar 12]. Available from: URL:http://www.health.gov.au/internet/main/publishing.nsf/Content/mr-yr10-dept-dept120210.htm

[6] Medical Deans Australia and New Zealand. Medical students may never qualify, warn Deans. [Online]. 2010 Mar 9 [cited 2010 Mar 12]. Available from: URL:http://www.medicaldeans.org.au/media_090310.html

[7] Department of Health and Ageing. Building a National Health and Hospitals Network: Training a record number of doctors [Online]. 2010 Mar 15 [cited 2010 Mar 20]. Available from: URL:http://www.health.gov.au/internet/ministers/publishing.nsf/Content/mr-yr10-nr-nr046.htm