Healthcare and education were (to my knowledge) at their freest point in Australia when Whitlam made major reforms in Australia, creating a proper public healthcare system and free tertiary education.
Ever since then, subsequent governments- from both the Liberal (read: Conservative) Party and Whitlam’s Labo(u)r (read: slightly less Conservative) Party- have chipped away at this foundation in the name of cost-cutting. I know of few other modern governments and opposition parties who are so addicted to the idea of a Surplus without understanding why they would want a Surplus.
When I started my degree, becoming a doctor was an option open to undergraduate, mature-age and postgraduate students, thus covering all the possible career paths into the degree. It was also usually a 5 year program with 2-3 years of “pre-clinicals” (anatomy, physiology and the like as well as patient communication, ethics, sociology classes) and 2-3 years of “clinicals” (attachments to a variety of medical specialities and tutorials in the hospital). It certainly seemed like a lot to learn, at a pace faster than anything I’d ever learnt before. In actual fact, the content in our course had decreased substantially from what it was like 3 years before us.
It was also composed of either local, publicly subsidised places or international student places (by nature full-fee). The AMA (the medical union) and AMC (the medical council) were steadfastly against the idea of local private fee places.
There were of course deficiencies in this system. With the vast increase in medical knowledge and a need for doctors to be able to keep learning, how do you work out what is required knowledge for doctors? How do you fund the training of enough doctors for the populace? And given that there was a certain lack of transparency as to which surgical candidates got onto the training program, and that the system seemed to produce some surgeons who were completely lacking in communication, management, leadership and academic skills, how best would well-rounded surgeons be created.
All noble intentions. However what has ended up happening is pretty contrary to those intentions.
Publicly funded medical school places increased dramatically. It in fact doubled in one year and next year the “tsunami” of new interns will start. The increase was necessary. Why it had to happen so suddenly with so little planning for providing have enough jobs or training positions in the future is a good question.
Partial “fee deregulation” (read: an increase in the cost of medical degrees by 25% in one hit) and the introduction of local “full fee paying” places has raised the barrier to entry for academically gifted poorer students substantially. At the moment, the fee for public places is almost $10,000 per year for which a student loan is available. The fee for a private place varies but is generally greater than $30,000 a year to the ridiculous $51,000 a year that the University of Melbourne charges. The student loan system (FEE-HELP for full fee places) only covers up to $115,000 in total, so I’m not sure what University of Melbourne students do halfway through their course. OH WAIT, RICH PARENTS! OR A CRIPPLING BANK LOAN! OR DROP OUT!
Some would argue that the full fee paying places are subsidising more public places, however the increase in public spots is almost completely due to more universities opening medical faculties. The University of Melbourne in fact has decreased the number of public places.
The academic barrier to entry by nature for full fee places is lower. Now, when you ask the general public what sort of doctors they want treating them, most of them want a clever doctor who knows things and can communicate to them. I would have thought that “clever” would have been more important than “has rich parents” but what would I know?
Postgraduate places are now the only option in the vast majority of medical faculties, another barrier to poorer students or those from less educated backgrounds.
The course is now 4 years for all postgraduate medical degrees. Basic sciences (anatomy, physiology, biochemistry, pathology, etc) have taken the biggest cut, especially with the entire final year being devoted to “pre-internship” which is essentially working as an intern full time (minus prescribing rights) for free. Because, you know, doctors don’t need to understand the basis of what they’re doing, why they’re doing it or future developments in their field.
The University of Melbourne, once again the worst offender, only devotes 1 year to pre-clinicals and 3 to clinicals. Remember that most hospital doctors- unlike university staff- provide teaching to students for free. Oh, wait, what’s that, University of Melbourne? You require your “MD” students to learn all the preclinical stuff as prerequisite subjects prior to doing medicine? I thought you wanted well-rounded doctors! Oh wait, that was me thinking that you weren’t a greedy institution capitalising on its snooty history. And an “MD” is now a Master’s Degree? You’ve got to be joking.
It’s expected that most medical students will do General Practice and to that end, clinical schools have been taking the scythe to the amount of speciality exposure students get. Neurosurgery? Who needs that! Certainly not GPs who have to refer on people with slipped discs or brain tumours! Or Infectious Diseases? GPs treating Infectious Diseases? In rural areas full of cattle and farmland? Well I never! Renal Medicine? Diabetic nephropathy? What’s that again?
Most speciality training programs aside from GP are now 5 years in length not including internship and residency. Given that most doctors will now graduate after a minimum of 2 degrees, this means the earliest you can finish speciality training is at the age of 32. That’s if you have a straightforward path where you’ve done a Bachelor’s Degree, gotten onto medicine straight away and then sailed into a speciality program without any waiting around. Which given the rise in medical students is unlikely.
The peak in fertility for females is in their 20s and there is significant pressure in Australia for professional women to reproduce. I should know, I get unsolicited lectures on how I’m sabotaging my fertility on a bi-weekly basis from virtual strangers at work(!) For women unlike me who do want to start a family earlier rather than later, the speciality training programs are not particularly supportive of taking time off or working or studying part time. A lot of women drop out of speciality programs due to ingrained sexism. Finishing medical school late does not help that cause in any way whatsoever.
Speciality training posts and programs themselves are moving away from basing entry on clinical exams and towards completing other lengthy and often expensive non-clinical courses and publications. What this has to do with choosing good clinicians is beyond me.
The net result is that things are heavily and unfairly weighted in favour of doctors’ children and other rich people.
Yes, we need a bigger variety of doctors. Yes, we need well-rounded doctors. Yes, we need doctors with greater maturity. Yes, we need more competent doctors with good clinical acumen.
How does diminishing academic standards and creating a system where people can pay their way into medical school achieve any of this?
There is good quality evidence out there to show that social equity, especially in education, results in improved outcomes for everyone. I don’t believe in Communist-style nationalisation of assets and enforced redistribution of wealth. But I do believe in providing equitable opportunities to deserving students and doctors.
It’s not just about working out who deserves to get into med school after all. It’s also about the lives of the general public.