Medical Training Review Panel: sixteenth report
The Medical Training Review Panel (MTRP) was formed under legislation in 1996 to report to the Commonwealth Minister of Health on the activities of the MTRP and provide data on medical training opportunities in Australia. Over the years the panel has aimed, through its annual report, to provide a comprehensive picture of medical education and training, supplementing this with other data on the medical workforce supply.
The sixteenth annual report of the MTRP, like its predecessor, provides information on university, prevocational and vocational medical training positions, students and trainees, examination results and college fellows. Information is also included on medical practitioners who have trained overseas seeking to and/or currently working in Australia.
The report was compiled in collaboration with Health Workforce Australia and the Australian Government Department of Health and Ageing, with oversight by the MTRP.
Data were provided by the Medical Deans Australia and New Zealand Inc (MDANZ), medical colleges, General Practice Education and Training Limited (GPET), state and territory health departments through their postgraduate medical councils and the Australian Medical Council (AMC). Selected administrative data from the Australian Government Department of Health and Ageing and the Australian Government Department of Immigration and Citizenship have also been included.
To aid readability, tables in the body of the report present time series information on the last five years for which data is available. Data for all years, where possible back to 1997, the first year of annual reporting by the MTRP, are included in Appendix D. For the purposes of the Executive Summary, the latest available data have been summarised and trends in the data have been examined across all years for which national data is available.
University Medical Training
Initial medical education is provided by university medical schools in Australia as five-year and six-year undergraduate courses or as four-year graduate courses. There are 18 universities with accredited medical schools. A number of these schools were established relatively recently, with the first graduates emerging in 2011 from the University of Western Sydney (UWS), Deakin University and Sydney Campus of Notre Dame University.
In 2012, there were 16,868 medical students studying in Australian universities, an increase of 377 or 2.3% from 2011. Just over two-fifths (7,358 or 43.6%) of these students were undertaking a four-year course. This was slightly higher than in 2011 (6,778 or 41.1%).
Over three-quarters of all places each year are Commonwealth-supported (Figure 1). This remained relatively stable from the previous year, with 13,289 or 78.8% of all students in 2012 receiving Commonwealth support. The majority of these (9,538 or 71.8%) received Higher Education Commonwealth Support (HECS). The remainder were in bonded places receiving assistance through the Bonded Medical Places Scheme (BMPS) and the Medical Rural Bonded Scholarship Scheme (MRBSS), which obligates the student to work respectively in a District of Workforce Shortage for a period of time equal to the length of the medical degree, and in a rural area for six continuous years. In addition medical students can be supported by scholarships through a variety of other sources, namely the state or territory, the university or other institutions and, for international students, their home country.
Overall international students occupied 2,691 or 16.0% of places. These students are studying as private or sponsored students and are not Australian citizens, permanent residents or New Zealand citizens. A small proportion of Australian citizens (801 or 4.7% of medical students) also pay fees. From 2009 new full fee paying undergraduate places for Australian students ceased to be available.
Figure 1: Medical students by type of student place: Number and proportion of places, 2012D
Source: Medical Deans Australia and New Zealand Inc
In 2012, 226 medical students identified that they were Aboriginal or Torres Strait Islander. Although this is a relatively small proportion of all medical students, the number is almost twice as high in 2008, when just 129 students identified as Aboriginal and/or Torres Strait Islander people(s).
Of the total medical students 3,686 were in the first year of their medical studies and 3,035 or 82.3% of these were domestic students.
Most students are under the age of 25 years when they commence their medical studies. Data from 2011 shows that just over four-fifths (81.6%) of students were under 25 years (Figure 2). A further 13.1% were aged between 25 and 29 years and 5.3% were 30 years or older.
Just over half (52.3%) of the medical students commencing in 2011 began their studies after finishing another degree.
The number of medical students studying in Australian medical schools has increased significantly since 2000 (when data were first collected on all medical students) and most markedly since 2006. In 2000 there were just 7,746 medical students and by 2012 the number has more than doubled to 16,868 medical students (an increase of 117.8%). In 2000, 14.6% of all medical students were from overseas and this had increased slightly by 2012, when 16.0% were international medical students.
Figure 2: Commencing medical students by age groups, 2011D
Source: Medical Schools Outcomes Database
Over the last decade, the total number of commencing medical students has more than doubled, with the intake increasing by 1,849 or 100.7% from 1,837 to 3,686 in 2012. This was primarily due to increases in the number of commencing domestic students, which rose by 106.5% compared with an increase of 77.4% for international students.
These increases are mirrored in the number of medical graduates each year. In 2011 there were 2,964 medical graduates, just over double the 1,400 graduates in 1999 (Figure 3). The increase of numbers graduating annually fluctuated slightly up until 2006, but since then there have been marked annual increases of over 10 percent, lowering again in 2011 with the number graduating in 2011 being only 8.5% higher than the 2,733 in the previous year 2010.
The trend is somewhat different between graduating domestic and international students. International students constituted just 10.3% (or 144 of 1,400 graduates) in 1999, the first year for which data on these graduates were published. Since then the number has more than trebled, rising by 217.4% to 457 graduating international students in 2011. The number has also increased as a proportion of all medical graduates, reaching a peak of 19.5% in 2009. The proportions of graduating international students have seen a downward trend since 2009, where in 2011 it was 15.4% of all medical graduates.
The increases in the number of domestic students graduating each year have been far greater over the same period, with domestic medical graduates increasing by 99.6% overall, from 1,256 in 1999 to 2,507 in 2011.
Figure 3: Domestic and international medical graduates, 1999–2011D
Source: Medical Deans Australia and New Zealand Inc.
From 2010 to 2011, the actual number of graduates increased by 8.5% rising from 2,733 to 2,964. Based on current student enrolments it is anticipated that the number of medical graduates will continue to increase in the coming years up to 2016 (Figure 4). It is projected that there will be 3,318 graduates in 2012, an 11.9% increase. Further increases in the number of graduates are anticipated up to 2014 with modest annual growth projected in 2015 and 2016 (1.8% and 1.7% respectively). The number of graduates in 2017 is expected to decrease by 0.3% to 3,832.
Figure 4: Projections of domestic and international medical graduates, 2011–2017D
Source: Medical Deans Australia and New Zealand Inc.
Prevocational Medical Training
Satisfactory completion of the first postgraduate year (PGY1) is required before junior doctors can receive unconditional general medical registration. After PGY1, and prior to starting vocational training, most doctors spend one or more years working in the public, private or community settings to gain more clinical experience.
In 2012, there were 2,950 trainees commencing PGY1 (Figure 5). This was an increase of 227 (8.3%) from 2011.
Just over three quarters (2,292 or 77.7%) of all PGY1 trainees commenced training in the state or territory in which they completed their medical degree.
PGY1 commencements have increased substantially each year, with the exception of 2007, showing an overall increase of 1,419 or 92.7% trainees from 2004 (when data was first collected for the MTRP) to 2012.
Figure 5: Postgraduate year 1 commencements, 2004–2012D
Source: State and Territory government health departments
In 2012, there were 3,101 trainees who were identified as commencing in PGY2 supervised medical training positions across Australia. This was an increase of 580 or 23% from the previous year (Figure 6). This is likely to be an underestimation of the true numbers of doctors undertaking their second year of prevocational training, as unknown numbers may be recruited by health services.
The number of PGY2 commencements appears to have increased substantially in recent years. However, it is difficult to ascertain the true extent of the increase due to differences in the way prevocational trainees are actually contracted and methodological issues in obtaining data. As a result of differences in the data captured through the various state and territory reporting systems.
Just over half (1,779 or 57.4%) of all PGY2 doctors commenced their second year of training in the state or territory in which they were trained in previously, compared with 404 or 13.0% that came from interstate.
Figure 6: Postgraduate year 2 commencements, 2004–2012D
Source: State and Territory government health departments
Not all junior doctors go on to train in a Medical Specialty. A number continue to work in hospital settings in non-vocational career roles, typically as career medical officers.
While a number of specialist medical colleges may accept entrants to vocational training programs directly following completion of PGY1, most require applicants to have completed the PGY2 year of general prevocational training.
Vocational Medical Training
Most junior doctors will seek entry into specialist or vocational training, which leads to a fellowship from a recognised medical college. Training is provided through the specialist medical colleges and, in the case of general practice, General Practice Education and Training Ltd. vocational training programs are accredited by the Australian Medical Council. Each college has its own training program and requirements.
Data covers all Australian trainees, as well as International Medical Graduates (IMGs) who were registered vocational trainees and who were working or training in an accredited training position, post, facility or program.
There were 16,740 vocational medical trainees in 2012 (Figure 7). This is over two and a half times the number reported in 2000 (7,262 vocational trainees).
In total there were 5,744 basic trainees, representing just over one third (34.3%) of all trainees in 2012. There has been a constant increase in the number of basic trainees since 2004, mainly due to some colleges having introduced basic training as a pre-requisite to entry into their advanced training programs. Of the total number of basic trainees, 1,805 or 31.4% were in their first year.
In total there were 10,996 advanced trainees in 2012, making up the larger proportion of the total number of trainees, 65.7% of the total number of trainees. The proportion between total and advanced trainees has seen a continued decrease since 2004, averaging between 60% – 90% per year, however total advanced trainee numbers have risen by 72.4% since 2004.
Figure 7: Vocational medical trainees, 2000–2012D
Source: Medical colleges
The education and training requirements of each medical specialty depend on the type of clinical medical practice, but commonly include basic and advanced training. Where required, a trainee can only apply for and compete for a position on an advanced specialist training program after successfully completing a basic training program or at a minimum PGY2.
Almost one third (31.5%) of all vocational trainees positions were in specialties governed by the Royal Australasian College of Physicians (adult medicine, occupational and environmental medicine, paediatrics, public health medicine, rehabilitation medicine, addiction medicine, palliative medicine and sexual health medicine), with 21.9% in adult medicine (Figure 8). One-fifth (20.6%) of all vocational trainee positions were in general practice and 12.1% in emergency medicine.
Figure 8: Vocational trainee positions by medical speciality, 2012D
Source: Medical colleges
When medical practitioners finish their vocational training and have met all other requirements of the relevant college, they are eligible to apply for fellowship of the medical college.
There were 2,629 new college fellows in 2011 (Figure 9). This is a significant increase since 2000, when the data were first collected with the number of new fellows having more than doubled (133.5%) from 1,126.
In 2011, just over two-fifth (1,149) of all new fellows were female.
Almost one-quarter (646 or 24.6%) of new fellows were overseas trained specialists who were assessed as having qualifications comparable with specialists trained by the medical college in Australia and given fellowship of that college.
Figure 9: New fellows by gender, 2000–2011D
Source: Medical colleges
The proportion of new fellows in each medical specialty is shown in Figure 10. The proportionate split has remained approximately the same across the specialties over recent years, with just over two-fifths (40.9%) in general practice.
General practice had the largest increase over the last five years in terms of absolute numbers, with 462 more new fellows in 2011 than in 2007. There were also large increases in the number of new fellows in adult medicine, anaesthesia and psychiatry (increase of 153, 73 and 59 in 2011 than in 2007 respectively).
In terms of proportional increases, the number of new fellows in paediatrics was two and a half times (117.0%) higher in 2011 than in 2007. Two other specialties, radiation oncology (83.3%) and psychiatry (81.9%), showed significant increases across the five years however, the numbers were small and fluctuated considerably.
The significance of the increased training activity and consequently the number of new fellows can be put into perspective by looking at it in relation to the total number of college fellows. There were 48,403 fellows of medical colleges reported as actively practising in their specialty. Overall new fellows represented 5.4% of all college fellows in 2011. The proportion varied greatly across specialties, with the largest proportions of new fellows in pathology for those completing joint programs with Royal Australasian College of Physicians (12.3%), followed by intensive care (7.9%) and radiation oncology (7.5%).
Figure 10: Proportion of new fellows by medical speciality, 2011D
Source: Medical colleges
In 2012 females comprised just under half (48.0%) of the students commencing medical studies (48.1% domestic and 47.5% international students) and a slightly higher proportion of medical graduates (55.0% domestic and 51.6% international graduates). This proportion has varied little over the last three years in which data is available, with females representing 53.6% and 54.1% of all medical graduates in 2010 and 2009 respectively.
The proportion of females going on to specialist training is slightly lower, comprising 50.8% and 50.3% of all vocational trainees in 2012 and 2011 respectively.
In 2012, over half (2,962 or 51.6%) of all basic trainees were females. The proportion of females was higher in certain specialties, namely obstetrics and gynaecology (79.4%) and paediatrics (72.7%). Half (5,536 or 50.3%) of all advanced trainees were female. This proportion was higher in some specialties, with females comprising at least three-fifths in seven specialties, namely, general practice, obstetrics and gynaecology, paediatrics, palliative medicine, pathology, public health medicine and rehabilitation medicine. In some of the smaller specialties there have been considerable fluctuations in the numbers of female trainees from one year to another.
The proportion of females who became new fellows in 2011 is somewhat lower than the proportion undertaking vocational training, remaining relatively stable at around two-fifths of the total new fellows each year since 2000. The proportion was slightly less than the previous year at 43.8% or 1,145 female new fellows in 2011.
In 2011, 16,031 or 33.1% of all college fellows were female.
International Supply of Medical Practitioners
Overseas trained medical practitioners form a key part of the medical workforce in Australia, not only in rural and remote areas, but in all areas of Australia.
In 2011-12 there were 3,560 visas granted to medical practitioners across the two main subclasses – 457 and 442. Almost two-fifths (39.6%) of visas under the two main classes were granted to applicants from the United Kingdom and Republic of Ireland. Just 4.5% and 2.8% of the medical practitioners granted visas came from Canada and the United State of America respectively. More recently, larger numbers of international recruits have come from a number of Asian countries. Almost a third (31.7%) of all applications were granted to medical practitioners from India, Malaysia, Sri Lanka, Pakistan, Philippines and Singapore (9.0%, 8.4%, 5.3%, 3.4%, 2.8% and 2.8% respectively of all visas under Subclass 457 and 442).
In July 2006 the Council of Australian Governments (COAG) agreed to the introduction of a nationally consistent assessment process for IMGs and overseas trained specialists. This process now consists of three main assessment streams: the Competent Authority Pathway, the Standard Pathway and Specialist Pathway. The AMC is responsible for processing applications by international medical graduates and overseas trained specialists.
In 2011, the AMC assessed a total of 1,401 applicants through the Competent Authority Pathway, with 475 applicants being granted AMC Certificates, allowing them to apply for general registration. Two-thirds of the AMC Certificates granted in 2011 were to IMGs from the United Kingdom.
Under the standard pathway 1,461 IMGs passed the Multiple Choice Questionnaire (MCQ) examination and 836 passed the AMC clinical examinations.
There were 1,984 overseas trained specialists, who applied to be recognised as a specialist under the Specialist Pathway to registration in 2011. Medical colleges conduct the assessments of comparability to Australian standards for the specialists and found 470 substantially comparable and a further 288 who were deemed as partially comparable and requiring further training and/or examinations.
Of these 470 overseas trained specialists that were recognised as substantially comparable, almost half (214 or 45.5%) were trained in the United Kingdom and Ireland. This is slightly higher than the number from these countries approved in 2010 (210 or 44.8%). The next largest number of specialists in 2011 came from India (65 or 13.8%) of all approved applicants (Figure 11).
Figure 11: Country of training of overseas trained specialists with approved applications, 2011D
Source: Australian Medical Council administrative data, 2011
Under Section 19AA of the Health Insurance Act 1973 (the Act) Special Purpose Training Programs provides for those doctors seeking vocational recognition, but who are not involved in a specialist training program. Some of these programs specifically cover medical practitioners who have trained overseas to assist with their integration into the Australian workforce and to promote them working in areas of workforce shortage.
At June 2012, there were 8,455 overseas trained doctors with section 19AB exemptions restricting their practice to District of Workforce Shortage (DWS) in order to access Medicare benefits for the services they provide.
Although overseas trained doctors comprise a higher proportion of the medical workforce in more remote areas of Australia, the majority work in Major cities and inner regional areas.
There is considerable variation between states and territories in the overall and relative numbers of overseas trained doctors. Queensland has relatively high numbers of overseas trained doctors across all regions, while Western Australia has relatively higher numbers in Remote and Very remote areas. Victoria continues to have higher number of overseas trained general practitioners in its Major Cities.