Dr Brian Morton: 'The information that the [Howard] government had was grossly inaccurate and shortsighted. Despite the [contrasting] figures that the AMA had at the time, the government wasn’t listening. The community is paying for that now.' A lack of timely access to doctors is a common complaint these days as waiting times blow out and people must go further afield or to bulk-billing clinics in search of medical help. This shortage of doctors can partly be traced to a 1996 decision by the Howard government, under then health minister Michael Wooldridge, to reduce funding for medical education places and to cut Medicare rebates for some doctors. The government relied on figures that forecast an oversupply of doctors by 2015. Dr Brian Morton, a Sydney GP and chairman of the Australian Medical Association's Council of General Practice, says: ''The information that the [Howard] government had was grossly inaccurate and shortsighted. Despite the [contrasting] figures that the AMA had at the time, the government wasn't listening. The community is paying for that now.'' Dr Morton says that although he is personally against clinics shutting people out, some overworked doctors see limiting patient numbers and therefore maintaining treatment times as the best way of ensuring they can control the quality of their service. One consequence of the cuts in the '90s has been that overseas-trained doctors have been brought in to fill the gap. In March, Health Workforce Australia, an agency established by the Council of Australian Governments to tackle health workforce issues, produced a report that quantified Australia's medical self-sufficiency problem, finding that a quarter of doctors practising here were qualified overseas.

In 2009-10, 4700 visas were granted to medical practitioners - double the number of medical students who graduated from Australian universities. Health Workforce Australia found that by 2025 there will be about 2700 fewer doctors than Australia needs. (The shortage of nurses will be even more dramatic, with a gap of 110,000 in the same period.) While importing doctors from abroad goes some way to filling the gap, George Jelinek, professor of emergency medicine at St Vincent's Hospital in Melbourne, says there are inherent problems such as the language and cultural differences that may exist. ''It is clear that cultural, religious and other differences can be a barrier to effective communication between patients and doctors of different ethnic backgrounds. While Australia is very much a multicultural country, many patients may experience difficulties communicating about sensitive issues such as those around sexuality or end-of-life treatment decisions with overseas-trained doctors.'' Another consequence of the influx of overseas-trained doctors is the devastating effect their departure has on their country of origin. Many, including health economist Gavin Mooney, consider Australia's dependence on doctors from other countries - often developing nations - as immoral. The obvious answer might appear to be that universities increase the number of medical placements they offer. Why not fill the gap with bright young Australian doctors? Universities have indeed responded by dramatically increasing the number of medical places available. In 2000 there were 1660 medical graduates in Australia; in 2011 the number hit 3028, and it is expected to grow by a further 500 this year. Providing the vocational training these new doctors need is the key problem. The AMA and the Australian Medical Students Association want universities to shut off new places for medical students entirely, because they say there is insufficient infrastructure to give the wave of graduates proper clinical training.

AMA national president Steve Hambleton says: ''We need to turn the tap off. We want not one medical student to come through. We can't train them. We need to get this surge dealt with and then we can wind the numbers [of students] up.'' AMSA estimates that by the end of this year nearly 500 medical graduates will miss out on the mandatory one-year hospital internship; these are most likely to be full-fee-paying domestic and international students, as there is a government internship guarantee for Commonwealth-funded (HECS) students. The students' association blames the shortage of vocational training positions on a failure by state and federal governments to align internship levels with the number of medical graduates. The organisation also points the finger at universities that have recruited more international students than there are available internships. AMSA national president James Churchill says the clinical training environment is under significant strain. ''The system is struggling to keep up with the increased number of students that have been pushed through. We're seeing that most clearly this year. The idea of training medical students here in Australia and then not providing the training places for them is ridiculous.'' Jelinek says there is no doubt public hospitals are unable to cope with the rise in students needing teaching and supervision, and that the traditional training model - which puts the emphasis on students completing their rotations in a public teaching hospital in a major city - is unsustainable.

''Much of our current mismatch of doctor numbers and type to [patient] requirements stems from decades of poor planning and attempts to curb the health budget, rather than realistically assessing the health needs and priorities of our population.'' Hambleton says there has historically been a lack of cohesion between universities, which offer the student places, and state governments, which have responsibility for patient care and funding internship places, and the federal government, which registers doctors and provides Medicare rebates to them once they are practising. He says there is an urgent need to take a bird's-eye view of training. ''Different parts of the medical training pipeline are owned and funded by different people. There's a huge disconnect.'' This view is shared by the universities. Justin Beilby, president of the Medical Deans of Australia and New Zealand, says universities recognise the need for better collaboration with governments, hospitals, non-government organisations and practitioners, but he is adamant the wave of students coming through presents an opportunity rather than a threat. ''We do need enough internship places. We need to look to see if we can create enough training pathways for interns to allow all the students the chance to do their intern year in Australia.'' Beilby also acknowledges that universities must keep their numbers in check. ''The deans agree that we should remain at this current state of play.'' The odd one out in the group, however, is Curtin University, which has angered the AMA with its plans to open new a medical school; it has appointed a medical dean but is awaiting federal approval. At the other end of the spectrum, in a sign of the growing paranoia over internship numbers, the Victorian government has controversially announced it will give international students who have studied in this state priority for the one-year hospital internship over Australian students who have studied interstate. Both groups previously had equal opportunity to enter the program. Australian students who have studied in Victoria will still have first option.

AMSA says Australian medical schools are underfunded by $23,000 per year per HECS student, so they have become reliant on international students to fill the income gap and keep the schools running. Hambleton is blunt in his assessment of what will happen to universities if current, let alone more, students are not given training: the full-fee-paying international student market will dry up as Australia loses the ''arms race'' with other countries competing for their dollars. ''Why would they study medicine in Australia if they won't get an internship? What's the point? They'll go to Canada, the United States, anywhere but here.'' THE Health Workforce Australia 2025 report recommends medical workforce planning be co-ordinated at a national level but does not specify that responsibility for this be withdrawn from the states. Without this reform, it says, the health service would be hit harder by further workforce shortages and more imbalances in the geographical distribution of doctors. This would result in even worse shortages in rural and regional areas, bottlenecks in the training system and a continued reliance on badly co-ordinated migration to fill the gaps. (Australia already has the highest dependence on internationally recruited doctors in the developed world.) The Standing Council on Health, which comprises the federal Health Minister and her counterparts in each state and territory plus New Zealand, has asked the HWA to produce concrete proposals for implementing the 2025 report by November. In a statement at the end of April, the council said the report would ''form the basis of the development of nationally co-ordinated responses''. HWA chief executive Mark Cormack would not be drawn on what form a nationally co-ordinated approach might take - whether one national agency would assume responsibility for medical training or states would be forced to take uniform action - but it is believed the HWA sees itself as being in the best position to take on the co-ordinating role given its existing relationships with key parties.

The federal Health Department would not comment on plans for national reform except to say that ''the Australian Health Ministers Advisory Council has considered the issue of provision of internships to the graduates of Australian medical schools'' and is ''aware of the change in the Victorian intern selection policy''. One suggestion included in the HWA 2025 report is to get the private and community sectors to become more involved in training new doctors. Morton says GPs and private specialists, even those who enjoy teaching, may be reluctant to take on interns because it slows down treatment times and therefore affects their revenue. He says the federal government needs to come up with ''real world'' financial incentives to encourage GPs to become more involved. ''If you're seeing 10 to 15 people in a morning, or roughly four per hour, and you add a minute per consultation over the morning to discuss the patient with a student, the time for one consultation quickly disappears.'' Add that up over a 10-week student term and the effect on the GP's revenues is substantial. ''I have students in my practice and have for a very long time. It adds to the workload, it adds to the time that it takes to see a patient. I can run an hour to an hour and a half late when I am training a student and feel pretty wiped out at the end of the day having a student in the consulting room.'' Morton is not optimistic that Canberra will increase its incentives for GP training.''There's no simple solution, obviously, but general practice seems to be a soft target for budgetary cuts: because of the number of GPs there are, if you add a dollar to the rebate then you've immediately increased health costs by a number of millions.''

The AMA's Steve Hambleton says despite the challenges of implementation, there must be a greater emphasis on promoting generalist experience for new doctors, to plug shortages in metropolitan and regional areas. ''If you just learn to operate on the left ear, for example, there's no place for you other than Sydney or Melbourne. We want to produce practitioners who can work in Bundaberg or Bendigo or Ballarat, as well as the cities. In the old days the surgeon did a bit of urology, would deliver a baby, could take out an appendix or do a bit of prostate work.'' A federal Health Department spokeswoman said the government had provided $195 million over five years to allow junior doctors to complete part of their internship training in non-hospital general practice settings. It also contributes to the funding of 110 intern places in former repatriation hospitals. The AMA and AMSA say this is not enough and are calling for an urgent, nationwide rethink of the way medical training is co-ordinated in the long-term. ''We need to make sure that the federal government takes the leadership on this,'' Hambleton says. ''They have to work with the states to find a solution. When we say leadership, we mean money. Leadership is all about bringing the dollars. These doctors are future taxpayers, I'm going to say to the minister. I'm sure they'd love to pay a lot of tax.'' Julia May is a Melbourne journalist.