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Medical Workforce and Training - 2013

AMA Position Statement: Medical Workforce and Training - 2013

16 Oct 2013

1.      Preamble

1.1.          The health of a population relies upon care from a highly skilled, well-trained medical workforce. To achieve this, medical workforce policy and planning must be aligned to fulfil long-term community health needs. At present, there are a number of key challenges facing medical workforce and training in Australia:

(a)     a global shortage of medical practitioners, with some specialties affected more than others; [1]

(b)     maldistribution of medical practitioners, in terms of both geographic distribution and specialty;[2]

(c)     bottlenecks in the medical training pipeline, caused by increasing numbers of medical graduates and a historically fragmented medical training system;

(d)     systematic underfunding of prevocational and vocational training positions by jurisdictions exacerbating the existing bottlenecks in the medical training pipeline; and

(e)     a heavy reliance on recruitment of International Medical Graduates to ameliorate workforce shortages, particularly in regional and rural areas.[3]

1.2.          The Commonwealth has taken steps to address medical workforce shortages by rapidly increasing Commonwealth supported medical school places (CSPs). Since 2002 the number of CSPs has grown by 90 percent,[4][5] with predictions of 3,830 medical graduates per year by 2017 once numbers stabilise.5 This provides a tremendous opportunity to address many of the aforementioned issues.

1.3.          However, there are a number of political, industrial, financial and workforce barriers that must be overcome to ensure that the medical workforce is appropriately trained to meet community need. This goal will only be realised if Commonwealth and State/Territory governments take a strong lead and co-operate, particularly in respect of funding and the implementation of other broader policy initiatives.

1.4.          This AMA Position Statement outlines the key principles that should guide medical workforce and training within Australia:

(a)     Supported by accurate data and projections

(b)     Driven by community need

(c)     Improved by better co-ordination

(d)     Enhanced by efficiency

(e)     Supported by sufficient funding

(f)       Empowered by equity of access

(g)     Underpinned by self-sufficiency

(h)     Linked to global medical workforce trends

2.      Supported by accurate data and projections

2.1.          Consistent, evidence based advice to government regarding long-term medical workforce and training requirements to meet community need is a pre-requisite for resourcing appropriate medical workforce and training initiatives.

2.2.          The AMA supports the continuing existence of an agency independent of both Commonwealth and State/Territory jurisdictions to collect data and provide advice on health workforce development.  Health Workforce Australia (HWA) currently fulfils this role and has the potential to increase its scope of work to further support improved planning and co-ordination of medical workforce and training.

2.3.          The release of workforce planning data on the medical workforce has been crucial in highlighting the need to train a highly skilled medical workforce in line with community demand.2 The AMA strongly supports yearly updates to the workforce modelling through ongoing reassessment of the assumptions upon which the model is based and the use of updated data.

2.4.          Improved data sets and data linkages with existing data sources such as the Medical Schools Outcomes Database and Centre for Research Excellence in Medical Workforce Dynamics (incorporating the Medicine in Australia: Balancing Employment and Life (MABEL) survey) should be an urgent priority and will improve HW2025 modelling.

3.      Driven by community need

3.1.          Medical workforce policy and planning must align with community demand for sustainable high quality health care.

3.2.          Medical student numbers (domestic and international, CSP and full fee paying) should match expected community demand for medical practitioners. This should be informed by:

(a)     data sharing between jurisdictions, health services, universities and other organisations to allow for appropriate workforce planning and alignment of training places; and

(b)     agreements between jurisdictions and universities to assist the Commonwealth balance Commonwealth supported (domestic) enrolments and full-fee (domestic and international) student intakes.

3.3.          To address the likely demand for medical practitioners by the community outlined in HW2025, it is critical that Australia retains all locally trained domestic and international medical graduates and provides them with sufficient prevocational and specialist training places.

3.4.          Policy initiatives that encourage improved distribution of the medical workforce should be evidence based.  Available evidence supports the following:6]

(a)     the early and continuing exposure of medical school students to regional/rural medicine, and measures to encourage students from regional/rural areas to enrol in medical schools, are likely to increase the workforce in these areas;

(b)     the use of integrated training networks that connect hospitals within a region can improve workforce distribution and supply, and provide training opportunities in areas of need;

(c)     proper medical infrastructure, a strong training experience, access to community and professional resources, and support for continuing medical education provide a rewarding professional and personal experience;

(d)     consideration of the needs of medical practitioners and their families including frequency of relocation, access to employment opportunities, health and education, and social amenities;

(e)     a critical mass of doctors within a region improves the viability of practice, and enhances professional development; and

(f)       appropriate remuneration and incentives attract and retain medical practitioners; this includes doctors in training and the specialist workforce.

3.5.          Early career decision-making must be supported by an understanding of potential workforce requirements and available areas of practice so that individuals have realistic expectations about career opportunities and can make informed career decisions. Attracting doctors to particular specialties and geographic areas could be achieved by improving financial incentives,[7] restructuring early experiences to align with predicted community demand, and increasing exposure during early prevocational training to specialties predicted to be affected by workforce shortages.

3.6.          The AMA supports voluntary schemes that offer incentives with return-of-service obligations in rural and remote areas as a mechanism to address workforce maldistribution. The AMA does not support bonding and students should not be forced to sign up to a bonded place in order to gain entry to medical school.  Available evidence shows that bonding does not deliver long-term improvements to the medical workforce in rural areas and can stigmatise rural medical practice for medical students and early graduates.[8]

4.      Improved by better co-ordination

4.1.          The AMA believes that improved coordination between key medical training stakeholders is necessary to:

(a)     provide sufficient training places for medical graduates throughout the medical training pipeline, with secure employment options post training;

(b)     streamline the postgraduate education and training pathway;

(c)     enhance vertical integration between prevocational and vocational training;

(d)     enhance horizontal integration between colleges in vocational training; and

(e)     provide transparent, accessible and affordable training and career pathways.

4.2.          At an undergraduate level, the ability of the Commonwealth to align medical student numbers (including full-fee paying medical students) with community demand is fundamental to effective medical workforce planning. 

4.3.          As medical graduate numbers increase, Commonwealth and State/Territory governments must continue to build on the significant investments they have made in prevocational and vocational training.  The creation of additional medical student, prevocational and vocational training places should be carried out as part of a planned response to current and future community need.

4.4.          The AMA calls for the development of a long term medical workforce training plan and for Commonwealth and State/Territory governments to reach agreement on:

(a)     the number of quality medical school, intern, prevocational and specialist medical training places needed, based on the analysis provided by HWA; 

(b)     the respective financial contribution of each government; 

(c)     robust performance benchmarks to measure achievement against HW2025 targets and COAG commitments, with regular reporting by HWA on progress against these targets; and 

(d)     the development, in consultation with the profession, of performance benchmarks to ensure that the quality of medical training is sustained.

4.5.          As the need to increase capacity for medical training increases at all levels, it is essential that maintaining the quality of training remains paramount, and that the current system of accrediting training places by postgraduate medical councils and Medical Colleges, under arrangements established by the Australian Medical Council and Medical Board of Australia, is maintained. The AMA strongly supports the roles of these institutions.

4.6.          Initiatives must be developed to measure the quality (effectiveness) of medical training. The AMA supports the development of a National Training Survey (NTS) to monitor the quality of medical education and training in Australia. This would form part of the evidence base to monitor standards in training, support accreditation and provide feedback to the providers of medical training in a similar manner to the NTS run each year by the General Medical Council in the United Kingdom.[9]

5.      Enhanced by efficiency

5.1.          An efficient medical training system is advantageous to both the community and trainees.  A shortage of specialists, workforce maldistribution and ‘bottlenecks’ to enter certain vocational training programs suggests that better integration between prevocational and vocational training is required.[10][11][12]

5.2.          Options to reform prevocational and vocational training pathways have been flagged with a view to increasing vocational training capacity and reducing the length of time to achieve specialist qualification. These include consideration of current entry requirements into vocational training, the value of clinical pre-requisites, the feasibility of converting unaccredited to accredited registrar training positions, and a review of training programs, governance paradigms and types of training providers. [13][14]

5.3.          The AMA believes that the purpose of prevocational training is to create an undifferentiated doctor with a broad range of experience in a range of specialities.  Hence, prevocational training should give junior doctors the requisite experience to commence vocational training. The AMA supports published explicit pre-requisites for vocational training programs where they are easily achievable by most prevocational trainees during routine prevocational training.

5.4.          The AMA supports an iterative and coordinated dialogue on reforming prevocational and vocational training that is inclusive of the Medical Colleges, jurisdictions, prevocational training providers and doctors in training. The safety and educational validity of training programs, their impact on career pathway and progression, clinical supervisor capacity and the ability of health system infrastructure to support new pathways must be key considerations.

6.      Supported by sufficient funding

6.1.          Jurisdictions must recognise postgraduate medical training as a core function of the health system. Sufficient, appropriately linked funding must be allocated to provide the required number of postgraduate training places so that junior doctors achieve specialist qualification and are able to practice independently; and the community realises the full benefit of its increased investment in medical school places.

6.2.          The development of a funding model that recognises the true cost of delivering training, and encourages facilities to support medical training, is critical to being able to continue to provide high quality training. The direct and indirect costs of medical training need to be met including the costs implicit with productivity loss associated with training, and removing the financial barriers to medical training. Funding must be linked to performance measures that monitor the extent of teaching, training and research activities occurring and serve to enhance quality and accountability.

6.3.          Domestic medical school places should continue to be publicly funded. Students from all cultural and socio-economic backgrounds should have access to a medical degree in Australia and medical student intakes should reflect Australia’s cultural diversity. This includes support for designated places for Aboriginal and Torres Strait Islander and rural students. This will facilitate equity of access to primary medical education and provide the Commonwealth with the policy levers it needs to regulate the medical workforce.

6.4.          The Higher Education Base Funding Review: Final Report [15] highlighted the urgent need for further investment in primary medical education as a result of significant underfunding by the Commonwealth government. This has led to the uncoupling of international medical student enrolments from community need and an increasing divergence between medical graduate numbers and the number of available prevocational and vocational training posts.

6.5.          The Commonwealth must allocate sufficient funding to medical schools and ensure that fee structures are transparent and accountable. Adequate funding will make sure the number of medical school places is consistent with workforce planning, allow medical schools to provide high quality clinical education, and continue to innovate and transform clinical education into the future.

6.6.          The AMA does not support any expansion of domestic full fee paying medical places in Australian medical schools.  This would impact negatively on access for potential doctors from low socioeconomic backgrounds and on the diversity, independence and career choice of the medical profession.

7.      Empowered by equity of access

7.1.          It is imperative that Australian Universities continue to openly advise and inform all potential students, but particularly international medical students, about the availability of prevocational training positions and the opportunities to complete their medical training and ultimately practice medicine in Australia.

7.2.          All medical graduates of Australian medical schools should have access to an internship in keeping with community demand. This should be supported by a nationally consistent intern prioritisation framework to ensure a transparent and level playing field is in place across all jurisdictions.

7.3.          With the introduction Doctor of Medicine programs in Australia, there should be no differentiation between primary Australian medical school qualifications when it comes to prevocational and vocational training entry requirements. Similarly there should be no discrimination between vocational training applicants holding general medical registration on the basis of their fee-paying or domestic/international status during their primary medical education.

8.      Underpinned by self sufficiency

8.1.          Australia currently utilises large numbers of international medical graduates (IMGs) to fill workforce gaps, particularly in rural and remote areas. For the purposes of this document, IMGs are considered to be international medical graduates who hold limited or provisional registration with the Medical Board of Australia (MBA).

8.2.          IMGs make an enormous contribution to the health system and should be supported in their role with access to structured and comprehensive training and continuing education.3

8.3.          As increasing numbers of local medical graduates attain specialist qualifications, Australia will be in a position to reduce its reliance on IMGs and harness the benefits of a larger locally trained medical workforce. Health services should ensure that recruitment of suitably trained domestic medical practitioners is prioritised over recruitment of IMGs. Shifting the equilibrium to slowly favour domestic training and reciprocal international exchange will be the most effective strategy to ensure continuous high quality healthcare for Australian communities, particularly in rural and remote locations.

9.      Linked to global medical workforce trends

Policies that aim to strength Australia’s medical workforce must take into account global trends in the supply and distribution of health workers. There is currently a worldwide shortage of health professionals, and developing ‘human resources for health’ is a key focus for international health agencies. Chronic deficiencies in skilled labour can seriously impact the strength and sustainability of health systems.[16]

9.1.          In this context, there is a strong imperative for Australia to develop a self-sufficient health workforce. Increasing numbers of local medical graduates should allow review of IMG recruitment targets and strategies. Particular effort should be made to reduce reliance on doctors from low- and middle-income countries, which commonly have more profound shortages of health professionals relative to Australia.

9.2.          Recruitment processes should be consistent with the WHO Global Code of Practice on the International Recruitment of Health Personnel.[17] This code defines the ethical principles that should underpin approaches to international recruitment, while acknowledging the rights and freedoms of individual health workers.

9.3.          A small number of doctors from low- and middle-income countries undertake periods of work and training in Australia as part of their ongoing professional development. These medical practitioners tend to undertake short placements with the aim of enhancing their knowledge and skills, which can then be applied to improve the health of their own nations.  This practice should continue, but care must be taken to ensure arrangements are equitable and sustainable for all parties.

9.4.          For trainees in the advanced stages of vocational training, overseas placements and fellowships in high-income countries are an important avenue for acquiring new knowledge and skills. They can also assist with the importation of novel procedures and treatments. Training systems must continue to support this practice.

9.5.          For trainees with an interest in practicing in resource-poor settings, a period of overseas work in a low- or middle-income country can be an effective component of global health training. Safe and effective placements rely on firm ethical foundations as well as strong and durable partnerships between Australian and overseas health services, educational institutions and global health agencies.[18]

See also:

AMA Position Statement: Fostering Generalism in the Medical Workforce - 2012

AMA Position Statement: Medical Training in Expanded Settings 2012

AMA Position Statement: Regional/Rural Workforce Initiatives - 2012

AMA Position Statement: Prevocational Medical Education and Training 2011

AMA Position Statement: The Role of Simulated Learning Environments in Postgraduate Medical Education and Training - 2011

AMA Position Statement: Overseas Trained Doctors - 2004

[1] Health Workforce Australia. Health Workforce 2025 – Doctors, Nurses and Midwives – Volume 1. Adelaide: HWA, 2012.

[2] Health Workforce Australia. Health Workforce 2025 – Volume 3 – Medical Specialties. Adelaide: HWA, 2012.

[3] The Parliament of the Commonwealth of Australia. Lost in the Labyrinth. Report on the inquiry into registration processes and support for overseas trained doctors. Canberra: House of Representatives Standing Committee on Health and Ageing, 2012.

[4] Commonwealth of Australia. Medical Training Review Panel Tenth Report. Canberra: Department of Health and Ageing, 2006.

[5] Commonwealth of Australia. Medical Training Review Panel Sixteenth Report. Canberra: Department of Health and Ageing, 2013.

[6] Australian Medical Association. AMA Position Statement. Regional/Rural Workforce Initiatives – 2012. Canberra: AMA, 2012.

[7] Cheng T et al. What Factors Influence the Earnings of GPs and Medical Specialists in Australia? Evidence from the MABEL Survey. Health Economics 2012; 21 (11): 1300-1317.

[8] Sempowski I. Effectiveness of financial incentives in exchange for rural and under serviced area return-of-service commitments: systematic review of the literature. Can J Rural Med 2004; 9(2) : 82-88.

[9] General Medical Council. National Training Survey. [accessed Jul 2013].

[10] McNamara S. Does it take too long to become a doctor? Part 1: Medical school and prevocational training. Med J Aust 2012; 196: 528-530.

[11] McNamara S. Does it take too long to become a doctor? Part 2: Vocational training. Med J Aust 2012; 196: 595-597.

[12] Kappagoda A. Training doctors – too long in the cellar? Med J Aust 2012; 196: 489.

[13] Roberts-Thomson R. Smarter, safer, stronger. Lessons from international models of prevocational education. Winston Churchill Memorial Trust, 2011.

[14] Mitchell R et al. Unaccredited registrar positions in Australian public hospitals: is it time for a rethink? Aust Health Review 2013: Published online 05 July 2013 [accessed Jul 13]

[15] Lomax-Smith J, Watson L, Webster B. Higher Education Base Funding Review Final Report. Canberra: 2011.

[16] World Health Organisation. The Global Health Workforce Alliance: Strategy 2013 –2016. Advancing the health workforce agenda within universal health coverage.Geneva, Switzerland: WHO, 2012.

[17] World Health Organisation. WHO Global Code of Practice on the International Recruitment of Health Personnel Sixty-third World Health Assembly - WHA63.16. WHO, 2010.

[18] Mitchell RD, Jamieson JC, Parker J, et al. Global health training and postgraduate medical education in Australia: the case for greater integration. Med J Aust 2013; 198 (6): 316-319.


Published: 16 Oct 2013