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16 Aug 2017

BY DR JOHN ZORBAS, CHAIR, AMA COUNICL OF DOCTORS IN TRAINING

There’s a key difference between bondage and bonding. One is a contract between two or more parties, requiring informed consent, and designed for the mutual benefit of all involved. The other is a terribly flawed stick that the Australian Government seems intent on bashing medical graduates with, in a poorly informed attempt to provide a rural workforce.

In Australia, we have two medical bonding programs: the Bonded Medical Places (BMP) scheme and the Medical Rural Bonded Scholarship (MRBS). There are several different versions of these schemes, if you count the number of different contracts that now exist since their inception, but they can broadly be summarised as follows. The BMP scheme provides participants with a Commonwealth Supported Place (CSP) in medical school in exchange for a return of service of one to six years in rural and regional Australia. The MRBS scheme provided participants with a CSP in medical school and by the time it was axed a scholarship of $26,310 a year in exchange for six continuous years of work as a specialist in rural and regional Australia. Sounds simple enough, but the more you dig, the more you realise just how bad a deal this is for these future doctors and the patients they’re supposed to be serving.

You see, the first major flaw in this plan is that bonding just doesn’t work. Funnily enough, if you force someone to do something on your terms in an uncertain and inflexible manner, it turns out that people don’t appreciate the experience and they don’t come back. When bonding in medical school was first conjured up, the AMA provided evidence that similar schemes overseas, especially in North America, had failed to provide any form of sustainable medical workforce. More than 13 years have now passed and an exceedingly small number of scheme participants have completed their return of service. In fact, more participants have withdrawn or breached their agreement than those who have completed their return of service. Not exactly a ringing endorsement.

Compare this with the other measures and programs that are supported by the AMA. We know that having a rural background significantly increases your chance of going rural, and we have strongly supported increasing the quota of students from rural backgrounds. We floated the idea of Regional Training Networks in 2014, to help allow those who wanted to work and stay rural obtain fellowship in a more sustainable manner and reduce infrastructure duplication in what is already a resource poor area of medical training. We supported the Prevocational General Practice Placements Program and, following its abolition by the Abbott Government, subsequently developed an alternative proposal for a Community Residency Program (CRP), to enable doctors to have meaningful rural experiences in their pre-vocational years, while they work out exactly what career they want to pursue. And we have long supported an increased rural focus in the Specialist Training Program (STP), allowing registrars to be adequately funded to work in rural areas on progression to fellowship. It’s a suite of measures that encourages positive experiences and supports trainees along their often complicated and difficult path.

But the Government has chosen to focus on draconian bonding schemes. Let’s explore the MRBS for a second, mostly as initially on paper it looks very attractive. You take a 17-year-old undergraduate student and you promise them $26,310 tax free and a place in medical school for a return of service. Sounds reasonable. Except what 17-year-old understands Medicare? Hell, how many healthcare workers and bureaucrats even understand Medicare? Do we adequately explain to them that leaving the scheme will result in a 12-year ban from Medicare, effectively killing their medical career there and then, simply because of a change in their life situation and circumstances? Do we explain to them that as they train to become a rural general practitioner, they will be effectively forbidden from working in the city for short periods of time, preventing them from upskilling in crucial rural skill sets such as emergency medicine, obstetrics and anaesthetics? Do we explain to the orthopaedic trainee that they only have 16 years from the start of medical school to complete their requirements? Caveat emptor is one thing, but conscriptive blackmail is another.

And even if you are one of the few to complete your return of service, just how happy will you be at the end of it all? What doctor, having had to deny themselves the opportunities of personal and professional development at the behest of such an authoritarian scheme, will look kindly on rural Australia? When you take away mastery, autonomy and purpose, you’re left with a bitter, angry human. That’s not the kind of person that rural Australia deserves.

The AMA Council of Doctors in Training is continuing to lobby government to adjust the BMP and MRBS for the good of its participants and the Australian public that it purports to serve. Nobody is arguing that a return of service isn’t owed, but it certainly shouldn’t function like this. If you or someone you know is affected by these schemes, we’d like to hear about it. Please contact me at cdt.chair@ama.com.au and let’s see if we can’t loosen the bureaucratic nipple clamps, just a little bit.

 


Published: 16 Aug 2017