The scheme is not delivering doctors for the bush. Are the students dodging their obligations, or is the concept flawed?
Is it realistic to expect young people to fulfil life-changing commitments they made as teenagers, when by the time the debt falls due their lives may have already completely changed?
Last week, a Senate committee recommended the bonded medical program be dissolved on the grounds that more students leave the scheme than complete it.
A 2017 audit found that of nearly 10,000 participants since 2001, less than 1% had actually completed their return of service obligation.
The committee also heard that many of the students who sign up never actually intend to practice rurally.
That the scheme is a failure isn’t in dispute – but medical students aren’t to blame for that failure, Australian Medical Students Association president Jasmine Davis tells The Medical Republic.
“In most circumstances, students don’t even know what the program is when they’re applying, so the idea that they would be rorting the system to somehow get one of these places to then just pay it back is completely false,” says Ms Davis, who is a bonded student herself.
“Students aren’t the problem with the bonded medical program, the program itself is the problem.”
The program has been in place, in various forms, since 2001 – first as the Medical Rural Bonded Scholarship Scheme, then the Bonded Medical Places Scheme and since 2019, the Bonded Medical Program (BMP). Alumni of the first two schemes can apply to be part of the latest iteration.
Universities are funded take on a certain number of new Australian medical students each year. Most of these are subsidised as a Commonwealth-supported place (CSP), but a certain number are subsidised as part of the BMP.
In return for the place in medical school, BMP participants commit to work in an MM2-7 region within 18 years of graduating medicine.
But the reason a student is offered a BMP place over a CSP isn’t clear, even to AMSA – it does not seem to be a simple matter of getting slightly worse marks at school or in the entrance exam.
“We don’t think it’s actually tied at all to someone’s application score, or how well they’re doing in the process,” Ms Davis says.
“Some universities have alluded to the fact it may just be a completely randomised process.”
In fact, the BMP and its predecessors are so opaque, Ms Davis says, that many would-be doctors only learn about it during the university application process or when they’re actually offered the place.
The person being offered that place is, more often than not, a fresh high school graduate – 17 or 18 years old – who then accepts that place, goes through their pre-med undergraduate degree and officially signs onto the BMP for their postgraduate qualifications.
The current amount of time required for a return of service is three years, but only half can be completed before fellowship.
Previous iterations of the scheme allowed doctors to do their return of service only once they had completed fellowship.
After the census date of their second year of medical school, the only way for a student to opt out is to pay back the money. Failure to complete obligations comes with penalties down the track.
Some cohorts of med students have found the goalposts moving after sign-on, with the requirements they had agreed to on graduating high school changing while they were still studying their undergraduate degree.
Students who graduated high school in 2016, for example, were offered a BMP place when the scheme requirement was one year return of service, but found when the time came to officially take up the place that the return of service requirement had changed to three years.
“There’s not currently great information or transparency from the department as to what your requirements are – it’s sort of something where you don’t get a lot of communication from them unless you look into it,” says Ms Davis.
“So most students accept their place. Of course they do, they’re excited to be accepted into medical school.”
These circumstances at sign-on perhaps give context to the failure of the scheme.
A 2013 audit of the Bonded Medical Places scheme found only one participant had commenced their return of service and three had bought out. Then there was the 2017 audit, which found only 1% had completed their return of service and 5% had withdrawn from the scheme.
Despite these outcomes, the BMP continued to receive funding, and didn’t even reach its current iteration until 2019.
Responding to questions on why it stuck with the program despite its poor retention rates, the Department of Health maintains that the schemes deliver more doctors for the bush.
“These programs are a long-term investment and complement other programs which seek to provide more timely access to health services in regional, rural and remote Australia,” a Department spokesperson tells TMR.
According to the Department of Health, there have been a total of 13,521 participants in the various schemes to date, of whom 597 have completed return of service (a slightly better 4.4%) and 779 (5.8%) have withdrawn.
Gaming the system?
The interim report from the Senate committee looking into the provision of general practitioner and related primary health services to non-urban Australians recommended that the program should cease taking new applicants.
“Inquiry participants also suggested that those who sign up to bonded medical programs do not intend to practice rurally and use it as a mechanism to secure a position in medical school,” the committee members wrote.
In a submission, Rural and Remote Services says many BMP recipients view the program as a “low cost or interest free loan that can relatively easily be repaid once fully qualified”.
Rural GP and Ochre Recruitment co-founder Dr Hamish Meldrum was also quoted in the report as saying some students have reacted with incredulity when asked why they chose to go rural.
“They laugh at me and say: ‘No. Nobody wants to go rural. We just put down that we want to be rurally bonded students so that we can get into medical school.’ They think the question I asked them is quite hilarious,” Dr Meldrum said.
Ms Davis defends the students, saying they – not just overstretched rural workforces – are victims of the poorly-designed program.
“The narrative that students are gaming the system is completely false and it’s really upsetting that there’s people within our profession that would place blame on a group who really are going into medical school with incredibly good intentions,” she says.
“[They’re] being brought into a program that doesn’t work, and to blame that group of people rather than people who are administering and coming up with this program but not reviewing it adequately – it’s really upsetting.”
Dr Meldrum, for his part, tells TMR that his comments to the Senate committee weren’t an attempt to lay blame on med students for the program failure.
“Eighteen-year-olds don’t really know what they want to do when they’re 24, 25 or 27,” he says.
“You get people who obviously tick that box and go down that pathway [not fully intending to go rural] – it’s just human nature.
“I don’t think there’s anything terrible about it, I know people want to be outraged and say ‘these people should be punished’ or worse – but I think we’ve all been 18.”
Still, doctors aren’t the only group who are critical of the medical students in the bonded program.
Far north Queensland MP Bob Katter was the latest to wade into the fray, urging the Department of Health to cut the length of time given to complete return of service down to three years.
“The government and Health Department did excellent work in establishing this scheme but having 18 years to complete the requirement to go rural is just unrealistic and is resulting in undesirable outcomes,” Mr Katter says.
“No doctor, after living in Brisbane on a much higher wage for a few years, is going to cart their family back to the boondocks.
“It’s never going to happen, and the stats show that. They should go out in the first three years, or they’ll receive no incentive at all.”
Less time for murder
On the contrary, according to Victorian rural generalist program resident Dr Amy Coopes, more than a decade is still barely enough time for many doctors, and significantly limits their speciality options.
Dr Coopes, a former journalist, accepted a Medical Rural Bonded Scholarship, the original iteration of the BMP, and was given 16 years to complete her return of service from the start of medical school.
“That seems like a long time, but it’s actually not, really,” Dr Coopes tells TMR. “I was in a six-year program, so [I then had] 10 years from finishing uni to fellow, which is all well and good for lots of things, but automatically counted [me out for] some of the surgical specialties.”
Some specialties would simply take too long to fellow, like neurosurgery, which takes about nine years.
Other specialty training programs, like ENT or ophthalmology, have significant bottlenecks, meaning applicants can spend years just trying to get into the program.
Then there are other specialties which just aren’t in the scope of practice for smaller rural or regional hospitals, making them essentially not viable to train in.
Luckily for Dr Coopes, she has a genuine passion for rural health and has always intended to go down a rural training pathway.
Under the current scheme, if the return of service is not completed within the 18 years of completing the course of study in medicine participants are liable to repay the government for the cost of medical school, with interest.
“The thing is, it is really onerous if you want to get out of it – I think what often happens is that people will discount that it’s so costly to buy yourself out of the scheme,” Dr Coopes says.
For people like Dr Coopes who were on the very first scheme, the Medical Rural Bonded Scholarship, not completing a return of service within the timeframe also results in a six-year Medicare ban.
“What if I start training for a specialty and I don’t like it, and then I’ve just wasted however many years that I can’t get back,” she says.
There’s always the option to apply for to additional time, but that’s at the discretion of the Department of Health.
“It’s pretty full on, having to go beg for the health minister to understand the vagaries of life which affect everybody,” Dr Coopes says.
“What happens if you get a sick child or your partner becomes unwell or there’s a death in your family? There are all kinds of extenuating circumstances that contribute to people’s training times blowing out massively.”
By the time they graduate, people may have complex family situations – a partner who has a career of their own, children who need schooling, sick parents – and maybe it’s not so shocking that people choose to pay out of the program rather than complete their return of service.
“You just can’t expect someone to sign over 16, 18 years of their life,” Dr Coopes says. “I wouldn’t get that much for murder.
“It’s a lot of time and it’s a significant, formative period of someone’s life for a government bureaucrat to have ultimate say over.”
A better solution
Even Australian College of Rural and Remote Medicine president Dr Sarah Chalmers – someone who arguably has the biggest vested interest in seeing more students go to the bush – wouldn’t be upset to see the scheme dumped.
“At ACRRM we’ve worked really hard to make rural and remote practice sustainable and we know that first of all, it’s about finding people who are interested in it in the first place,” she tells TMR.
“People have to be thoughtful – if you said to a 17-year-old, ‘hey, I’ll give you $20,000 a year if you sign up for rural practice in 15 years’ time’, it sounds great – but do they actually know what rural practice is?”
Dr Chalmers acknowledged that while “one or two people” may go into a rurally bonded scheme with no intention of doing return of service, the downfall of the scheme is probably more to do with people who go in with good intentions but whose circumstances change.
“I remember when they were talking about introducing [the first scheme], and I was a member of my [university] rural health club, and we were really against it at the time, for exactly that reason,” she says.
“People may have really great intentions but if they’re signing up before they even go to medical school to go and pay back several years [of work] maybe 10 or 15 years later – that’s a big commitment.”
The vision that Dr Chalmers has for rural medicine has less to do with sticks like BMP places, and more to do with carrots.
“There are registrar training programs, like ours, that encourage people to understand what they’re signing up for, to train in a place where they supported, confident and competent at the end of their training,” the ACRRM president says.
“Nurturing and supporting registrars as junior doctors is part of that pipeline – I would think that [is more sustainable] than almost tricking young medical students into ending up in areas of workforce shortage that they actually don’t want to go to, and therefore probably won’t stay in.”
If the government does decide to cease the bonded places scheme, Dr Chalmers says that ACRRM’s door is open.
“People with FACCRMs are 80% more likely to still be in their rural and remote community after five years,” she says.
“Nobody else has got those statistics – so when somebody is designing a new scholarship program, I think taking some advice from the college that has documented success in rural recruitment and retention is probably not a bad idea.”