This year’s Australian Medical Students Association president says he’s happily fallen victim to ‘rural generalist propaganda’.
With GP registrar numbers bouncing back, it’s beginning to look like the storied anti-GP medical school bias has finally been quashed.
It’s fitting, then, that this year’s ambassador for the next generation of doctors – Australian Medical Students Association president Seniru Mudannayake – hopes to one day work as a rural generalist paediatrician.
Mr Mudannayake sat down with The Medical Republic for a chat about placement poverty, equity and flying guinea pigs.
TMR: Serving as president of AMSA means you effectively have to take a year out of medical school – it’s a pretty full-on role. Why did you throw your hat in the ring?
Mr Mudannayake: AMSA is a federally representative body that has a council of representatives elected from each medical student society at each medical school, and it’s been running consistently since 1960 – so that’s a long tradition of representation and advocacy.
But another large thing that AMSA does is events and community. I got involved through AMSA’s global health division from the first year of medical school, and I’ve really found a community of mentors and friends, like-minded people, and really special people from across the country.
I’ve found a lot of meaning and a lot of joy and a lot of my most special memories in medical school are associated with AMSA.
Having been through some of the issues that we advocate on, particularly placement poverty, I found it really meaningful to put my hand up and give back to an organisation that gave me so much.
But I am also trying to do my bit to make sure no one goes through what I had to go through, or worse.
TMR: Placement poverty has already been a big focus for AMSA. Can you tell me about your experience?
Mr Mudannayake: I had to support myself while living out of home, like a lot of medical students do.
I lived out of home, and still do, and needed to work for around two days a week through the entirety of medical school and in the preclinical years. That was difficult, but I managed to do it without too many consequences for my academic performance [at first].
But that extra 10 to 20 hours a week on top of the full-time placement load really did begin to take a toll both on my academic performance, but also my mental health. I really struggled.
Students in my position feel trapped because you need to be able to afford rent and food and it backs you into the corner.
At the same time, you know that your academic progression is at risk if you find yourself in a position where you can’t dedicate as much time to academics as your peers can.
I did have to repeat placement blocks. I have had to have deadlines extended continuously. I’ve found it difficult at times to balance being a medical student and surviving out of home.
And it’s not a unique experience, but it’s definitely something that was very formative for me. My struggle is really the tip of the iceberg, and I definitely found through my experiences that I needed to rely heavily on my friends, for everything from finances to academic support and community.
But I know for many medical students, that’s not the same, and this is me trying to take care of myself.
My heart really goes out to all the medical students who are parents, who have caring duties and responsibilities.
One in five medical students have had suicidal ideation in the last 12 months, and 40 to 50% have symptoms of anxiety and depression. You’re already overburdened by medical school, and now you’re overburdened by the need to support yourself. It doesn’t take many more stresses or life events to really, really blow you into a dark place.
That’s fundamentally a big part of why AMSA has focused this year, and for the last few years, on placement poverty. No one deserves to be in a position where they are so compromised for reasons that are not their fault.
We believe in an Australia where any anyone can become a doctor, and your ability to become a doctor is determined by your intention for the community and not by how much your parents earn.
But the reality of medical school is, because of that onerous placement burden of more than 4000 hours, this degree locks out a lot of students from even considering applying.
For those who dare apply and try to face another hurdle in a society that’s already difficult to thrive in – someone from a lower socio-economic background – this degree divides students into those from wealthier financial backgrounds and those without that background.
TMR: And what does the community lose from poverty placement?
Mr Mudannayake: Our data shows that around 45% – nearly one in two – Indigenous medical students will have to drop out of their degree.
There might be a variety of factors involved, but we know that financial distress is a very major one.
Because the government has invested billions into trying to close the gap and [fix the] stain on our national legacy that takes the form of the life expectancy gap between Indigenous and non-Indigenous Australians, we find that [drop-out rate], in particular, to be egregious and unacceptable.
The same goes for the fact that many students from rural backgrounds and many students from lower socio-economic backgrounds similarly have anecdotally high attrition rates.
I think a really important part of this picture – beyond just the ethics of forcing these students to work so much on top of their degrees, compared to their peers – is that these are the future doctors for communities that really need doctors.
Lower socio-economic areas, rural areas and Indigenous communities are where we need doctors most.
But what’s also really important to understand is that, at the moment, with the way that the government is increasing Commonwealth Supported Places and pumping out more medical students from medical schools, these students are not actually going to the places where the healthcare gaps are.
Many of these students will end up becoming part of a training bottleneck in a metropolitan area. The increasing number of medical students across the country isn’t matched by an increasing number of specialty training positions, and that results in a situation that realistically both doesn’t address workforce demand and results in mental health burdens as the competition for these spots ratchets up.
In terms of the community’s perspective, when they see new medical schools built and they see medical student positions added, it’s very reasonable to think, ‘oh, this means that there’s more doctors in the community’.
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The government sells it that way when they should know better, when they know very well that these medical students don’t become GPs when they come out of medical school, and they don’t become doctors in in communities that need it.
We pour millions and millions of dollars into these [medical student places] that end up just forming a progression block, and where we now have situations where the ratio of applicants to job openings is often five to one – or worse – in many specialties in metropolitan areas.
TMR: It all does come back to placement poverty. What are some of the other issues that AMSA will be looking at this year?
Mr Mudannayake: Workforce planning is a huge part of what AMSA looks at, and the issue of placement has a big intersection with that.
Because we have more and more medical students, we’re facing issues around progression block.
There can be more medical students in this country and more junior doctors, but that needs to be matched with more training positions.
It also means that the medical students that come into medical school have to be the right kind of medical student – in the sense that they have to be more likely to go and practice rurally or to go and practice in low socio-economic areas or Indigenous communities and fill the healthcare gaps that we have, which is why those two parts of advocacy are very intertwined.
[Addressing placement poverty can] help the government achieve more rural doctors and more doctors in those healthcare deserts in the outer metropolitan areas.
These students, we know, are more likely to become GPs. Indigenous students are around four and a half times as likely as their peers to become GPs. Doctors from low socio-economic backgrounds are around twice as likely to return to those areas. Rural students are much more likely to return to rural areas. And those are the areas of need.
We’re very interested in improving the number of medical students that that choose to work in places that actually need doctors, as opposed to the numbers of medical students that end up fighting each other for limited training positions in the cities.
A really big part of this is also the fact that the career of general practice itself has become a lot less attractive for medical students.
In the 2010s, the number of students who wanted to become GP was around 40% – that number now hovers around 10%.
That decline is mirrored almost perfectly by the failure to index the payment given to GPs to help support them to take on medical students. This payment hasn’t been increased for the better part of 10 years now.
That means that the GPs taking on medical students lose thousands of dollars a year in the costs of taking time out of their day to teach them or to get them to parallel consult.
We now have less than a third of GPs even having medical students in their clinic. It’s a lot more cost-effective to have a student in the corner of the room and try to, you know, maybe sneak in a word or two here and there.
In a Medicare system that relies on throughput [of patients] and where more items means more income, there’s a huge disincentive to taking on medical students.
TMR: Last time we spoke, you said you were keen to go into rural generalist paediatrics as a specialty. Are you a rural origin student yourself?
Mr Mudannayake: I’m from an outer metropolitan area – that’s where I grew up, and that’s where I had my formative experience, seeing a lot of the socio-economic issues that we’ve been talking about.
For me, rural generalism is both an opportunity to help bridge that divide and help close that gap in healthcare, but also a chance for me to use a diverse array of skills and still be in touch with that interest in paediatrics that I have.
I think it’s particularly attractive to me, to be a part of a community and serve a community, and to learn how people live in a place and become an important part of the social fabric there.
I also particularly enjoy the idea of living outside of a big city. I think my time growing up in Melbourne was enough.
I’m very happy to have a much shorter commute and to enjoy the calm of rural life. I have also been exposed to what we jokingly call “rural propaganda” at a lot of AMSA’s events and conferences. Over the years of medical school, it’s actually worked on me.
All those sponsors and all those speakers, I think, have seeded the thought well enough into my brain that I have become one of those metropolitan students who wants to try and help address the rural workforce gap. In a way, my story is testament to how those outreach programs – when done in conjunction with medical students and medical student organisations – can actually work.
I look forward, hopefully, to a career contributing to my country.
TMR: We like to end on a silly question. My favourite is: what would your pets do if they had human careers?
Mr Mudannayake: I had guinea pigs growing up, one was called Chowchow and one was called Ginger.
I think Chowchow would have been a chef, because he really, really liked food. He would eat Ginger’s food as well. He seemed to savour the different flavours, and he ate very dramatically.
I think Ginger would have been a pilot. He had this precision about his movements and this intention about the way that he looked at you that would have suited a career in aviation.
This interview has been edited for length and clarity.
