International medical students and migration: the missing dimension in Australian workforce planning?

To the Editor: The article by Hawthorne and Hamilton, International medical students and migration: the missing dimension in Australian workforce planning?,1 highlights the issue of international students wanting to stay in Australia for internships and beyond. While the ethical dilemma created by keeping much-needed future doctors from their own countries has been extensively debated, the reality is that Australians, especially those in rural and remote settings, will rely on overseas-trained doctors for health care until the “tsunami” of current Australian medical students complete their training (in about 2020).

The health workforce initiative of the Department of Health and Ageing Rural Clinical Schools (RCSs) promotes rural careers by funding 25% of Australian students for a year of rural clinical training. Funding is not provided for international students because of cost and limitations of rural training capacity (supervisor and infrastructure shortages). While “most” international students are interested in metropolitan practice,1 our RCS, at the Melbourne Medical School’s Rural Health Academic Centre, has had repeated, passionate requests from international students to attend the RCS. And quality rural placements increase (international) student and trainee interest in rural practice.2,3

Even if about 80% of the 25% of students who undergo a year of rural training (20% overall) return to rural health care (an optimistic assumption), Australia will still have a shortage of Australian-trained doctors willing to work in rural Australia (about 20% of medical graduates for 29% of the population). We suggest that the cost and capacity to train an international graduate of an Australian medical school may be less than the cost of recruiting, acculturating and up-skilling an international medical graduate. And targeted training and retention of international students from less disadvantaged countries will decrease recruitment from countries with severe health worker shortages.4 Thus, it might be wiser, more ethical, and perhaps more cost-effective to allocate funding to truly interested international students to attend an RCS or an extended quality placement in rural Australia; and then to support them for postgraduate training positions in exchange for rural payback (“bonding”).

Of course, the challenge will be to identify international students with a true interest in rural health care and a willingness to be part of the solution. But if such students were willing and could be selected, they might fill the estimated 10% gap between the 20% of Australian students intending to practice rurally and the 29% of the Australian population that lives rurally. We hope that a cost-effectiveness analysis of trade-offs discussed here will become a priority for Australian health-workforce researchers so that the feasibility of this strategy can be determined.