For four years I was the Executive Medical Director at the Health Education and Training Institute of NSW. Amongst one of my many responsibilities was the oversight of the allocation of the 1000+ NSW internships each year, as well as governance of the accreditation and training system for medical interns and residents in NSW. So basically I know quite a bit about how medical internships operate in Australia. Some of which came from the heavy burden of responsibility but much of my insights were also gained from interacting with interns as part of regular stakeholder meetings which are really important if you truly want to have a high-quality process.
This post will form part of a guide to the medical training continuum such that it exists in Australia. Which will describe the processes by which people become doctors and how they end up working in certain areas or careers in medicine.
Before getting into depth and details. Let’s go over the quick facts about the medical internship in Australia.
- The purpose of the internship is generally seen to be an opportunity to consolidate after medical school and be assessed as a safe practitioner prior to general registration.
- Medical internships are intended to provide graduates from Australian medical schools a provisional year experience and are not intended for other doctors, such as international medical graduates.
- In 2020 there are approximately 3,515 medical intern posts in Australia.
- Applications open in about May every year and allocations occur from around July to November.
- Internship requires you to successfully complete a full year of work, including mandatory terms in medicine, surgery, and emergency medicine.
- Interns get paid somewhere between $68,000 and $78,000 per annum, not accounting for additional income from things like overtime.
What Is the Purpose of the Medical Internship?
Put simply the medical internship forms a provisional or pre-registration year between medical school and working as a clinical doctor. It can be considered as a final test or assessment of a trainee doctor’s capabilities prior to being able to work independently.
Historically the internship formed the final barrier to general registration after which doctors could work independently in a number of roles, including as general practitioners. At one point in history, medical schools were, in fact, more clearly focussed on preparing their graduates for general practice.
However, the amount of medical knowledge and the nature of general practice, in particular, has expanded so significantly that sending doctors out into the community to work independently after only an internship is no longer considered safe. And the option to work as what is termed a “non-vocationally registered doctor” in general practice was closed down in 1996.
So whilst officially the successful completion of the internship is the last step in obtaining general registration. The reality for trainee doctors now is that they continue to work in supervised roles for a number of years after completing internship.
In fact, the nature and purpose of the internship in Australia has recently come into question with a national report recommending significant changes. See more about this below.
Who Is Eligible For a Medical Internship?
As I have highlighted in other posts medical intern positions are reserved for students graduating from Australian medical schools. This includes both Australian citizens and permanent residents who are enrolled in these schools as well as international students. By virtue of the close relationship between the countries of Australia and New Zealand, which includes sharing a medical school accreditation system, graduates of the two New Zealand medical schools are also able to apply for internship in Australia, although generally very few do.
A common misconception is that IMGs are eligible to apply for internship. Whilst technically they can in limited circumstances the reality is that most do not need to and that the chances of obtaining an internship as an IMG are extremely limited.
The reasons for this misunderstanding are complex but possibly stem from both the fact that the “provisional year” that IMGs undertaking the standard pathway process towards general registration is quite similar to the one that interns are required to complete. And that it is a requirement for registration that you have completed an equivalent internship process in another country.
There are simply not enough internship positions available each year to permit the many hundreds of IMGs in Australia to also undertake a provisional year and so these doctors have to look for alternative posts, usually resident medical officer positions.
How Many Interns Are There?
The number of intern positions in Australia goes up at a steady but small pace every year. The number is fluid as there are often a handful of increases after each State and Territory publishes its official numbers around Mar/April of each year. Also, there are sometimes a few late withdrawals which brings down the total number of positions occupied.
The most significant way the total numbers tend to be reduced is via the Junior Doctor Training Program Private Hospital Stream, which provides capacity particularly for international students who are unable to secure a place. In past years the total number of positions has tended to be significantly undersubscribed at the final analysis
You also need to take into account that a small number of the positions may also split amongst 2 doctors undertaking a job-share arrangement (this is pretty rare but is possible).
For the 2020 clinical year the approximate number of Intern posts in Australia are as follows:
Table of Intern Post Numbers.
|State / Territory||Number|
|Australian Capital Territory||95|
|Junior Doctor Training Program Private Hospital Stream*||115|
The deeper question is why this particular number of Interns?
The major driver of increases in Intern numbers is generally the number of medical students graduating from Australian medical schools. Failure to provide provisional registration opportunities for these graduates has downstream effects on the other parts of the medical training continuum or pipeline illustrated above. A fair deal of work goes into working out how many medical students Australia needs. This is mainly based on predicting how many overall doctors Australia needs now and into the future. But as Medicine is a complex field with various specialties and future changes in practice and service need are also hard to predict, medical workforce planning is not an exact science. It is also safe to say that a fair bit of politics is involved in the internship debate. Announcing new medical schools, particularly in rural and regional areas is a popular thing to do for political parties. And with each new medical school, there comes a need for more internships. Finally, hospitals themselves grow and new hospitals are also often being built. Many of these new hospitals need “junior doctors” to run them. So this also drives up the demand for positions.
How Do You Apply for Internship?
In a nutshell, you fill in a form (online) for each State and Territory you are applying to. You will need to submit a number of details. It’s worth checking ahead of time what these are. Because you may be asked to do things like certifying your English language proficiency, your change or name, citizenship or visa status.
You will also need your Intern Placement Number (IPN). The Intern Placement Number is a unique nine-digit number which is generated by the Australian Health Practitioner Regulation Agency (AHPRA) and is provided to all medical schools to issue to their graduating students. The IPN helps to track candidates through the system.
Note: The Intern Placement Number is not your University Student Identification Number!
In most States and Territories you will also be asked to submit a Resume and referees. This is not the case for NSW (other than its Rural Preferential Recruitment pathway).
Most but not all of the application processes require you to participate in some interviews.
What Is the Process of Allocation? Are There Any Special Options?
Most of the jurisdictions use some form of software program or database to fairly allocate or match graduates to placements.
Within these systems, there are usually options for you to apply for rural placement options. In which case you will generally be allocated first. NSW also offers a preferential option for Aboriginal graduates to be placed and the other States and Territories really should be doing the same.
There are also processes for applying for special consideration (for e.g. requesting certain locations due to carer responsibilities or health reasons).
Some jurisdictions will allow you to be allocated with your partner (if you happen to be in the same graduating class). Victoria even allows you to defer your placement for a year.
For medical students who are classed as international the Junior Doctor Training Program Private Hospital Stream provides an opportunity to gain an internship outside of the normal jurisdictional processes. Australian medical students are not eligible to apply for this scheme. Notably, if the scheme is undersubscribed this is also one of the few ways of International Medical Graduates gaining an internship experience in Australia.
How And When You Are Allocated Depends On A Few Key Factors.
The main things that will affect how and when you are allocated are:
- If you are a citizen or permanent resident
- If you are graduating from a medical school in that State or Territory
If the answer to both of these questions is yes. You will normally be given the highest priority for that particular allocation process.
The rankings then vary for each State and Territory. But in general medical graduates with citizenship or permanent residency get higher preference than students on visas.
When Do Applications Occur And When Are Offers Made?
Each State and Territory is slightly different. But in general, most of the dates are aligned.
Applications are normally open for around a month in May each year.
The first round of allocations normally occur in July and continue till around November. Offer timings are coordinated across all the jurisdictions
After this, there is what is called a Late Vacancy Management Process where each State and Territory is free to make offers as they need to.
The Junior Doctor Training Program Private Hospital Stream process is advertised as an EOI process later in the year and its allocations are done separately and normally after most of the jurisdiction places have been allocated to.
Does Anyone Ever Miss Out On An Internship?
Since about 2012 there have been concerns that some types of students (particularly international students) are at risk of missing out on an internship. There is no hard evidence that this is actually the case. Whilst the final figures for the intern allocation process are hard to come by. Information from organizations like HETI indicates that very few applicants are left in the system by the time of the start of the new intern year. Through a combination of the State and Territory and Commonwealth internship process, as well as opportunities to do internships overseas it appears that at least for now all graduates are gaining an internship position.
Applicants who do miss out in one year are eligible to apply in the following year. I have not heard of any doctor who has been in this situation due to having missed out the year before.
What Happens During the Internship?
You are given 2 weeks to gain an orientation to your hospital or network, which normally includes a period of overlap with a current intern.
After this most interns tend to work in either rotation of 4 blocks (12 weeks) or 5 blocks (10 to 11 weeks). By Medical Board requirement these blocks have to include a medical rotation, a surgery rotation, and an emergency medicine rotation. Most interns also have to work a relief term (where they cover other interns on leave and often take their own leave). So this usually doesn’t leave much room for any choices in terms. Mostly you will be offered the choice of one additional rotation, which could be another medical or surgical term or perhaps from another specialty like psychiatry.
What’s the Job Like?
It’s been many decades since I have been an Intern. So I have to rely on what the Interns that I work with tell me and what I observe from them.
The positive aspects of the job are often reported to be the amount of support and supervision reported from not just more senior medical colleagues but other health professionals and managers. Everyone tends to recognize that you are new and are keen to help where possible. Added to this is the collegiality and help that you can expect from your colleagues. Plus you are now getting paid!
The key downside tends to be the feeling that you are often employed as a glorified administrative assistant. Interns tend to confront and deal with the brunt of the “paperwork” (really computer work) in the hospital and some days can seem like an endless parade of updating the notes, completing discharge summaries, following up consults and checking on results.
Many interns that I speak to tell me that the best learning experiences often come after hours when you are doing things like evening and overnight cover. These are the times when you can feel like you are truly using your medical knowledge to address things like urgent patient reviews.
However, the amount of overtime and after-hours cover that Interns get exposed to has significantly reduced over the last 2 decades.
You can also expect to get some regular formal teachings (about half a day a week or fortnight). But most of your learning and teaching will occur opportunistically on ward rounds and in other clinical episodes. Being proactive and asking for feedback and opportunities from seniors is a vital key to getting most out of the experience.
How Much Do Medical Interns Get Paid?
This varies around the country. The lowest annual wage currently is in the ACT at a little over $68,000 per annum and the highest is in Western Australia at a bit over $78,000. Depending on where you are working you should factor in about 25 to 50% extra for doing some overtime or working weekends and evenings and accumulating penalty rates.
What Do You Learn During Internship?
There are formal outcome statements for Internship written by the Medical Board of Australia. Funnily enough these align with the Medical Graduate Outcome Statements and like most Medical Competency Frameworks resemble the CanMEDS Framework.
If I was to be critical of one aspect of these statements is the lack of inclusion of the word “communication” in the top-level domains. It seems strange that we would not feel this is important at the Intern level.
Whilst I was at HETI I also sponsored the writing of a more detailed curriculum for internship.
Whether you achieve all of these outcomes or not is a bit of a moot point as the individual sign off is more dependent on supervisor reports than a focus on the curriculum. The postgraduate medical councils do however try to assess whether the hospitals are attempting to implement a learning framework.
On a practical level you can expect to consolidate the medical knowledge you gained in medical school and develop or improve a whole range of new skills, particularly tactical skills like personal and team time management, collaboration and of course verbal and written communication.
How Is Internship Completed?
As hinted at above currently you complete internship by. Successfully completing 47 weeks of full-time work, including successfully completing specific terms comprising 8 weeks of emergency medicine, 10 weeks of medicine and 10 weeks of surgery.
Your terms and rotations are assessed by completing a mid and end of term supervisor report. Your supervisor is generally a consultant and they are meant to sit down with you and go through a series of questions and ratings that assess things like your knowledge, prescribing, procedures, communication, teamwork, and professionalism.
Hospitals and networks have committees to review the progress of all interns, including flagging those that they may have a concern about or whom they may feel need additional support. These committees receive the supervisor reports. They may have some additional requirements for your progression, such as a minimum attendance at teaching sessions. But largely they rely on the supervisor reports to assess your progress.
If your supervisor reports are satisfactory you will probably be signed off at the end of the year.
If not. You may need a bit more time to complete the requirements. This might be due to a performance issue or maybe because you had to have some time off for another reason. This is usually not a problem. In the case of some States, you have a 2 or more year contract so there is some leeway. But at most hospitals, they will give you some more time if you need it.
What Happens After Internship?
Once the hospital is satisfied with your completion of internship you will be recommended to the Medical Board for general registration. For most doctors, not much else different happens as they elect to stay in the hospital system for another year as a resident medical officer. You will be able to call yourself something other than Intern and get a slight bump in your pay.
In some cases, you can apply to enter into specialty training (General Practice is one of the big ones where you can apply as a PGY2). But most choose to wait another year before trying.
Question: You Say That International Medical Graduates Cannot Apply for Australian Internships. So What Are My Options?
What you are generally looking for is what is called a Resident Medical Officer position (sometimes House Officer in certain States) role. Most of these are not advertised as intended for IMGs. But some are. The key thing for you to be looking at are the Selection Criteria and an indication that they will take someone who is “eligible for registration.” See this video for a deeper explanation.
Question: Can I Apply to New Zealand?
Yes. All Australian graduates are eligible to work in New Zealand without having to sit further exams. As mentioned this is a reciprocal thing as NZ graduates can apply to work as interns in Australia as well.
New Zealand intern/ house surgeon positions are offered to doctors by the District Health Boards (DHB) that administer the hospitals. Job offers are allocated to graduates through a system called ACE (Advanced Choice of Employment), which matches applicants’ preferences to available DHB positions. There is a special portal for Australian graduates to apply for access to these posts.
Question: Are There Any Planned Changes to Internship?
Yes, there are.
In 2015. The Council of Australian Governments received the final independent report into the Australian Intern system. This report noted a number of problems with the current model of internship in Australia which has largely been unaltered for many decades. These included finding that:
- While the concept of a general internship remained valid, the current model was not fit for purpose, particularly in light of major changes in the health system and in medical education.
- The internship is currently not aligned with societal health care needs, plays a limited role in supporting generalist practice and has variability in the quality of the learning experience.
- While the internship has a role in career planning, a more holistic approach to planning is needed than the current reliance on clinical exposure.
- There is a need for expansion in intern training settings for educational and capacity reasons and to align the internship with modern health care delivery.
There were many recommendations made, some of which have been enacted already, such as the introduction of a national training survey to ascertain how the internship is performing. Many others remain in a state of development. But you should expect to see in the next coming years:
- Formalization of a 2-year approach to the prevocational training phase, which already occurs in some States.
- Reduced emphasis on the amount of time spent in certain terms and experiences
- Greater emphasis on learning goals and outcomes as well as better processes for assessing these
Reflecting back on this report and the progress that has been made in 5 years. My personal opinion is that this was a missed opportunity to do something more radical. I’m really surprised that politicians essentially accepted that the length of the internship period needed to be actually extended, rather than some option for reducing the overall time for producing specialist doctors.
The rotating internship was abolished in Canada in the 1990s and replaced with a system of matching into specialty training similar to the United States. From all accounts, the sky did not fall in.