The job of a doctor is admired for its stability but the path to becoming a specialist (aka. consultant) is far from predictable. Each stage of this 10+ year journey has a different level of uncertainty about the future direction of a medical career. Particularly vulnerable times occur before acceptance into a medical school or specialist training program, whereas the completion of medical school is relatively predictable, even if difficult. I first came across the concept of periods of vulnerability through the Behind the Knife surgical podcast and I believe it’s a helpful perspective through which to think about a medical career. As someone on this path, I want to map out the road ahead to prepare for the challenges to come. In this article, let’s explore what potholes and speed-bumps lie at the beginning of a medical career.

Pre-medical Years

A medical career begins with medical school but preceding that is the first period of vulnerability - the pre-medical years. Available medical school spots are far outnumbered by the multitudes of people wanting to become a doctor. To select for future doctors, almost all med school admissions require good performance in coursework as well as an additional medical school entry exam. High schoolers applying for undergraduate medical programs sit the University Clinical Aptitude Test (UCAT) while graduate medical program applicants take the Graduate Medical School Admissions Test (GAMSAT). In 2021, approx. 14,000 candidates sat the UCAT¹ and we can roughly estimate that 21,000 candidates sat the GAMSAT², yet only 4,065³ students are expected to commence at an Australian medical school in 2022.

This large number of crushed dreams slightly exaggerates the competition. The UCAT and GAMSAT are not solely used for medical admission, nor are they Australia specific. These tests are used for entrance into other health programs - notably, dentistry - and are used in other countries like New Zealand and the United Kingdom. Since only applicants for undergraduate programs sit the UCAT, we get a better sense of competitiveness by also looking at undergraduate admissions data for Australian universities. Despite 14,000 candidates sitting the UCAT in 2021, only 7,972⁴ students applied for an undergraduate medical program suggesting the true number of applicants with a serious desire to study undergraduate medicine lies somewhere between these two numbers. Of those that submitted an application 30% (2,399) received an offer⁴. Unsurprisingly, this is comparatively lower than the average offer rate of 82% across all undergraduate programs. Although I cannot find such comprehensive data for graduate entry programs, unpublished data from a major Australian medical school suggests a similar 30% offer rate.

I suspect undergraduate and graduate admissions follow a similar pattern where a large number of prospective applicants sit the entrance exam, those who receive a competitive score apply and some lucky few receive an offer. In the context of the whole medical career, medical school admission has perhaps the greatest difference between number of prospective applicants and available positions which makes the pre-med years a vulnerable and uncertain time.

Medical Student Years

In contrast to the pre-medical years, the 4-years⁵ of medical school are relatively stable and predictable. It is not without challenges (e.g. exams, OSCEs) but almost all students will overcome these and graduate. It’s estimated that only 2.9% of students who commence medical school will fail to graduate ³.

Following graduation from Med school, these newly minted doctors receive provisional registration with the Medical Board of Australia and must complete a year of internship before being granted full general registration as a doctor ⁶. Most students enrolled in med school occupy a Commonwealth Supported Place (CSP) where the government heavily subsidises tuition cost and guarantees an internship job upon graduation⁷. Although domestic full fee paying and international students do not enjoy this luxury, almost all of of the 3,697³ students projected to graduate in 2021 will be placed in some 3,590 intern positions⁸ in 2022. In general, medical students have a very good chance of graduating and landing an internship position with relatively little career vulnerability.

Discussion

The competitiveness of a medical career arises from many more people aspiring to be doctors than job positions available, that’s supply and demand 101. It follows that at various points in the medical career there will be bottlenecks and corresponding periods of vulnerability where the many are whittled down to a few.

The further along a medical career someone is, the more investment there has been in their training and the more of a waste it would be for them to not land a job at the end of the training. This is perhaps why the biggest bottleneck is at the beginning, during the pre-medical period, before any specific medical training. Medical school is a big investment (read, expensive) so much so that 90%³ of domestic students starting med school in 2021 did it under a CSP where the government pays for most of the tuition. For example, a full fee paying student at The University of Melbourne will pay $322,742⁹ across the 4-year graduate degree whereas a CSP student would “only” have to pay $45,200¹⁰. Considering the government is investing hundreds of thousands into each med student, they want to get their money’s worth and land them in an internship position where they get to do all the grunt work of the hospital system. This is likely one of many factors contributing to the relative stability of the medical school period and high graduation rate. In turn, this pushes the bottleneck forward to the medical school admission process leading to much uncertainty and career vulnerability in the pre-medical period.

I want to make a distinction between vulnerability and difficulty. Although periods of career vulnerability tend to correlate with competition and challenges, that doesn’t necessarily mean periods of career stability will be easy. I doubt many would say medical school is easy, even though most make it through. I wish I could say the journey beyond med school is smooth and predictable but we will see similar patterns of bottlenecks, vulnerability and stability. Stay tuned for the next article, where we will dive into the junior doctor and registrar years!

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1. UCAT Summary Statistics 2021 ↩︎

2. 3,184 candidates sat the GAMSAT in 2005 and 9,307 sat it in 2014 according to a paper. This is a increase of 12.66% every year which projecting into 2021 gives us 21,443. ↩︎

3. Medical Deans Aus & NZ Student Statistics Report 2021 ↩︎

4. Department of Education Undergraduate Applications, Offers and Acceptances 2021 Spreadsheet ↩︎

5. For graduate entry programs. Undergraduate entry programs range from 4-6yrs. ↩︎

6. Medical Board of Australia - Intern Registration ↩︎

7. Medify - Medical Student Places in Australia ↩︎

8. https://advancemed.com.au/blog/medical-internship-australia-2021/ ↩︎

9. The University of Melbourne Tuition Fees 2021 ↩︎

10. Calculated from 4-years at the 2021 maximum contribution rate of $11,300 per year ↩︎

11. Medical Education and Training 4th edition report 2019 ↩︎