A decade of GEM

Of Dr Paddy Hillery’s 30 Irish classmates from medical school, about one-third are now in Australia. The favourable programme for repayments on loans they took out as graduate entry medicine (GEM) students is a key ‘pull-factor’.

The loans are tax deductible under Australia’s tax programme and the cost of servicing them is “negligible compared to here”, says Dr Hillery, who is Chairperson of the IMO NCHD Committee and a 2011 GEM graduate from the RCSI.

“A lot of [colleagues] would have gone through the intern programme here, as they wanted to become fully qualified in Ireland and would have ended up paying interest-only during that period, which, even at that stage, would have run into about €400 a month with a salary of just over €2,000,” the trainee anaesthetist tells the Medical Independent (MI).

Doctors who obtained the full loan amount of €25,000 per annum to cover fees and living expenses during their four-year degrees need to pay back about €140,000 including interest, over 10 years. The gross salary of an SHO begins at €38,839 and rises to €54,746.

A number of years ago, financial institutions moved to offer fees-only loans. A Bank of Ireland spokesperson says that “as a responsible lender” it must ensure “borrowers aren’t put in a position where they are likely to experience repayment difficulties”.

The spokesperson tells MI: “The level of loans that can be provided correlates to the repayment capacity of graduates, which for medical students has been influenced by factors including fluctuations in overtime hours. However, unlike other providers, Bank of Ireland has continued to offer students finance to cover the cost of tuition.”

The spokesperson provided no indication of the proportion of GEM graduates defaulting on their maintenance/tuition fee loans.

AIB says it offers “a standard student loan at a very competitive rate, which graduate medicine entry students would be eligible for”.

On its withdrawal of maintenance loans a number of years ago, it says this was “a commercial decision”.

The spokesperson said information on numbers of GEM graduates defaulting on loans is “commercially sensitive”.

Ulster Bank told MI that it offers a graduate loan of up to €6,500, subject to a credit application and terms and conditions. It does not provide loans directly to new undergraduate students at this time. However, a fixed rate parental loan of up to €40,000 can be taken out by the parent. Students studying medicine (including graduate entry), can apply for an interest-free overdraft up to €2,500. It would not comment on arrears for GEM graduates.

<h3 class=”p4″>High Costs</h3> Four colleges in Ireland offer GEM programmes: The RCSI, University College Dublin (UCD), University College Cork (UCC), and University of Limerick (UL).

Currently, the RCSI’s overall EU fee for its GEM programme is €16,940 per annum. In 2016/17, its non-EU tuition fee for GEM is €53,500 per annum (provisional non-EU tuition fee for 2017/18 is €54,500).

At UCC, EU GEM students are paying €14,580 per year and non-EU students pay €47,000 per year.

At UL, EU GEM fees for 2016/17 are €14,843, while the non-EU fees are €41,000.

UCD’s EU GEM fees are €14,931 for 2016/17 and its non-EU fees are €50,000.

Some of the current student cohort are under particular financial pressures due to burdensome rent and living costs.

“One of the problems is that, even with having the fees so high, there is no access to Student Universal Support Ireland (SUSI) grants for people who are going for this and there are no other (standard) grant programmes available,” says Dr Hillery.

He was contacted last year by a student who was in jeopardy of dropping out of their course for financial reasons. “Because the fees are so onerous they already have a loan for that and they can’t get funding elsewhere,” he explains of the predicament.

The accelerated nature of the four-year GEM programmes also makes it “very hard for them to have time to work elsewhere”, he noted.

<h3 class=”p4″>Debt campaign</h3> The debt problem affecting many GEM students and graduates is the negative counterpoint to an educational development that has yielded so many positives.

Prof Mike Larvin, Head of the UL GEM School, agrees the debt issue is concerning. That is why the School “has continued with our access scholarship scheme”, he adds.

“The Fottrell report called for a system of student loans, recognising that qualified doctors would be in a good position to pay these back in the early years of their career,” he notes.

“That was left to the major Irish banks and in 2012 they all withdrew [offering] maintenance loans without notice and without discussion and offered fees-only loans. When UL retendered for its own banking contract two years ago, we asked that the successful tender include a return to the provision of maintenance loans and the Bank of Ireland has now been providing these to suitably qualified students over the last two years.”

On this point, Bank of Ireland’s spokesperson says loan applicants can apply to borrow additional funds, but standard lending criteria applies and each application is individually assessed.

Some graduate-entrants may have had previous debt-related problems. Poor credit records remain an issue for some applicants, says Prof Larvin.

“We now encourage all applicants to consult with our campus Bank of Ireland branch team up to a year before joining. In some cases they will be advised to build up a stronger credit record ahead of accepting an offer. The HEA [Higher Education Authority] provides a generous financial contribution of €9,500 per student per year, but that was reduced some years ago thus increasing the student contribution, although thankfully that level of support has remained stable over the last three years.”

In 2014, an energetic campaign was mounted by GEM graduates and students on the matter of debt. The campaigners developed a document titled Proposal for Income Tax Relief for Graduate Entry Medicine Loan Products, which was informed through a process of lobbying at Leinster House.

The proposal involved the introduction of tax relief on repayments of approved loan products. Relief would be permitted as a deduction against an individual’s taxable income at their marginal rate rather than as a standard rate tax credit.

According to the paper, the income tax relief as proposed would have reduced loan repayments for GEM graduates by 37-38 per cent. The annual cost of the scheme was put at approximately €5 million.

Senator Colm Burke, Fine Gael’s Seanad Spokesperson on Health, championed the proposal. He lobbied on the issue again in the weeks preceding Budget 2017, but to no avail.

The Government is “afraid that if they take it on board, there will be other groups looking for a similar facility”, Senator Burke tells MI.

A Department of Health spokesperson informs MI that Minister for Health Simon Harris “made representations” to Minister for Finance Michael Noonan “regarding the possibility of providing tax-relief to doctors from graduate-entry medicine who had taken out loans to finance their medical degrees”.

SHO Dr Brian Doyle, who has been involved in the GEM debt campaign, says Budget 2017 “does nothing to help or encourage recently graduated young doctors to stay in Ireland”.

“Young doctors have put forward solutions but these have largely fallen on deaf ears. For example, an education loan interest relief scheme could allow graduates who take out education loans to write off a portion of the interest against their income tax. Such a measure would immeasurably improve the quality-of-life for debt-ridden young doctors. It would only be available to doctors working in Ireland and would have the obvious benefit of incentivising more doctors to stay working here.”

Senator Burke has set his sights on much more achievable goals, principally around better medical education and training grants for NCHDs, which have been cut over recent years.

In his view, the debt issue facing GEM graduates has exacerbated Ireland’s medical recruitment and retention problems.

In years past, consultant posts attracted between four and eight applicants on average, but now there are “a whole lot of posts where there is no applicant”.

“Even the Dublin hospitals, especially in maternity, are finding it difficult to get junior doctors. Whereas before, the Dublin hospitals never had a problem.”

The debt situation has pushed some doctors into more lucrative work as locums, causing further expense to the State.

NCHDs experienced “the same cuts as everyone else back in 2009/2010”, says Senator Burke. He believes the decreased availability of overtime associated with European Working Time Directive (EWTD) implementation has been a financial hammer-blow for doctors who graduated via GEM.

“This is where it is going to be an interesting challenge for us after Brexit, because the European Working Time Directive – I think that will go out the door in the UK once they are gone out of Europe. And therefore, you will have junior doctors going to England, knowing full well that while they might have to work harder, they will get paid for overtime, for doing so many hours overtime, which they can’t do here. That is a big issue, I think.”

Dr Hillery was involved in the GEM debt campaign, which was run independently by GEM students and graduates. He notes that the IMO also raised the issue again in its pre-Budget 2017 submission, where it called for tax relief on loan repayments for GEM students.

The NAGP’s submission highlighted the matter as well: “We are now beginning to see the entry of graduate medical students into general practice. These new entrants are saddled with a considerable level of student debt, which makes practising in this jurisdiction challenging.”

According to Dr Hillery, the Departments of Education and Health have tended to view the matter as “each other’s responsibility”.

He suggests inaction will have clear consequences. “My colleagues who live in Australia, they are in training there and progressing through it – they intend on finishing their training there and potentially staying there, as they don’t see it as a viable option to come back to Ireland.”

<h3 class=”p4″>Celebration</h3> The RCSI made no mention of the sticky issues of debt and retention in its celebratory press release on 10 years of its GEM programme. Instead it focused on the more positive fact of 415 doctors having graduated since inception. Admitted students have had a broad range of primary degrees from nursing to aeronautical studies, music to neuroscience.

Irrefutably, the GEM programmes at the RCSI, UL, UCC, and UCD have afforded people a chance to study medicine who otherwise may not have done.

Dr Hillery attended the RCSI anniversary celebrations. “I personally have benefited from graduate-entry by having an alternative route to access medical training. It is something I had always intended on doing and something that I am glad I had a pathway to get into apart from the Leaving Cert.

“From what I have seen both as a trainee and as a trainer, when I am looking at junior colleagues who are doing the graduate entry programme, their level of maturity is something I think is well-suited to training in medicine,” he adds.

A paper by RCSI researchers, published in BMC Medical Education in 2014, found that GEM students “perform at least as well, or even better, than a corresponding undergraduate-entry group”. It reported that having a scientific background on entry confers no advantage in final assessments.

Prof Seamus Sreenan, Director of the RCSI’s GEM programme, says one of the concerns when the course was initiated was how people from non-science backgrounds would fare.

“But our research has shown they perform equally well,” he tells MI. “I mean, it is difficult for them starting out if they come from a non-science background; for the first few weeks they are dealing with different concepts that are very novel to them, but even by the end of the first semester their performance is essentially indistinguishable from those who come from a science background.”

What trends have emerged in respect of chosen specialties?

Prof Seamus Sreenan

“We haven’t formally studied this and it is something we want to look at, as we are interested to see if there is a difference in the pattern of career choice between those who come through the graduate-entry programme and those who come through the regular entry,” says Prof Sreenan. “Anecdotally, we think maybe more of them are going into general practice, but we would like to study that in a more formal way.”

Intake into the RCSI GEM programme is approximately 30 EU students and between 30-40 non-EU students annually. Prof Sreenan acknowledges that finances are a concern for some students.

“We have had very few drop-outs over the years. I think we might have had one person who dropped out and said it was because of financial reasons,” he adds.

He also recognises that the full impact of the repayments’ schedule only materialises after graduation.

As with other third-level institutions, the RCSI has access routes for disadvantaged students. However, there “probably haven’t had been too many from disadvantaged backgrounds applying to the GEM programme”, he concedes.

On whether the introduction of the Physician Associate Master’s Degree Programme at the RCSI has decreased interest in the GEM course, Prof Sreenan says it is too early to say. That two-year programme began last January.

“There were only seven entrants into the first group of physician associates and whether they would have gone on to do graduate-entry medicine is very hard to say. I suppose we will probably learn a bit more about that as the years go by.”

<h3 class=”p4″>Quality improvement</h3> As the RCSI’s GEM course evolves, one of the current focuses is quality improvement aspects.

“We are always reviewing our curriculum and learning opportunities for the students, so right now what we are concentrating most heavily on is incorporating principles of quality improvement into the curriculum,” Prof Sreenan explains.

It is crucial that doctors are able to identify areas where clinical services can be improved and have the tools and knowledge to implement change, he underlines.

Prof Mary Horgan, Dean of UCC’s School of Medicine, echoes the sentiments of many medical educators involved in GEM programmes, in describing how it offers “people who are passionate about doing medicine” another route besides the Leaving Certificate/HPAT.

Prof Mary Horgan

It brings a diversity in the way people think and the maturity of those who have experience with university.

GEM graduates “tend to be a bit more focused on their career in that, because they are older starting, they hit the ground running”.

Graduates have entered a wide range of areas, but anaesthetics has been an especially popular choice. Basic and higher specialist training in anaesthetics is a ‘run-though programme’ that can be completed in six years, which is among the factors making it attractive.

“Initially, we thought that they’d predominantly go into general practice…. While some of them do, that is not always the case,” she comments.

UCC has an annual intake of around 70 GEM students, split about 50:50 between EU and non-EU students. Interestingly, the programme has been seeing more and more students who achieved very high Leaving Certificate points but fell down on the HPAT exam. Most entrants are people who recently completed their primary degree and are aged around 22/23 years.

The financial burden is a concern for a number of students, confirms Prof Horgan, “but very few drop out because of it”.

The UCC GEM course was initiated in 2008 and is continually reviewed and refined, she says. Some newer developments include the use of simulation in paediatrics and adult medicine and more out-of-hours training.

“Students usually work nine-to-five but that is not life as a doctor. We try to do some out-of-hours experience with them – so in the emergency department doing sessional work from five to 10 so they can get that experience, and rounding early before nine o’clock – I am not sure students always like it, but it does prepare them for what is real life.”

Prof Jason Last, Associate Dean, Programmes and Educational Innovation at UCD’s School of Medicine, says the “widening participation” in medicine facilitated by GEM programmes has been a really positive development.

“The opportunity for students who have already achieved a primary degree to do medicine is important, because not every student at 17 or 18 knows for sure what they want to be…. Having both routes is still important – some students are aware of what they want to be, so I am delighted Ireland has both of those options.”

Prof Jason Last

UCD’s GEM programme has an approximate intake of 100 students per year. Around 75 per cent are EU students and 25 per cent are non-EU students. The programme commenced in 2008.

There is a focus on making learning “very digestible”. For example, there could be clinical anatomy, clinical physiology, pharmacology, and pathology modules all within the same semester. “One aim is to have the students thinking about the structure, the function, the disease, and the treatment of the disease, all within a week or similar,” outlines Prof Last.

One interesting observation is that more students are coming from scientifically-orientated/science-related disciplines than previously.

“In the early years, we actually had students coming from a very wide discipline base – business, law, etc. We still do, but more and more, the students tend to be coming from a slightly more scientific base than previously.”

It is not yet clear why this is.

“What I do know is that the students, no matter what background they come from, perform very well in the programme. It is probably the most important point from our research to date – we have obviously been very keen to make sure that the students who come from humanities, for example, feel as confident in the programme as those who come from a science background. In fact, we see the students performing well, overall.”

Prof Last also reports that drop-outs are rare in both the undergraduate and GEM courses. He says the issue of fees is a challenge for all students across disciplines at the moment.

“I think this is a very challenging issue for the higher education sector in general, so I wouldn’t highlight this as something that is specific to graduate-entry to medicine. Of course the fees that have to be paid in graduate-entry medicine are much more than the levy that students are asked to pay for their primary degree,” he comments.

He notes that supports for disadvantaged students, across higher education, are commonly focused towards those embarking on their primary degree rather than at graduate-entry stage.

Prof Last is especially proud of the patient input into both the GEM and undergraduate medicine courses at UCD. “We have a patient and advocate-centred education initiative, which crosses both of our graduate-entry and undergraduate-entry medicine programmes where we involve patients as partners in the classrooms…. Anything that demonstrates to the students how important it is to be empathetic and to listen is worth highlighting.”

<h3 class=”p4″>Adult learners</h3> Like colleagues in other universities, Prof Larvin at UL says it is too soon to say definitively how their GEM graduates are faring in clinical training and practice.

“We had 30 graduate in 2011, that’s just five years ago so they are all still in their early professional training. As the numbers have increased we have noticed that general practice seems to be a more popular choice for them, but we have trainees across all of the specialties now. The UK started graduate-entry in 2000, so there is more data from there emanating from the UKMED research group. The numbers are greater there obviously and the follow-up longer.

“Although there are many similarities with the UK the conclusions cannot necessarily be applied to what may happen in Ireland. One early conclusion from the UK is that they seem to do equally well in formal postgraduate assessments as the direct entry graduates do.”

Prof Larvin says graduate entrants bring the ability of having ‘learned to learn’, and some additional life experience. “At teaching hospitals sites where they mix with direct entrants, the two groups work very well together, as they do in the intern year, despite their different backgrounds and entry routes into medicine. The older students are very helpful to the younger students, particularly in dealing with personal problems. The older students seem to benefit from the youthful idealism of the direct entrants too.

“Treating graduate entrants as adult learners from day one at medical school makes them take responsibility for their own learning and that is what is needed after graduation as life-long learning is a must for practising doctors who need to keep themselves constantly up-to-date.”

He says the School is particularly proud that it has access scholarships, partly-funded by the UL Foundation and Atlantic Philanthropies.

“These are awarded by an independent committee of up to 10 per cent of our EU entry. This broadens our socio-economic profile and is in keeping with the Fottrell report’s aim to widen access to medicine.”

There is a heavy reliance on problem-based learning whereby students work in groups of eight or nine to identify and remedy gaps in their learning, using real-life clinical stories each week to bring the basic and clinical sciences alive.

“Uniquely we have a compulsory Special Study Module, the brainchild of our Founding Head of School, Prof Paul Finucane, whereby students produce a piece of artwork, sculpture, poetry, etc, based on a patient they have met,” reveals Prof Larvin.

“This encourages them to think beyond being a science ‘geek’ and to consider the emotions and feelings of patients as well as themselves. Some of the resulting creations surprise the students themselves and many are up to professional standards.”

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