With so many changes in medical education in the past decade in Australia and overseas, we might have expected a period of consolidation and stability. Not so, for seven new Australian medical schools are now at various stages of development. Except for the James Cook University medical school in north Queensland, which opened in 2000, these are the first new medical schools in Australia in 30 years. We talked to the Deans of the five schools which are closest to opening to find what has been happening and what they hope to achieve.

The schools are marked by their differences, not only from most of our established medical schools, but also from each other. These differences lie not in their curricula and courses, which incorporate many recent reforms in medical education, but in the ways the new schools are structuring themselves and harnessing resources for delivering the curricula, as well as in their priorities and the specific qualities they wish to foster in their graduates.

First to open was the Australian National University (ANU) in Canberra, which enrolled its first students in 2004 and is taking over the Canberra Clinical School facilities from the University of Sydney. Griffith University and Bond University on Queensland’s Gold Coast, and the University of Notre Dame Australia in Fremantle, Western Australia, plan to take their first students in 2005, the University of Wollongong in 2006, and the University of Western Sydney in 2007. A medical school at the proposed Sydney campus of the University of Notre Dame has been announced, but its exact status is unclear.

We interviewed the Deans of Medicine at ANU, Griffith, Bond and Notre Dame. At Wollongong, the Dean of Medicine, John Hogg, was yet to assume full-time duties, and we spoke instead to Don Iverson, Dean of the School of Health and Behavioural Sciences, who has overseen the planning of the new medical school, and to key faculty members. As the Western Sydney school appointed its Dean, Neville Yeomans, in October 2004, and had yet to develop the details of curriculum, location and student numbers, it was not included in our survey.

The new schools are fostering diversity, bringing their programs to an even broader range of institutions than the traditional “sandstone” universities. The ANU is one of Australia’s “group of eight” research-oriented, capital-city-based universities (and the last of these to open a medical school), whereas the other four universities are regional, and two are private — the Catholic University of Notre Dame and Bond University (the former having some Commonwealth-subsidised places, but the latter being “entirely free of government subsidy and influence”, said Chris Del Mar, Bond). The new schools are also bringing an academic presence to the medical community in regions where this has previously been lacking.

The schools are small, with intakes about, or even slightly below, 80 students per year — sometimes deemed to be the “critical mass” to sustain a medical school (Box). But small size may have advantages (“the Dean might even know your name”, said Paul Gatenby [ANU]). All the new schools lack the traditional departmental structure. They emphasise collaboration, and are harnessing teaching and learning resources in innovative ways from within their universities, their local communities, around Australia and internationally.

“The emergence of the new schools is clearly being driven by workforce issues”, said Judy Searle (Griffith). They have a commitment to fill particular workforce needs, local or national. Because of their responsiveness to local needs and dependence on local resources, each school is unique.

The new schools are incorporating the recent reforms in medical education. All will provide curricula with problem-based, self-directed learning; horizontal integration between disciplines; vertical integration between basic and clinical sciences; early exposure to patients; and increased emphasis on communication skills, ethics, and personal and professional development.

However, the new schools “are not reinventing the wheel”, said Iverson (Wollongong). All are obtaining a curriculum from an established medical school and modifying it for local conditions: Griffith from Flinders University, Notre Dame from the University of Queensland, the ANU and Bond from the University of Sydney, and Wollongong from a UK medical school. Iverson explained that Wollongong has turned overseas as it plans a model he believes is new to Australia — a community-based medical school, which conducts most of its clinical teaching in the community rather than in hospitals. This model is most developed in the United Kingdom.

Four of the new schools will also follow the lead of Flinders, Queensland and Sydney in offering a 4-year graduate-entry program, creating a more equal balance between graduate and undergraduate medical programs in Australia. Bond will offer a 5-year undergraduate course, but this will be similar to the graduate-entry program, preceded by a “science-heavy, case-based first year” to bring school-leavers up to the necessary level, said Del Mar.

The new graduate schools are also adopting the now almost universal criteria for graduate entry — grade-point average in a first degree, performance in the GAMSAT (Graduate Australian Medical School Admissions Test) and interview. The differences from established graduate schools will be in the details: for example, whether all criteria must be satisfied individually or may be combined, and, in particular, the content and weighting of the interview. For instance, at Wollongong, the planned weighting reflects the school’s aim that 30% of its students should come from a rural, regional or remote background. In addition, the ANU has a pathway whereby high-achieving school-leavers enrolling at the university in other disciplines may be interviewed and guaranteed a place in the medical school when they graduate, provided they pass the GAMSAT.

Entry criteria at Bond are similar to those at other undergraduate schools, comprising the UMAT (Undergraduate Medicine and Health Sciences Admission Test), school academic achievement and interview. Fees are about $45 000 per annum, and Bond, like the other new medical schools, is actively seeking support for scholarships, particularly for Indigenous students and those from East Timor.

As new initiatives, the schools have the luxury of first choosing a curriculum and then devising the best way to deliver it, unlike older schools which had to impose new courses onto pre-existing structures. In keeping with the principle of integrating the disciplines, the schools are not setting up traditional discrete departments. Nor do they expect to derive all their expertise and resources from within the medical school. Instead, they are drawing on the resources of the parent university and, where necessary, forming collaborations with other institutions, locally and further afield.

For example, at Griffith, which already has many health students (especially in physiotherapy), the medical school will be one of 11 schools, including dentistry and pharmacy, consolidated into a new Health Group. Within this group, academics will be organised into “discipline clusters”, said Searle. The medical school will draw on clusters in the Health Group and the Science Group for subjects such as biochemistry, physiology and microbiology. This has the added advantage of allowing cross-fertilisation, said Searle. Where more specialised expertise or resources are required, the school is appointing academics who report directly to the Dean (eg, in molecular pathology, anatomy and paediatrics). The university has pre-existing excellent “wet” anatomy laboratories, and the school is setting up a pathology laboratory and museum.

Bond, which lacks other health courses, is following the principle of obtaining expertise through appointments direct to the school — many part-time — and providing resources through collaborations with other institutions. For example, Bond will rent pathology resources from the Queensland University of Technology, and, for anatomy, the University of Queensland laboratories for a week of intensive dissection to complement prosected specimens, computer simulations and high-fidelity medical imaging. Bond is also keen to collaborate with nearby Griffith medical school.

Availability of patients for clinical teaching is an increasing concern for medical schools in developed countries, as hospital stays become shorter, patients in hospital tend to be sicker, and, at the same time, courses increasingly require early patient exposure. How will the new schools meet this challenge?

All are looking at new ways of accessing patients and more efficient ways of conducting clinical teaching, as well as collaborations to make best use of available resources. Perhaps most innovative is Wollongong, which plans a community-based medical school, where 80% of exposure to patients is in the community rather than in hospitals. This will include general practices, specialist rooms and community clinics, such as diabetes and sexual health clinics. “The school will use a good portion of its budget to offset the income lost by clinicians through taking students, as well as providing an academic rank commensurate with clinical experience”, said Iverson. Furthermore, community clinicians are an untapped resource — only about 15% of general practitioners in the region, and even fewer specialists, take students into their practices, and the local clinical community is enthusiastic about the plan.

Notre Dame is enlisting private and outer metropolitan hospitals to avoid overlap with the established medical school at the University of Western Australia. A bonus is the different casemix. “Exposure to patients in the tertiary system alone gives a distorted view of medicine,” said Bower. “Clearly we need tertiary hospitals for areas such as acute psychiatry, major trauma, some paediatrics. But the casemix at private and outer metropolitan hospitals gives a brilliant experience of the sort of medicine faced by most medical practitioners, as opposed to ‘super’ specialists in tertiary hospitals.”

Elsewhere, overlap seems inevitable, and schools are collaborating. Bond will share six of Griffith’s seven hospitals, having established together that there are enough student places. At present, Gold Coast hospitals accept around a hundred overseas students on electives (mostly from Europe), but will reduce this to make way for Australian students. Where overlap occurs, clinical teaching will be modified to meet the needs of the two student bodies.

There is also a move for students to learn basic clinical skills not on patients, but in simulated environments — clinical skills laboratories, using models, simulated patients, and clinical teaching associates. These methods are used particularly for intimate physical examinations, such as breast and pelvis, but are also being applied to a wider range of skills. For example, Bond will have some experiential learning on the wards in Years 2 and 3, but will teach basic clinical skills predominantly “in-house” in clinical skills laboratories.

A concern raised by several of the Deans is the need to improve teaching in the clinical placement years, which have traditionally been regarded as an “apprenticeship”. Searle sees a need for a better scientific underpinning in Years 3 and 4 of the course, and is investigating how to provide a core academic spine to the curriculum. In addition, Griffith is considering how to “do clinical teaching better”. For example, the “1-minute preceptor” is a strategy for clinical teachers to make the most of teaching time through effective assessment of the learner’s needs, instruction and more efficient feedback.

An innovation at Notre Dame that Bower believes is unique in Australia is a weekly clinical debriefing tutorial, guided by a clinician, in which students reflect not on clinical content but on the doctor–patient interactions and the impact of the experience on themselves. This aims to put flesh on the “reflective practitioner” and to inculcate a culture of doctors caring for their own health.

The Deans commonly felt that clinical teachers require better support and training. “A lot of curriculum reform has put clinicians offside, but clinicians are our best asset”, said Searle. “We need to use them ‘smarter’ and make sure the university provides adequate administration support.” Wollongong is ensuring the quality of its clinical teachers by setting up medical teaching programs. Unfortunately, most of the medical schools (with the possible exception of Wollongong) cannot properly reimburse clinicans for time with students.

Information technology (IT) has facilitated the design of the new schools and is central to delivery of their curricula. Indeed, Bond will be using the Sydney problem-based course live — Sydney’s web interface, which includes formative assessment, was a criterion for its choice.

The schools are exploring the further potential of IT. For example, the ANU school will be the university’s “guinea pig” for advanced IT presentations (such as generating three-dimensional “virtual reality”), with the university’s latest facility for this housed in the medical school. Its uses include training in procedural skills, such as inserting intravenous lines.

Griffith will integrate IT resources, including interactive programs, into its course. The schools will also be teaching students how to make more efficient use of IT, such as personal digital assistants, in clinical practice, with the proviso, said Bower, “never to make patients feel they take second place to the electronic apparatus”.

Assessment, like other areas of medical education, is also becoming more collaborative. The new schools are typically joining international assessment consortia, which provide banks of assessment items and allow comparison between schools. For example, the ANU belongs to a Hong Kong-based consortium, and Wollongong will join a similar UK consortium.

Assessment serves a range of functions, and the Deans emphasised the importance of differentiating these and tailoring each assessment task to the desired function. In general, the new schools will emphasise formative assessment (a learning tool) and will use summative assessment only when required (such as accreditation for progression to the next stage and ranking).

For instance, Notre Dame will have “lots of formative assessment” in Years 1 and 2 and a single, summative examination at the end of each year. Similarly, Griffith will have a major barrier at the end of Year 3 to ensure students enter the pre-internship year with adequate competence. Searle believes assessment should reflect “real-world” requirements; Year 4 assessment is “around the sorts of behaviour and performance they will need as junior doctors”, she said.

Indeed, the new curricula typically include a professional and personal development theme, which includes communication skills, procedural skills and other aspects of fitness to practise. These are assessed as academic endeavours against predetermined requirements. In this way, the schools are ensuring their graduates are equipped for practice with more than just scientific knowledge.

Further changes in assessment are mooted. Del Mar praised the North American system of a national licensure examination, although he considers this approach may be too radical for Australia at present.

Not surprisingly, all the Deans are ambitious to produce “quality graduates” who will be in demand for postgraduate training. But they are distinguished by their specific goals for their graduates. For example, Iverson hopes that 60%–70% of Wollongong graduates will choose general practice, and the rest specialist practice, not in capital cities, but in rural, regional or remote areas. Strategies to achieve this include:

• recruiting people with “strong ties to regional, remote or rural areas” (initially through aggressive recruitment of professionals already established in a rural or regional area);

• ensuring the curriculum reflects clinical situations common in general practice and a full range of the procedures possible in general practice; and

• providing as many general practice placements as possible throughout the course.

At Notre Dame and Bond, the goals for medical graduates reflect the particular philosophies of the universities. All Bond students, including medical students, are required to study four core subjects — business and entrepreneurship, IT, communication (community advocacy rather than the one-to-one communication skills usual in medical programs) and law and ethics. This reflects Bond’s origins as a private university funded by the entrepreneur Alan Bond and a Japanese consortium. Del Mar hopes that the resulting Bond-specific attributes in organisation and administration will create “future leaders in medicine”.

Notre Dame aims to produce graduates who will fill areas of unmet need and appreciate the Catholic values of compassion, respect and service. All students study philosophy, ethics and theology. The theology course is being modified to increase its medical relevance, with more emphasis on human spirituality, belief systems and their significance in life than on the gospels. Although Catholic ethics will be taught, the requirement is to understand, not necessarily to espouse, them. Bower wished to put to rest the canard that the Catholic ethos will affect education about some topics. “Our students will be exposed to all the information necessary to talk to their patients in a non-judgemental, respectful and ethical manner about any sensitive issue, such as abortion, contraception and end-of-life decisions. For example, if a woman asks one of our graduates about contraception, they would talk about it in relation to her needs and circumstances. They would not say it is an immoral act, which is the Catholic doctrine. That in itself would be unethical.”

Notre Dame is also trying to instil the concept of medicine as a vocation with a service component, and students are expected to perform voluntary work for the practices providing clinical placements. “This has further educational value”, explained Bower, “as students learn about themselves, the practice, and their interactions with others.”

Searle and Gatenby have specific goals for their schools as well as their graduates. Both wish their schools to take leadership roles in medical education and to develop strong research programs (see next section). In addition, “developing a regional identity and providing an academic focus for the local clinical community is also a major goal for Griffith”, said Searle, who wishes to improve healthcare in south-east Queensland.

Although all the schools wish their teaching to be informed by scholarship, they differ in their emphasis on research and their attitudes to the tripartite model of academic medicine, which combines excellence in teaching, research and clinical practice.

For the ANU, research is a priority and a selling point. The school wishes to take its place within the strongly research-based university — the only Australian university consistently ranked among the “top 50” universities in the world — and to capitalise on its strengths in anthropology and sociology. Its strategy is to enlist staff from the ANU research schools to teach, supervise student projects, and contribute to developing the faculty. Gatenby believes that “enquiry-based learning can really only occur in the context of a research-rich university. While it is possible to teach medicine in a TAFE, I do not know whether it is desirable.”

Griffith also wishes to develop a research agenda. “That is why we are an academic institution”, said Searle. “The appointments we make should provide leadership in research as well as around teaching and learning.” Griffith proposes to link with existing strengths and fill the gaps, particularly in translational research and research into health outcomes in primary care and the community.

Searle also wishes Griffith to be known as “a strong protagonist of evidence-based practice in medical education”. A frequent criticism of the changes in medical education is that they have not been rigorously evaluated. Searle believes that, as randomised controlled trials of the new courses are not possible, medical education must look to evaluative methods from other disciplines, such as psychology. She hopes that the register for longitudinal follow-up of medical students, which is being set up by the Committee of Deans of Australian Medical Schools, may answer some of the questions.

A lack of resources for basic science research is a current problem at some schools. To overcome this, Notre Dame is developing research partnerships with other institutions (eg, through part-time appointments). It will also pursue research in areas requiring less infrastructure, such as primary healthcare and epidemiology. The Bond school is not yet undertaking research, but sees itself capitalising on the university’s strengths in applied research; it will provide seed money and statistical support for research by clinical teachers as well as university academics.

For Wollongong, research is less of a priority than ensuring a high-quality medical education. Iverson believes Wollongong graduates will be as clinically competent as those who went to more research-intensive schools. However, Wollongong’s community-based school is an experiment in medical education, which they hope will yield objective evidence of its educational and economic effectiveness.

Even the Deans with a strong research commitment have reservations about embodying the traditional tripartite model of academic medicine in all staff. Both Gatenby and Bower emphasised that it is not necessary for each academic to be a stellar performer in all three domains, as long as the organisation as a whole meets its obligations. “With the pressures of today it is impossible for an academic to excel at all three. The polymath academic is a dying breed”, said Bower. Perhaps this is revealing what was once covert — he was taught by some excellent researchers who were awful teachers. “We need to move to the North American model, where a member of staff can elect to follow either a research tenure track or a teaching tenure track — although the latter has to be informed by scholarship.”

If Australia’s older medical schools are the “department stores” of medicine, providing graduates for many different purposes, then the new schools may be the “boutiques”. They are pioneering new ways of delivering a medical education and aim to produce graduates with qualities unique to their schools. How successful they are in providing for Australia’s future medical needs will be followed with great interest by politicians, practitioners and patients.