For colleges that cannot place all suitable applicants, creating more training positions is a vexed issue, as other stakeholders are involved: these positions are traditionally in public hospitals and financed by the state governments, with the colleges responsible for their accreditation. Not only is adequate funding required, but the colleges demand adequate educational value. The situation is not helped by the move of many doctors from the public to the private sector, particularly in specialties such as pathology and radiology.

Several Presidents talked of working hard and “knocking on every door” to meet or exceed AMWAC targets for positions. President Vincent Caruso says the College of Pathologists has lobbied state and federal governments with limited success. The College has tapped into the private sector to fund a number of training positions either fully or with support from the federal government.

The College of Surgeons, in particular, blames government for a shortage of advanced surgical training positions. “We think it is morally reprehensible that, earlier this year, 130 people were in this transitional position [awaiting advanced training posts]”, said the President, Russell Stitz. “We are keen to look at integrating basic and advanced stages. Politically that is difficult because health departments want people at the basic training level to fill their service requirements.”

On the other hand, colleges that cannot fill all their training places see the need for their specialty to be made more attractive to junior doctors. “Recruitment is a key issue for colleges of obstetricians and gynaecologists around the world”, said President Kenneth Clark. Indemnity must be kept under control and negative lifestyle portrayals avoided to encourage recruitment. The College of Psychiatrists has developed a recruitment package to encourage medical students to consider psychiatry as a career. However, President Julian Freidin does not feel that solving the psychiatric workforce shortage is the College’s responsibility alone, as it does not control all the workforce and financial levers. “The College is talking with the government about significant issues that deter students — all training positions are hospital-based, in acute settings that can be highly pressured, and psychiatry is less well paid than other branches of medicine.” The youngest specialty, emergency medicine, has also not reached AMWAC targets as quickly as expected, said its President, Andrew Singer, for similar reasons: “the pay structure, with most employed as staff specialists at lower pay than, say, procedural specialists; and perceptions that the work is difficult and high pressure”.

However, some Presidents see the problem arising further upstream, from past government decisions limiting “the pipeline” of medical students. With the recent proliferation of medical schools, numbers will increase, but there will be a long lag before any effect is seen on workforce numbers.

Most Presidents dismiss the suggestion to reduce training time as being neither practicable nor a solution to workforce shortages. “If you just rush some people through faster, you will help for a couple of years, but you are still on the same conveyor belt”, said Sewell.

Training has traditionally been time-based, with a certain number of years required in a registrar position before a barrier examination. Although some colleges are planning to move from a time-based to a competency-based program (see Training programs), they do not feel this will allow any substantial reduction in training time because of the amount of material that needs to be covered and the nature of rotations. Many colleges defend the length of their program because of a desire for their fellows to be generalists. For example, according to Michael Cousins (College of Anaesthetists), an anaesthetist in a country hospital must be able to cope with a wide range of patients and situations.

Freidin also pointed out that there is a large service component during training. “Over the 5 years that psychiatrists work as registrars, they spend only a short time training. They are working to keep the state system from falling apart.”

The medical workforce pressures mean that Australia relies heavily on overseas-trained doctors. All the colleges have procedures, in conjunction with the Australian Medical Council (AMC), to assess the suitability of these doctors to practise in Australia. Kidd summed up his college’s position, which is typical: “Any doctor recruited to work in independent practice anywhere in Australia should be at the level of a Fellow of the College and should either have attained that Fellowship, be judged by the College to have had equivalent training and assessment, or be working under supervision towards meeting the Fellowship standard”.

However, the colleges find assessing overseas-trained doctors a challenge. There is “such a difference between qualifications on paper and actual competencies of practice”, said Kenny. And the procedures of some colleges have been criticised as overly slow, onerous and even anticompetitive.

A range of other schemes allow overseas-trained doctors to practise in Australia without ever coming into contact with a college, and required standards vary between schemes and also between different states and territories. Cousins elaborated: “In states such as Queensland, it has been possible to employ overseas-trained doctors in career medical officer positions and to allow them to practise de facto as specialists, without going through the college process”. The colleges want to see standardisation of procedures and requirements across colleges and jurisdictions.

The federal government has asked the colleges to define rapid assessment pathways, particularly for areas of need, and to identify appropriate overseas qualifications. A continuing concern in this process, according to Cousins, is indemnification against claims of discrimination against particular overseas programs.

Another suggestion that might help relieve medical workforce pressures is to transfer some tasks of doctors to other health professionals. Indeed, the Productivity Commission proposed a multiskilled “generic” health worker in its recent position paper on issues affecting the health workforce.1

While Presidents such as Sewell felt there was merit in “skills transfer and better use of the health workforce in a broader way”, all stressed the need to maintain quality of care. For example, Allan Rosenberg of the College of Ophthalmologists contended that, “with adequate training, substitution of certain tasks is possible, but only a doctor has a holistic approach to treating the patient as a whole person”. For the College of Obstetricians and Gynaecologists, task substitution is probably their greatest recent challenge. Their President, Clark, said the College is not anti-midwife. “It is perfectly reasonable for women to have other care options. What they must have is immediate access to specialist care.”

Some colleges strongly support the development of health care teams headed by doctors. The College for Emergency Medicine sees itself as a leader, having “embraced advanced nursing roles and brought allied health staff into non-traditional areas in the emergency department”, said Singer. Similarly, public sector psychiatry is very open to the idea of clinical teams with a psychiatrist as “the leader who has the best ability to integrate the biological, psychological and social”, said Freidin. Kidd would like to see dedicated GP nurses in every general practice. Kenny believes in “role evolution”, and is evaluating its potential together with the radiographer and medical physicist professional bodies.

In addition, many specialist colleges are willing to share workload with appropriately trained GPs. For example, the College of Dermatologists sees that GPs, including those working in specific skin cancer clinics, fill a need in the detection and management of skin cancers.

Yet, a concern for many is the potential for task substitution to create a two-tier system, whereby some Australians receive a lower level of care than others. For example, the College of Anaesthetists wishes to maintain Australia’s pre-eminence for low anaesthetic mortality. “The general public expects not to die undergoing anaesthesia for a routine procedure”, said Cousins. Moreover, many Presidents pointed to a shortage of other workforce in their respective fields (eg, nurses and biomedical scientists), limiting the potential for task substitution.

The review of the colleges by the Australian Competition and Consumer Commission (ACCC) originated in the widening of the Trade Practices Act 1974 in the mid-1990s to include the medical profession. The ACCC began investigating allegations that the College of Surgeons was in breach of the Act by restricting entry to advanced training. The implication was that the college was a “closed shop”, inflating specialist incomes by limiting competition. To avoid legal action, the College applied for authorisation of its conduct, which can be granted if the ACCC is satisfied that the public benefit outweighs any detriment caused by the lessening of competition. In 2003, this authorisation was granted for 4–6 years, subject to the College making reforms to increase transparency, accountability, stakeholder participation and procedural fairness of its processes.

Stitz believes the situation is now largely resolved. “The end result is we have robust processes, and jurisdictional representatives on all our major educational committees. But we are having a bit of trouble with the resources needed to service the ACCC requirements for timely accreditation of hospitals and assessment of overseas-trained surgeons.”

The ACCC then turned its attention to the other colleges and began a joint review, with the Australian Health Workforce Officials’ Committee (AHWOC), of the extent to which college processes for selection, accreditation and assessment incorporated the general principles of the College of Surgeons’ authorisation.

Several other Presidents mentioned going out of their way to make contact with the ACCC and trying to work “within the rules”, believing the recommended changes were desirable. Sewell (Physicians) said: “They are wanting us to do certain things slightly differently. Many we have been trying to achieve anyhow, such as working more closely with the [government] jurisdictions about the distribution of the training workforce and our educational processes”. Others, such as Freidin (Psychiatrists), feel there is no suggestion their colleges are restraining trade — they have been “caught up in the general review”.

The ACCC–AHWOC report on the colleges earlier this year observed that many had implemented, or were intending to establish, approaches similar to ACCC recommendations, but that implementation was in its very early stages and varied between colleges.2 The colleges were invited to assess their progress individually.

In the past 5 years, the colleges have also been scrutinised by the Australian Medical Council (AMC), which has long accredited medical schools and their curricula. In 1998, the AMC was invited by the federal government to develop processes to accredit the college programs for specialist medical training, continuing professional development and assessment of overseas-trained doctors. The AMC has been reviewing the colleges at the rate of one or two a year since 2001.

The Presidents described the AMC reviews as exhaustive: “It was a major evaluation, with face-to-face meetings and site visits relating to our entire educational and examination program”, said Cousins. The College of Physicians underwent the process in 2004; Sewell considered it “a really important opportunity to look at everything we do educationally”.

Those still to be reviewed are anticipating the challenge. Anne Howard (College of Dermatologists) commented that the review (scheduled for 2007) is “a good opportunity to work out our curriculum and make sure we have the correct selection, training and assessment processes. But it will be fairly time consuming and expensive, especially for small colleges like ours, because they want a lot of material”. Similarly, Philip Montgomery of the College of Medical Administrators (scheduled for 2008) said “the most important challenge for us is making sure that all our processes and the quality of our education program are such that we get full accreditation”.

A major role of the colleges is to oversee vocational training in what has been traditionally a time-based, master–apprentice system. Several Presidents highlighted changes to the underlying philosophy of their programs. For example, the College of Anaesthetists has “modularised” training and is adapting these modules for distance education.

Both the College of Physicians and the College of Radiologists are moving to competency-based rather than time-based programs. Kenny said the College of Radiologists is putting enormous effort into curriculum development. “With the help of professional educators from the University of NSW, we are looking at a project that articulates the skills and competencies we expect of our trainees and graduates. These will be part of the actual training program and will be assessed.” She believes that defining required competencies could also have benefits in assessing overseas-trained doctors and task substitution. The College of Physicians intends its planned competency-based program to increase flexibility, as “trainees will be able to demonstrate their competencies at their own rate”, said Sewell. (The College has allowed part-time training for many years.)

Not all colleges have complete responsibility for training in their specialty. For the College of GPs, a major crisis was the loss of the contract for vocational training in 2002. GP training is now overseen by a government-owned company and contracted out to regional consortia, which include the College, to be performed to College standards. Another exception is the College of Medical Administrators, which includes, as its basic qualification, a university masters degree in public health or administration. Montgomery explained: “We used to run the program itself and set the curriculum and examinations, but it was a little antiquated. The universities are very good at running these masters programs, and the courses are available”.

In fact, the Committee of Deans of Australian Medical Schools has suggested to the Productivity Commission that universities should have a “major role” in vocational training.3 Overwhelmingly, the Presidents thought this was not practic-able. Many questioned where the universities would get the required teachers, as all their fellows are already involved in college programs. Sewell saw benefit in “working together with universities around specific skills and specific courses”, but “would not want to see a wholly parallel system of university vocational training which competed with the colleges. We are not that big a pond”. She also pointed out that “as clinicians provide an enormous amount of teaching to medical students (often unpaid) as well as to vocational trainees, there is considerable expertise in medical education outside the universities”.

Traditionally, continuing professional development (CPD) for college fellows is a voluntary program comprising lectures, seminars and conferences. However, a number of colleges feel more is required, such as making CPD compulsory and introducing audit components. The College of Surgeons is keen for its Fellows to participate in external audits, such as the national breast cancer audit, and is supporting the roll-out of a binational audit of surgical mortality.

The College of Obstetricians and Gynaecologists is the most demanding: “For the last decade we have required adequate compliance with our continuing education program, which includes compulsory practice review. We can — and do from time to time — remove the Fellowship”, said Clark.

His college has also led a national project on CPD — the LEAP (Learning, Education and Professionalism) framework. This includes practice review and is being trialled by other colleges under the auspices of the Committee of Presidents of Medical Colleges (CPMC) (see below). “We have now reached a joint belief at CPMC level that this is the way we should be going. We are trying to counter the position that it is an optional extra”, Clark continued. Nevertheless, while other Presidents support CPD, most are dubious about the value, or even the possibility under their by-laws, of making Fellowship contingent on revalidation.

Traditionally, colleges have been run by councils of their members, plus a smaller executive. There are moves to create smaller, more business-oriented governing bodies. In addition, the ACCC is pushing for governing bodies to include representatives of other stakeholders — trainees, the government jurisdictions and the community.

The College of Ophthalmologists moved 2 years ago from an executive council to a board run along the lines of corporate law. Rosenberg believes they are “ahead of the pack”. “We were looking at ourselves long before the ACCC review. The aim was to make changes to work within the law and look after our fiduciary interests, while retaining the collegial feel. We have pretty well followed the AHWAC and ACCC recommendations. We try to prevent crises by being proactive.”

Many colleges now have trainee repres-entatives on their federal or state councils or other committees. The move to include community representatives has been slower, and those appointed tend to have other desirable expertise. The GPs have just appointed the first layperson to council. “She is bringing a strong background in financial management, strategic planning and corporate governance, as well as the layperson’s perspective”, said Kidd. The College of Physicians has longstanding relationships with several consumer organisations but has not involved them in council. Sewell believes “they do not want to sit on a lot of committees, as there are not enough of them. They want to be involved when significant policy decisions are being made”.

The colleges are also beginning to involve the government jurisdictions, particularly in educational planning (eg, the College of Physicians has an AHWOC representative on its educational strategy implementation board). However, the ACCC–AHWAC report in July 2005 called for more progress in involving the jurisdictions in decisions affecting the workforce.2

In the face of the pressures, some Presidents see a particularly important role for their professional association, the Committee of Presidents of Medical Colleges (CPMC). “The Colleges have tended to be their own little worlds and to act in isolation”, explained Clark. “We need to be supporting each other more, and looking after the smaller and weaker colleges. We have been slow to share teaching and staff resources.” Some Presidents also believe the CPMC needs to move from being just about information-sharing to being a body in its own right.

The smaller colleges particularly appreciate the CPMC. According to Howard, “The meetings are terrific, with a real feeling of cooperation. We are looking at what sort of training modules we can help each other with”. Montgomery said, “The CPMC is a collaborative body, and very good for networking with other colleges, learning from each other and keeping up to date. It is particularly useful in being able to communicate directly with the Department of Health and Ageing and the peak bodies around Australia”.

On the other hand, some groups have criticised the CPMC as too timid and too agreeable with government, and some colleges may continue to put their own case.