To the Editor: McGrath and colleagues raise important questions about medical training in Australia.1 Their solutions take an admirable overall approach to policy, but fail to fully acknowledge the current reality of training and service delivery in the health sector. The Productivity Commission is certainly taking a broad approach to these matters,2 but I wonder if more lateral thinking and a reference to the past might help provide a solution?

In 1910, the landmark Flexner report recommended that universities take over undergraduate training so that a uniform standard could be achieved.3 Previously, many hospitals trained their own doctors, hence the term “teaching hospital”. I am increasingly of the opinion that the pendulum has swung too far since Flexner, and that universities now are ill-equipped to train the doctors of the 21st century. Doctors in hospitals and communities are largely responsible for the clinical training of students anyway, and it is also in these arenas that prevocational and vocational training occur. It appears that the universities are the odd ones out when the full spectrum of medical education is considered. Very little “higher education” takes place during a basic medical degree — it is hard to argue against the notion that a basic medical degree has more in common with “further education” and the training of a trade. With this in mind, might it not be sensible for hospitals to take over the training of doctors again? There have been similar recent calls for nursing and school-teacher training to return to workforce-based training, and they moved to universities far more recently than doctors.

Such a move could have a number of tangible benefits. All levels of training would be in alignment, thereby achieving the educational Holy Grail of “vertical integration”. Medical students would be immersed in a clinical environment from the start, thereby experiencing a true integrated curriculum. They would also be exposed to workforce requirements and this could address a number of current concerns surrounding graduates’ readiness for work.4 It would return public hospitals to being eminent training institutions, and would give true meaning to the term “teaching hospital”. Other health professionals could be trained within a similar model, introducing an interdisciplinary approach to training from an early stage. Basic sciences could be taught by scientists and clinicians alike throughout all stages of the course, all employed by the one institution and providing many educational benefits. Community-based education would be incorporated in a “hub and spoke” model, and clinical linkages would be significantly improved.

Such an innovative move could bring medical education and service delivery back into alignment. Any impediments would be purely technical and, of course, political — and easily overcome.