In Australia, doctors must complete a 1-year internship and generally spend at least 1 additional year rotating through various terms before entering a specialty training program. These prevocational years should provide a bounty of opportunity for doctors to develop essential skills, but currently this process is impeded by several factors, including the lack of a formalised national prevocational training program, inadequate funding of education and skills training, and high service demands. To ensure a high quality medical workforce, the needs of doctors in training must be identified and met.
Here we discuss how the Australian Curriculum Framework for Junior Doctors, which was launched in 2006, could affect prevocational medical training, as well as important issues regarding implementation and resource allocation. Our conclusions represent a consensus of personal opinions of the Chairs of the Junior Medical Officer Forums of New South Wales, Queensland, South Australia, Victoria and Western Australia, who all contributed to the ideas expressed in this article.
There is a common misconception that a medical graduate steps into a hospital and instantly becomes a doctor. In reality, the process of becoming a doctor is gradual, beginning at the undergraduate level, where one learns the principles of sound clinical practice, and continuing through the supervised hands-on experience of prevocational and vocational training. This process involves the acquisition of skills, knowledge, reasoning and experience, and is a vital foundation for later unsupervised practice. Although clinical experience during training is essential, it must be supplemented by on-the-job teaching from senior clinicians and structured education programs.
There are no published data documenting the amount of teaching available to prevocational doctors in Australia, so we make generalisations based on our experience. On a daily basis, doctors in training spend minimal time at work involved in dedicated education and training activities. As a vital cog in the day-to-day operation of the public health system, much of their time is occupied by repetitive administrative tasks. In many hospitals, the only structured education interns and residents receive is 1 hour of formal teaching a week. This teaching is of variable quality and relevance and, because of service demands, junior doctors are frequently too busy to attend these sessions. When they are able to attend, interruptions to answer pager calls often make effective learning virtually impossible (although some hospitals now have pager-free teaching time). Valuable teaching from consultants and registrars also takes place, but this is sporadic and impromptu. Teachers are left with the difficult task of determining what should be taught and how this should be done.1 The systems that do exist for delivering education are inefficient, under-resourced, under pressure and unsustainable.2 Ultimately, prevocational doctors have little time for learning, and little formal teaching is provided.
To illustrate these issues, a recent national survey, commissioned by the Australian Government Department of Health and Ageing, showed that 64% of prevocational doctors felt generally prepared for their job, 31% felt adequately prepared for clinical emergencies and 45% felt prepared for performing procedures.3 Only 20% reported exposure to clinical skills training and 56% felt that they had adequate contact with consultants. More than 80% of these trainees wanted more formal instruction from their registrars and consultants, and increased exposure to high-fidelity simulation and to professional college tutorials.
Although a high workload makes learning difficult, increasing numbers of junior doctors will not alleviate this problem unless adequate resources are provided for training. A survey of medical students and interns in WA showed that 80% of respondents predicted a negative effect of the increased medical student numbers on teaching, and 77% predicted a negative effect on training positions for junior doctors.4 A very strong emphasis on training is necessary to cope with increasing numbers of medical graduates. In keeping with this, the Productivity Commission has identified the inadequacy of funding for clinical training, and a failure to consider the clinical training implications of increases in the number of undergraduate university places.5
The state of prevocational medical education in Australia stands in stark contrast to that in the United Kingdom, where an overhaul of training for junior doctors has recently taken place. The resulting Foundation Programme is well organised and has pledged funding of £73 million.6,7
With the development of prevocational curricula overseas, there has been a move towards curriculum development in Australia. This has led to the production of a draft Australian Curriculum Framework for Junior Doctors (Box 1), based heavily on existing curricula developed by the Postgraduate Medical Education Councils of NSW, SA and WA, the Committee of Deans of Australian Medical Schools, the Australian Council for Safety and Quality in Health Care, and curricula from the UK and Canada.7,9-14 The Framework, produced under the auspices of the Confederation of Postgraduate Medical Education Councils, will be available for viewing and feedback at http://www.cpmec.org.au/curriculum.8 The first substantive version of the Framework was launched at the 11th National Prevocational Medical Education Forum in Adelaide on 29 October 2006.
The Framework recognises many of the training needs of prevocational doctors, and has created a unique opportunity to improve the quality of medical training in Australia. The long-term outcome depends on how conscientiously and effectively it is implemented and resourced. Some brief suggestions regarding implementation appear in the preamble of the current version of the Framework, and it is expected that implementation will vary with local practice. A steering committee will be formed to discuss implementation in more detail, but it is important that we, as junior doctors, express our views beforehand.
The Framework is designed to support the process of turning medical graduates into generalist doctors. For this objective to be met, a number of areas must be addressed (Box 2).
The use of the Framework must not become a chore for the junior doctor to complete in his or her free time. The demands of working as a junior doctor are too great to have this additional burden. Training of junior doctors should be seen as a key result area for every Australian hospital. As such, the hospital and individual departments should take responsibility for the education and competency of junior doctors. Hospitals and governing bodies have a duty of care to the Australian populace that requires they ensure doctors are trained as well as possible. Not adequately meeting these needs has far-reaching implications for the general community for years to come.
Australia has the economic and intellectual resources necessary to train the best doctors in the world, and we believe that this should become a reality. The education of junior doctors as generalists before entry into vocational training is integral to the development of highly skilled medical practitioners. Ensuring that this process is as effective as possible will require debate and centralised organisation. Although ostensibly daunting, this is by no means a far-fetched task — it merely requires a modicum of funding and some creative changes to our training system and culture. The Australian Curriculum Framework for Junior Doctors has the potential to add to this process, provided it is well resourced and implemented in an effective manner with substantial input from junior doctors (Box 3). At stake is the standard of health care provided to the community. For this to be protected, an ongoing investment in prevocational medical education is required.
1 The Australian Curriculum Framework for Junior Doctors8
The Framework is an educational template that identifies the core competencies and capabilities necessary to provide quality health care. It will enable individual doctors to assess their education and training needs.
It outlines the general knowledge, skills and behaviour that prevocational doctors should acquire, regardless of their planned specialisation or training location.
It bridges undergraduate curricula and college training requirements, and is intended to assist education providers, clinical teachers and employers to provide a structured and planned program of education for junior doctors.
It is built around three learning areas — Clinical Management, Communication, and Professionalism — which are divided into 11 categories.
Each category comprises a number of learning topics, each of which details the associated capabilities expected.
It is envisaged that learning and assessment resources will be made available to support each learning topic.
2 Issues to address in adopting the Australian Curriculum Framework for Junior Doctors
3 Recommendations on implementation and resource allocation for the Australian Curriculum Framework for Junior Doctors
- Andrew J Gleason1
- J Oliver Daly2
- Ruth E Blackham3
- 1 The Alfred Hospital, Melbourne, VIC.
- 2 The Royal Women’s Hospital, Melbourne, VIC.
- 3 Sir Charles Gairdner Hospital, Perth, WA.
We thank the following for their invaluable opinions and contributions: Marion Mateos and Anand Rajan (Co-Chairs, Junior Medical Officer Forum, NSW Institute of Medical Education and Training), Matthew Peters (Chair, Resident Medical Officer Committee, Postgraduate Medical Council of Queensland), Anna Lowe (Representative, Resident Medical Officer Committee, Postgraduate Medical Council of Queensland), and Michael Edmonds (Chair, Junior Medical Officer Forum, Postgraduate Medical Council of SA).
Andrew Gleason received funding from the NSW Institute of Medical Education and Technology to attend meetings of the Writing Group of the Australian Curriculum Framework for Junior Doctors.
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Abstract
The current system of prevocational training does not meet the needs of junior doctors because of a high administrative workload, insufficient funding for education, and a lack of centralised guidance for trainees, teachers and hospitals.
The Australian Curriculum Framework for Junior Doctors is designed to identify the training objectives for the prevocational years.
The Framework has the potential to improve the quality of training of junior doctors, but this depends on how well it is implemented and resourced.
It is imperative that any group responsible for implementing or assessing the Framework have a representative junior doctor, among others, on its decision-making committee.
Stringent accreditation of training institutions is vital to the effective implementation of the Framework.
The Framework should be used to promote teaching and learning, not as a barrier to vocational training or as a check-list to complete.