Prevocational medical education at the coalface: report from the 2006 national junior medical officer and director of clinical training/registrar forums

The Australian Curriculum Framework for Junior Doctors:2 The launch of this framework stimulated discussion about implementation and assessment; JMOs felt they should be involved in any planning or decision making. The forum identified potential for the framework to be “misused” for differing agendas that are not beneficial to JMOs. These include the misuse of the framework as a direct assessment tool (eg, as a checklist or logbook), or as a step to a 2-year internship, or replacing core terms with a competency-based system. JMOs believed the framework should not form a barrier to entering vocational training. They felt the emphasis of the framework should be in guiding allocation of specific and adequate funding for JMO teaching and resources, and to ensure educational opportunities are available for JMOs. They identified a need to recognise and reward the teachers and trainers who provide educational opportunities.

JMO involvement in medical school curricula: The forum felt that JMOs are under-recognised in their integral role in teaching medical students, and that they feel unprepared for this role, as well as for the work required in their first years after graduation. The forum believed JMOs can offer details and a realistic perspective on immediate postgraduation requirements to medical school curriculum committees.

Accreditation is key to JMO training, ensuring JMOs have sufficient educational opportunities, support and facilities. The postgraduate medical councils (PMCs) and equivalent bodies in each state have been diligent in accrediting PGY1 positions. Since last year, there has been increasing JMO involvement in accreditation visits; the forum felt this should be mandatory. Additionally, it was felt that a pre-accreditation survey could involve more JMOs in accreditation, allowing a snapshot of JMO roles and support mechanisms. A role for continual feedback between the PMCs and JMOs, including feedback on accreditation outcomes, was also identified. The forum felt there was limited evidence of PMCs enforcing their findings.

The forum noted an ongoing lack of universal accreditation of positions for junior doctors in PGY2 and above. An example cited from Queensland involved PGY2 doctors sent to rural placements in the first week of their training year. The JMOs were the sole doctors for an area of over 3000 people, and the only support mechanism was a phone number. The JMO forum believed this was unacceptable. The forum felt that with expansion to accommodate the imminent increase in graduate numbers, rigorous accreditation of all JMO positions will be required — the focus of expansion should be on existing institutions and programs, and international medical graduate (IMG) positions should be considered.

It was recognised that rural and remote positions are prone to a lack of support mechanisms for JMO welfare, and that there is a bias towards service rather than education. It was felt that rural and remote positions must be focused on education, not backfilling workforce shortages. Furthermore, these positions have different welfare and educational considerations, so that unique solutions are required to achieve a satisfactory standard for accreditation. It was agreed that the accreditation criteria for rural and remote positions should be the same as for metropolitan positions.

JMO welfare was considered an under-recognised issue, highlighted in the past year by tragedy, including the suicide of two registrars in Victoria. The forum considered JMO welfare a responsibility for all stakeholders from the top down, and that it should be a priority for institutions and PMCs. PMCs were considered appropriate bodies to ensure resources are available for JMO welfare. The forum felt that JMOs lack awareness about their own welfare issues, their rights and responsibilities, and the support mechanisms available when difficulties arise. The forum felt these issues and specific lines of support should be addressed during JMO orientation.

It was felt that JMOs don’t raise problems with clinical superiors and directors of clinical training because they perceive it may adversely affect their careers. This suggests that a cultural shift is required in medicine. Some strategies were suggested to improve JMO welfare, including changes to workplace conditions (eg, safe working hours, adequate supervision), strengthening existing support mechanisms (eg, medical education officers, mentoring) and third-party support mechanisms (eg, independent JMO welfare officers, general practitioner availability for JMOs).

The national curriculum framework was well received; it was thought to provide an explicit structure for prevocational training. The forum felt that a structured framework will help DCTs move from the traditional approach of “doing terms” towards “achieving competency”. The DCTs agreed that the framework could add value to the working aspects of the current system. They believed other intangibles should be considered, including professional development, acquiring experience, bedside manner, and safe practice in a complex environment. These were considered the difference between clinical competencies and competent clinicians. The forum supported a national approach to performance assessment to rationalise the methods and tools being used. It recognised the difficulty of demonstrating competency, although this endpoint remains the expectation of the public and government. DCTs and registrars felt there is more to safe, high quality practice than demonstrating core competencies.

IMG issues featured throughout the forum, especially in light of our changing workforce. IMGs among the DCTs offered insights into the IMG training experience in Australia. The forum noted an irony in the tiny and reluctant expenditure made for IMG work preparation compared with the cost of producing an Australian graduate. However, the forum recognised that the system has become dependent on this inexpensive supply of doctors. It felt the Confederation of Postgraduate Medical Education Councils (CPMEC) should lobby governments to provide resources for effective preparation and support of IMGs entering and working in the health system.

The forum noted that DCTs and the units they run have few resources to provide generic skills training for trainees and their supervisors. Important examples include clinical simulation and programs such as “Teaching on the run”.3 This was considered another advocacy issue for the CPMEC; the PMCs should consider the national accreditation standards as a useful tool for obtaining resources for specific training activities.