Medical education

The medical schools at the University of Western Sydney, University of Wollongong and University of Sydney have developed a joint program for training medical students through placements of up to 40 weeks on the New South Wales North Coast. The new partnership agency — the North Coast Medical Education Collaboration — builds on the experience of regional doctors and their academic partners. A steering committee has identified the availability and support requirements of local practitioners to provide training, and has undertaken a comparative mapping of learning objectives and assessments from the courses of the three universities. The goals of the program include preparing doctors who can perform effectively in rural settings and multidisciplinary health care teams, and to advance research in medical education.

Sue L Page BMed, FRACGP, FACRRM · Hudson H Birden MPH · J Nicky Hudson BM BS, MSc, PhD · Jill E Thistlethwaite MB BS, PhD, MMEd · Chris Roberts MB ChB, MMedSci, PhD · Ian Wilson MB BS, PhD, FRACGP · John Bushnell PhD · John Hogg MB BS, PhD · S Ben Freedman MB BS, BSc(Med), PhD · Neville Yeomans MB BS, MD

The Australian School of Advanced Medicine at Macquarie University, Sydney, will provide competency-based university medical specialist training in a private hospital environment. The rationale is the need for additional and innovative programs to meet emerging demands, and alternative training programs to increase the opportunities for doctors to achieve their career goals. The programs will focus on learning (not teaching), on developing a comprehensive set of professional competencies, on teamwork, and on research. Special features of the programs include: the potential for scholars to progress at a variable pace; the use of facilities for simulation and practice; and rigorous evaluation. The school is developing strong linkages with other institutions, nationally and internationally. Challenges include the recruitment of fee-paying trainees; the time commitment required of faculty members; a reliable and bias-free assessment system; and ethical concerns about undertaking training activities on private patients.

Rufus Clarke MD, PhD, FAFPHM · Michael K Morgan MD, MMedEd, FRACS

Is it heading in the right direction? The preceding article by Clarke and Morgan discusses a new form of education and training for medical specialists in Australia. The programs at the Australian School of Advanced Medicine at Macquarie University have pre-Fellowship (general specialist training) and post-Fellowship (subspecialist training) components.1 Here, I concentrate on the former. Both the formal university involvement and the new funding model proposed in the article have major implications that warrant widespread discussion. The authors imply that the university environment will enhance the educational experiences of trainees, but they have not provided supporting evidence. If it is true that the new model of training will result in better outcomes than our current system of medical college training in hospitals, should we consider other alternatives? In Canada, most specialist training programs are contracted to university medical schools and affiliated hospitals by the Royal College of Physicians and Surgeons of Canada.2 Would this be a better approach for Australia? Alternatively, should there be competing programs? Traditionally, medical specialist education and training has been seen to be both a public good and a benefit to the individual, with costs shared between the Australian taxpayer and trainee. For almost all trainees employed in public hospitals, the taxpayers’ costs have been met by hospital budgets. It has not been possible to separate out the costs of specialist training because most training is directly associated with patient care.3 There has been considerable debate as to whether the additional costs are significant and whether the benefits to the system outweigh the costs. Undoubtedly, trainees incur costs — unpaid overtime, fees to the specialist colleges, and fees for courses, attending lectures and meetings and the like. The Commonwealth Government, with some understandable ambivalence from state governments wishing to protect the public hospital workforce, is seeking greater private-sector involvement in specialist training. The reason is not only to cater for increased numbers of medical graduates, but because many essential learning experiences in most specialties are now available only in the private sector.4 These include less complex elective surgery, such as stripping of varicose veins, repair of bunions, and plastic surgery procedures, much of dermatology, rheumatology and endocrinology, and management of patients with anxiety and less complex depressive disorders. Funding remains contentious. The sums initially suggested by the Commonwealth Government during the discussion process would have barely covered salaries and on-costs for trainees. Indirect costs to hospitals and supervisors are substantial. The presence of trainees in operating rooms would be likely to lead to a 30% slow-down, reducing the income of both hospitals and supervisors. In the case of ambulatory consulting, the income of supervisors would be affected by about the same percentage. There will be other costs, including office space, access to computers and journals, medical indemnity insurance, consulting rooms, and administrative support staff. These costs may well be equivalent to about 50% of the salary and on-costs per trainee and so not too dissimilar to the fee proposed by Macquarie University. If these costs are not met by government, it is unclear how private hospitals will recover them. Some surgical trainees may be able to claim assistant fees from Medicare, but the issuing of Medicare provider numbers for physician trainees seems unlikely. Would private health insurance funds view funding for specialist training as a legitimate additional hospital cost? Would some not-for-profit hospitals be prepared to cover part of the cost as a community service, even though margins for hospitals able to provide appropriate experience are probably not great? Would for-profit private hospital providers be interested? Private hospitals gain no direct financial benefit. If the proposal outlined is successful, it may well represent the model for funding these additional costs — the trainee pays. This may become a disincentive for trainees to seek essential private-sector experience. However, it has even wider implications. Almost certainly, in the 1990s, one of the drivers for identifying costs of medical specialist training in public hospitals was a desire by some politicians and bureaucrats to recover at least part of those costs from trainees or their colleges, effectively the same source. If the Macquarie venture succeeds, this issue will almost certainly be revisited. Therefore, the proposal described by Clarke and Morgan could lead to a fundamental change in the way specialist training is paid for in Australia — to more user-pays funding — and this may well influence recruitment, training opportunities, and the quality of training, among other things. Just as we need to question increased university involvement, we must ask ourselves if this funding model is a direction in which we want to go. What are the advantages and what are the disadvantages?

Peter D Phelan BSc, MD, FRACP

To the Editor: I read with interest the recent correspondence on “patient privacy and Latin”.1,2 The wheel continues to turn! In 1927, matriculation for the Faculty of Medicine at the University of Sydney demanded passage in the subjects of science at the Intermediate Certificate examination (equivalent to the present Year 9) and Latin at the Leaving Certificate examination (equivalent to Year 11). The 1937 edition of Cunningham’s textbook of anatomy contains no less than a 29-page glossary of “General terms and parts of the human body” listed in four columns headed “British revised”, “Latin form of British revised”, “Basle Nomina Anatomica” and “Nomenklatur Kommission”, respectively (the last three columns representing alternative versions of the Latin terms). A final thought — how much human anatomy is taught in the present-day curriculum?

Keith S Jones

To the Editor: The recent letters1-5 on the “lamentable decline in the use of both Latin and Greek terms in medical practice”4 activated a not-too-distant memory for me. In the 1980s, the Department of Academic General Practice at the University of Western Australia was an orphan, struggling for resources and a toehold in the medical curriculum. Having exhausted all avenues of progress, I managed to obtain an appointment with the Vice-Chancellor. His prior meeting that day had been with leaders of the Greek community, who trooped out of his office looking rather glum. They were unhappy that ongoing financial support would not be provided for the teaching of Modern Greek at the University. That night, I had a dream. In it, the V-C returned home to his wife, who asked, “And how was your day, Bob?” “Oh, just like any other”, he replied. “Kamien from General Practice was in, complaining about the demise of classical Greek from the medical curriculum”. The next day, I rang the V-C to tell him about the dream. He laughed. I have wondered, since, whether such unlikely events may have strengthened his resolve to provide the toehold that our Department so desperately needed.

Max Kamien

Medical education faces global challenges because of the changing health care needs of an ageing and more demanding society, and the consequent requirement for increased health care workforce capacity and different workforce models. In the United Kingdom, education reform has spanned the medical, nursing and allied health professions, and has introduced new health professions with specific roles within a new, team-based model of comprehensive health care. In medical education, the UK reforms span undergraduate, prevocational, vocational and continuing education, with the aim of providing a framework for faster, more flexible career development that can adapt to future changes in workforce need. While some reforms are controversial, most appear sensible and are supported by most observers. The Modernising Medical Careers process suffered implementation difficulties in 2007: the national, web-based application scheme for vocational training posts could not cope with such a large process, disrupting both the recruitment of an appropriate workforce for hospitals and the career progression of many recent UK medical graduates. The main problem appears to have been in management of change — too much was attempted too quickly on too large a scale — resulting in a backlash against any significant change. There may be lessons for Australia and New Zealand, which face similar challenges and are considering broadly similar changes.

Richard B Hays MD, FRACGP, FACRRM, MRCGP

Education of our doctors needs to be a priority for the health services, not an add-on Training of doctors is expensive and takes a long time, and so we need to make sure all parts count. It had been recognised for some time that the PGY1 and PGY2 years, sitting between undergraduate and vocational training, were a lost opportunity, with no defined outcomes and marked variation in experience and supervision.1 Gaps in knowledge and skills were often likely after completion of this part of training. A significant number of junior medical officers (JMOs) feel unprepared to deal with, for example, medicolegal issues, emergencies or some procedures, which is unacceptable.2 Worryingly, they receive varying degrees of feedback and often feel inundated with administrative tasks. Many states had started working on defining outcomes for the PGY1 and PGY2 years, and, with leadership from the Confederation of Postgraduate Medical Education Councils and funding from the Medical Training Review Panel of the Australian Government Department of Health and Ageing, they collaborated to develop the recently launched national Australian Curriculum Framework for Junior Doctors (http://www.cpmec.org.au/curriculum). They drew on previously published frameworks from Canada3 and the United Kingdom,4 and the Australian National Patient Safety Education5 and Committee of Deans of Australian Medical Schools Indigenous Health Curriculum frameworks.6 The Framework documents key areas that we all know are important (clinical management, therapeutics), but also makes explicit areas that are usually minimally addressed, such as patient safety, communication and cultural safety. The consensus is a significant achievement in terms of agreement and collaboration across states. A curriculum can be viewed as a statement of the philosophy, content, learning methods and implementation of a course, which ideally would be linked with assessment. The Framework provides one part of a curriculum, namely the knowledge, skills and behaviours expected to be attained by PGY1 and PGY2 trainees, which they will carry forward into practice. However, will the Framework make any difference to the educational experience in those transitional years? This is a point of concern for JMOs, as discussed by Gleason et al in this issue.7 Two key aspects of training relate to how learning and assessment occur. Firstly, as regards learning, the curriculum framework working group recognised that learning will be progressive and opportunistic, and will occur in the work setting, and that effective supervision is important. Most learning still occurs in the work setting, and currently is unstructured and unlinked to any overall outcomes. The term “deliberate practice” has been used to define a model of learning characterised by good supervision and feedback, focusing on well defined tasks that can improve performance, and ensuring plenty of opportunity to practise these tasks.8,9 This requires a teaching program, guided by the Framework, which runs alongside clinical work, including simulation, tutorials, debriefing and online learning. However, this is not enough. A recent study on communication skills taught in a simulated setting showed that a program to transfer those skills back to the clinical setting (through close clinical supervision and feedback) is required for simulation training to have any effect on practice in real life.10 Assessment may be even harder. Although the JMOs are not keen for assessment to be used for registration,7 registration is a recognition of a level of competence and needs to involve some form of assessment. How can we be sure that doctors have reached a level of competence where they can be left to care for patients independently or are ready to move to the next stage of training? Currently, requirements vary from state to state, and may involve no more than completion of a form on overall impressions by supervising consultants in the PGY1 year. Although staff training has improved the amount of feedback JMOs receive, it is still lacking. The UK has moved down the pathway of having detailed determination of competence with multiple observed activities. Insufficient resources were provided for administration and training of staff, and this has led to both junior doctors and their supervisors developing innovative ways to subvert the system (Professor Janet Grant, Chair of the Curriculum Subcommittee, Postgraduate Medical Education and Training Board, UK. 11th National Prevocational Medical Education Forum, Adelaide 2006). Rather than moving straight to a complex system, at risk because of insufficient resources, we could continue to improve our current assessment of overall “global” competence of trainees, backed up by assessing essential areas in simulated settings (such as cardio-pulmonary resuscitation). When a trainee’s global competence appears inadequate, a second look, using assessments such as those used in the UK, could take place and more support be instigated. This may shift our assessment culture from punitive (blocking progress) to formative (helping progress), which presupposes that JMOs will all eventually be successful. JMOs may fear this aspect less. All of this is a big ask in an overburdened health system. Without resources, little is likely to change. We need to define and run simulations and tutorials. We need to train clinicians to facilitate learning and give feedback (professional development for clinical teachers). We need to train clinicians to recognise who is struggling. For both teachers and learners, we need to make sure there is enough time to do all this. The health services need to make education a priority, rather than an add-on.1,2 We agree that JMOs should be involved in developing and implementing an assessment plan. They also need to understand their responsibility in this partnership of learning. It is of interest that JMOs mostly request more tutorials and simulation to support training and think they learn little in the work setting. Learners need to be taught to recognise and make the most of learning opportunities, in part through reflection (teach the learners11). We cannot make all JMOs’ experiences uniform. It is unnecessary and impossible. However, the Framework allows administrators, clinicians and junior doctors in different states and clinical settings to consider the best ways to implement a better learning and assessment system for JMOs. Rather than lose the momentum, let us share resources and ideas nationally, and evaluate implementation through education research to make sure outcomes are achieved. We need to lobby as a group to make sure our clinical sites (including hospitals, community settings and new models of interdisciplinary care) are best structured and resourced to optimally train and assess our junior doctors.

Fiona R Lake MB BS, FRACP, MD · Lou Landau MB BS, FRACP, PhD

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.

Andrew J Gleason MB BS(Hons), BSc · J Oliver Daly MB BS, BSc(Hons) · Ruth E Blackham MB BS

Why is so little known about what works in selecting medical students? In the past decade, some 15 000 students entered Australian medical schools, and in the United Kingdom, four times that number were admitted. Such a large number should imply that much is known about what to select on, how to select and whom to select. The sad reality is that surprisingly little is known. Instead, strongly held opinions are rife, inertia predominates, and change occurs more because of necessity, external pressure, political force or mere whim, than because of coherent evidence-based policy or theorising. Selection sometimes seems more to ensure the correct number of entrants on day one, than to identify those best suited to the course and profession. As if to illustrate the problem, the University of Adelaide recently reduced its emphasis on selection interviews, the University of Sydney extended its use of interviews, the University of Queensland may be ending interviews, and a meta-analysis in Medical Teacher suggested that selection interviews have only “modest” predictive validity and “little” or “limited” practical value.1 However, interviews differ in many ways, and although the meta-analysis found no moderating effect of factors such as interview method, structure, training, or scoring, some forms of interview may still be valid, as found outside of medicine,2 particularly for situational interviewing.3 An innovation in selection is written tests of “cognitive aptitude”, such as the Undergraduate Medicine and Health Sciences Admission Test and the Graduate Australian Medical School Admissions Test (GAMSAT) in Australia, and the BioMedical Admissions Test, GAMSAT and the UK Clinical Aptitude Test in the UK — tests whose enthusiastic adoption belies the absence of published evidence on predictive validity.4 In this issue of the Journal, an important article by Groves et al5 evaluates GAMSAT, used in nine Australian and four UK universities and which claims to measure “the mastery and use of concepts in basic science as well as the acquisition of more general skills in problem solving, critical thinking and writing”.6,7 The study by Groves et al is not large, but like another small study,8 addresses the predictive validity of GAMSAT, as well as further questioning the value of interviews. Cognitive aptitude tests4 measure either intellectual ability, general mental ability or intelligence (all effectively synonymous), as in GAMSAT’s first section, or academic achievement or attainment (typically with specific scientific content, as in GAMSAT’s third section, “Reasoning in Biological and Physical Sciences”). Although intellectual ability does predict outcome in primary and secondary schools, its prediction of university outcome is poor, tertiary-level performance depending more on motivation and specific knowledge. Consequently, achievement measures, such as A-levels in the UK, are more effective predictors of medical school outcome4,9,10 than are measures of intellectual ability, which predict little10 — a result known since the 1970s.11 For GAMSAT, Groves et al found a significant correlation with Year 2 examination results only for the biological and physical sciences section assessing achievement, and not for the sections assessing “more general skills in problem solving, critical thinking and writing”.5,6 It has to be acknowledged that even measures of achievement are not strong indicators of medical school outcome, with much variance still to be explained.9 A major problem for people developing and evaluating selection criteria is the lack of adequate outcome measures reflecting the broad and complex day-to-day behaviour of doctors. A rare and important exception is the study by Papadakis et al,12 who found professional misconduct was related both to unprofessional behaviour in medical school and to poor academic achievement before and during medical training. In medical school and beyond, most measures of competence assess knowledge, whereas being a competent, safe and effective doctor probably depends to an equal extent on behaviour, attitudes and approaches. Adequate knowledge is a necessary part of good medicine, but is far from sufficient for competent practice. Without robust, objective and valid measures of other professional skills to complement our robust measures of knowledge, any post-hoc assessment of selection criteria will be lopsided. The study by Groves et al is significant for including clinical reasoning skill as another outcome measure, but here there was a negative correlation with GAMSAT.5 Students from only two universities were included in the study by Groves et al, and the authors comment, “there is an urgent need for collaborative studies to explore these issues further”.5 Inadequate numbers of patients are the bane of clinical trials, so collaborations between hospitals are now standard when testing new drugs. Large-scale evaluations of medical education should be relatively easy, but few studies have been done. Randomised controlled trials (RCTs) should surely also have a place in assessing selection methods, but reasons are too easily found for them being impractical or unethical, despite being the ideal way to answer questions on the validity of novel selection procedures. If RCTs are ethical when assessing the effectiveness of drugs given to patients, they are surely also ethical for assessing the efficacy of tests used for selecting the doctors giving those drugs to patients. A more general issue raised by the very scarcity of studies like that of Groves et al is why, despite educationalists proliferating in medical schools, so little is known of what does or does not work in selection. The psychologist William James, more than a century ago, characterised his own nascent discipline as “A string of raw facts; a little gossip and wrangle about opinions; a little classification and generalization on the mere descriptive level [but] not a single proposition from which any consequence can causally be deduced”, concluding, “This is no science, it is only the hope of a science”.13 Recently, Schuwirth and van der Vleuten were equally critical of much medical education research, with its often “poorly performed or poorly reported” studies, problems that need solving “if the specialty wants to be taken seriously”.14 Selection encapsulates most of the important questions that medical education faces. The problems are not insoluble, and the intellectual tools mostly exist. The problem is in finding the collaborative will to solve them, and to confront negative answers when they arise.

Chris McManus · David Powis

Objective: To examine the relationship between medical school applicants’ performances in the Graduate Australian Medical School Admissions Test (GAMSAT) and structured interviews and their subsequent performance in medical school.Design: Students in Years 2–4 of two graduate-entry medical programs were invited to complete two previously validated tests of clinical reasoning. These results and their Year 2 examination results were compared with their previous performance in GAMSAT and at interview.Setting: The graduate-entry programs at the Universities of Queensland and Sydney.Participants: 189 student volunteers (13.6% response rate).Main outcome measures: Students’ test results on a set of Clinical Reasoning Problems (CRPs) and a Diagnostic Thinking Inventory (DTI) and their Year 2 examination results.Results: There was no association between performance in GAMSAT and performance in the CRPs; there was a weak negative correlation between performance in GAMSAT and the DTI (− 0.05 > r > − 0.31, P = 0.03). The correlation between GAMSAT and examination results was weak (r < 0.24, P = 0.02). The correlation between GAMSAT and interview scores for each school was weakly negative for University of Queensland (r = − 0.34, P < 0.01) and weakly positive for University of Sydney (r = 0.11), with a combined significance level P < 0.01.Conclusions: We did not find evidence that GAMSAT and structured interviews are good predictors of performance in medical school. Our study highlights a need for more rigorous evaluation of Australian medical school admissions tests.

Michele A Groves BSc, PhD · Jill Gordon MB BS, PhD · Greg Ryan RN, PhD

Innovation, fitness to practise and medical education as a discipline were the themes of a recent colloquium Medical education is currently under the spotlight both in Australia and internationally. It is, for example, influencing and being influenced by major global initiatives such as the International Campaign to Revitalise Academic Medicine (a collaboration of medical academics seeking to secure a vibrant future for academic medicine) and the recent Productivity Commission’s report on Australia’s health workforce, which highlighted the need for more responsive education and training.1,2 New medical schools are being established, with some seeking to develop innovative programs and access perceived niche markets.3 Some of these issues were debated at a conference in March 2005 hosted by the Committee of Deans of Australian Medical Schools.4 It was against this background that the School of Medicine at the University of Queensland hosted the first Australian National Medical Education Colloquium in August 2005. Innovation, fitness to practise and medical education as a discipline were the themes of the 2-day Colloquium. It brought together over 120 participants from Australian medical schools, who were challenged to consider future directions for medical education. Plenary sessions were delivered by Ron Harden (Director, International Virtual Medical School [IVIMEDS], and former Professor of Medical Education, and Director, Centre for Medical Education, University of Dundee); Thomas Aretz (Director of Education, Harvard Macy Institute, Harvard Medical School); Merrilyn Walton (Associate Professor of Ethical Practice, University of Sydney); and David Prideaux (Professor of Medical Education, Flinders and Griffith Universities). Priority directions for medical education identified by plenary speakers were student-centred learning, adaptive curriculum, teaching innovations, systems approach, academic medicine, fitness to practise, and medical education research. Student-centred learningHarden highlighted the importance of student-centred learning as being pivotal to thinking about learning and teaching. He suggested our medical education programs need to see the student at the centre of the learning process, with a futuristic option that includes learning becoming personalised through “blended learning” — a mix of e-learning and face-to-face study — and truly individualised programs. IVIMEDS, a worldwide partnership of leading medical schools, is an example of an organisation working to develop e-learning opportunities in medical education. IVIMEDS includes a bank of learning objects (eg, x-ray images, decision-making scenarios, videos), curriculum maps, virtual patients, and guided learning that is responsive to the learning needs of individual students and is an example of what is called an “adaptive curriculum”. Adaptive curriculumAn adaptive curriculum modifies and personalises learning by designing teaching and learning experiences geared to the specific needs of individual students. As Harden explained, the concepts of “just for me” learning and “just in time” learning are accommodated by technology — when the learner is ready, the teacher will appear via technology. Programs such as IVIMEDS provide the framework and resources for this type of learning to be further developed. Teaching innovationsInnovations in medical education extend to curriculum, technology, assessment and professionalism. The curriculum model of the future should be student-centred, problem- or task-based, integrated, interdisciplinary, interprofessional, community-based and elective-driven, with core and student-selected components. The goal is systematic, outcome-based education.5 But how is this ideal to be achieved? And how do we move beyond a list of motherhood statements? Curricula are already becoming blended, using different technologies that allow students to access learning opportunities for what they need to know and when they are ready to learn. Technology will continue to be an important aspect of future medical education, with simulation a key feature.6 To keep pace with curriculum changes, assessment must move beyond multiple-choice tests of knowledge and multistation tests of “pretend” clinical skills using simulated patients. There is increasingly a need to assess aspects of professional behaviour and competence within the health system. Portfolio assessment may be one way to do some of this, but we have a long way to go before we can be sure we are graduating truly competent doctors with the necessary professional behaviour. Systems approachAretz stressed the need for medical education programs to prepare graduates who are responsive to both the needs of the health system in which they will function and the needs of the patients they will treat. Currently, medical students spend most time in teaching hospitals, but they will eventually work in the commun-ity, where most patients present and are treated. Aretz challenged delegates to prepare interns who are immediately ready for the workplace and have the prerequisite skills and knowledge required by the health system and the consumers of health services. The future of medical education was presented from global, system, institutional and individual perspectives. Global perspectiveWith the mobility of the health professional workforce, changes — including international accreditation, increased competition between medical schools, and increased cybermedicine — seem to be the way of the future. Global alliances for teaching resources and assessment are efficient, as is developing new assessment technologies, including consortia for practical clinical examinations, simulators and web-based clinical evaluation systems. There is a need to develop a global perspective such that equivalent standards across countries and medical schools are defined, including mechanisms for global standards, accreditation and curricula. System perspectiveMedical schools increasingly require their students to have an understanding of the evolving health industry structure from all levels, including self-care, nursing, general practice and specialist areas. The system works through partnerships between all components, such as academic institutions, biomedical research centres, the insurance industry, government, regulators and health care providers. Users of the medical school product, including health systems and patients, require and demand input into how medical education works. Institutional perspectiveMedical school programs will probably increasingly seek differentiation. Some will focus on interprofessional education (in which students in various health professions, such as medicine, nursing, and allied health, learn together); others will be for profit; and some will develop niche markets (eg, providing accelerated pathways to a particular speciality). A key challenge for medical programs is appropriate reflection of the health system they serve so that medical training mirrors actual health care delivery patterns and recognises non-traditional training sites. Faculty development plays an important part. Multidisciplinary teaching teams can be developed so that centres and institutes, rather than traditional medical disciplines, are the organisational framework for creating integrated curricula that cross traditional departmental lines. Individual perspectiveMedical schools should be educating for capability, so that indi-vidual learning tested once is insufficient and competence requires repeated demonstration. The ability of individuals to adapt to change, generate new knowledge and improve their performance and professionalism is as important as specific knowledge and skills. Academic medicineMedical schools and health systems need to recapture the educational mission by protecting time for teaching and faculty development. Academic medicine must be fully engaged with its real stakeholders — the health system and the patient. The International Campaign to Revitalise Academic Medicine has presented a range of provocative possibilities.7 Fitness to practiseAccording to Walton, fitness to practise is an issue with which all medical schools are currently grappling. There is still debate about what it really means, what its components are, what we are currently doing well, and what we need to do much better. Overall, we are probably handling the issues of knowledge and clinical skills quite well. However, there was broad agreement that we have a long way to go in terms of attitudes and behaviour. How can we define them, develop them in our students and then assess them? Medical education researchPrideaux challenged Colloquium participants to embed medical education research into academic medicine. In order to validate the effectiveness of new teaching approaches, medical education research must emphasise appropriate methodology. “Very little research is undertaken of our teaching programs in medical schools, and that which is done is usually methodologically unsound”, said Prideaux. Current problems with medical education research include no clear focus or standards, no strong evidence base, little research in key areas, methodological confusion and inappropriateness, poor design, wrong questions, atheoretical approaches, and reduced generalisability. He challenged delegates to make robust medical education research an integral part of their school service. SummaryThe Australian National Medical Education Colloquium provided a productive forum for medical educators to meet and to discuss and debate important contemporary issues affecting Australian medical schools. None of us know what the future will hold, and some of the possibilities discussed at the Colloquium were futuristic indeed. We would be wise to keep an open mind, to focus very much on competence and fitness to practice, and to develop a strong evidence base, as we travel this important path.

Louise Young MPsychEd, PhD · David Wilkinson MBChB, FRACGP, DSc

Objective: To determine whether grand rounds are becoming less common in Australian hospitals.Design and participants: Between November 2003 and April 2004, we surveyed 88 clinicians with educational responsibilities in Australian hospitals. A written questionnaire evaluated whether grand rounds were held and how frequently; the structure and percentage of attendees; and the perceived value of grand rounds with regard to education, professional development and general characteristics.Results: Clinicians in 73/88 hospitals completed the survey (83% response rate). Of the 73 respondents, 63 reported that their hospitals continued to hold grand rounds, and most considered them to be valuable in the areas surveyed. Grand rounds were more common in larger hospitals, public hospitals, and those having junior medical officers. The proportion of clinical staff regularly attending grand rounds was estimated to be 10%–50% by most respondents.Conclusion: Grand rounds continue in the majority of hospitals and are considered valuable for educational and professional reasons. There may be scope for improving attendance at grand rounds by greater emphasis on the specific needs of attendees.

Richard Tarala FRACP · Alistair W Vickery FRACGP

Factors to be considered in planning our medical workforce to meet future needs include: Need for outcomes-based curricular designs in medical schools and postgraduate training. Shortening the length of medical training. Improving career flexibility to permit professional reinvention. Developing awareness within the profession about how innovation happens.

S Bruce Dowton MD, FACMG, FRACP

Exploring the “norms” or principles of bioethics, health law and international human rights is central to personal and professional development courses of contemporary medical schools. Despite the increasing popularity of using the insights of fine art and literature (particularly through resources such as the New York University Literature, Arts and Medicine Database1), how these dovetail with the former objectives remains something of an academic puzzle. Further, curricula use of the medical humanities often meets with scepticism and disinterest from exam-oriented students. Teaching application of principle through medical humanitiesThe Personal and Professional Development course at the Australian National University Medical School has taken a unique approach. The course aims to teach not just the relevant norms or principles of bioethics and health law, but to encourage their consistent and practical application throughout a medical career, despite personal, collegial and institutional obstacles. This process may be linked to a tradition of scholarship known as virtue ethics, as its aim is character development rather than intellectual recall of abstract rules.2 I have argued in a previous publication that medical humanities has “normative” (or “principle-developing”) aspects, particularly when linked to a process of reasoning that strives to achieve coherence between laws and fundamental social virtues, such as justice, fairness and respect for human dignity.3 This process of reasoning is designed to give students the capacity not only to critique and weigh compliance with such norms or principles, but to assist in developing them, be they derived from ethical, legal or human rights traditions.4 Over the first 2 years of the course, each fortnight four students are required to develop and present a collaborative half-hour PowerPoint analysis of a staff-selected contentious issue in bioethics, health law or international human rights. These include the standard components of bioethics and health law, but many of the presentations relate to a major theme of this course — that, while corporate globalisation may enhance efficiency and innovation, its “lobbying” principles and strategies may be having a major adverse impact on current health policy and on the foundational medical virtue of loyalty to the relief of patient suffering.4 In addition to using selected online resources and nominated experts, the students are required to incorporate in their presentations imaginative insights and arousals of conscience gained from examples of fine art, including visiting a nominated work of art at the National Gallery of Australia. Thus, in addition to the well accepted works from the medical humanities canon (eg, Edvard Munch’s Death in the Sickroom [Nasjonalgalleriet, Oslo, c. 1893] and George Tooker’s Corporate Decision [private collection, 1983]), students are asked to consider, with expert guidance from the gallery staff, selected works from the National Gallery of Australia; for example, John Longstaff’s Motherless (1886), Anselm Kiefer’s Twilight of the West (1989) and George Lambert’s Chesham Street (1910) (Box 1). Bill Viola’s The Passions and medical, personal and professional development trainingThe course recently took advantage of a relevant temporary exhibition. Between 29 July and 6 November 2005, the National Gallery of Australia exhibited a collection of architectural video installations, The Passions, by the artist Bill Viola. Viola’s art uses actors in slowed video performance of narrative moments eliciting heightened emotions, disturbances of consciousness and a search for meaning in the face of tragedy. His art provided a good example of how our students are encouraged to use the medical humanities to incorporate, within their conscience, career-long respect for implementing principles of bioethics, health law and the international right to health in the face of challenges, such as those posed by corporate globalisation. This approach goes beyond suggesting that such works merely heighten clinical observation skills.5 It attempts to enhance professional loyalty and normative thinking toward individual patients in the face of the unique contemporary pressures created by corporate globalisation. Such contexts include tragic narratives involving: breaking bad news to a couple (Viola’s Dolorosa shows the grieving faces of a man and woman [Box 2]); assisting a mother and her daughter grieving about the death of their son and brother (Emergence depicts the dead Christ emerging from a tomb and being laid to rest by two distressed women [Box 3]); or watching relatives view the body of a loved one who has just been removed from life support6 (Observance displays a procession of 18 people slowly taking turns to confront a disturbing sight and expressing and sharing emotions [Box 4]). Viola’s The Passions were developed, primarily from a tradition of Christian iconography, during a residency at the Research institute of the J Paul Getty Museum in Los Angeles in 1998. Viola’s Emergence, for example, draws upon Descent from the Cross by Rogier van der Weyden (1435, The Prado, Madrid, Spain). His work, Observance, has artistic roots in The Four Apostles by Albrecht Dürer (1526, Alte Pinakothek, Munich). The use of such representational narrative paintings for private devotion was a dominant feature of 15th century art. Such treatises instructed the laity to participate empathically in the picture, to become a meditative “co-sufferer”. The medieval artist, as does Viola, strove to overcome complacency in matters of spiritual development, the art arousing heightened emotions which could then be harmonised in prayers for forgiveness and by redemptive grace.8 Viola’s exhibition also draws on Hindu and Zen spiritual traditions. This is particularly evident in his depictions of hand “mudras”, and in Five Angels for the Millennium, a video projection with stereo sound in which five large simultaneous videos depict the human shape distorted in light, fire and water within a darkened, cloistered space, with accompanying sound crescendos as the human forms gradually appear (Box 5). This evocation of the meditative human spirit may also resonate with our students who commence each personal and professional development session with a five-minute, staff-directed relaxation exercise, lacking overt religious elements. A medical version — “Five Angels for the Medical Millennium” — could shape the following particular resonances for students studying the pressures on patients from corporate globalisation: the recrudescence of scholastic dogmatism and lack of local industry support, which is inhibiting stem cell research; the regulatory panics over pharmaceutical patents associated with emergent infectious disease; persecuted whistleblowers nonetheless leading quality and safety in an increasingly privatised health care system; the frequently blasted expectations associated with lucrative artificial reproductive technology; and the uncertain legitimacy and health care values of entrepreneurs directing public health policy through the principles and strategies of corporate globalisation. The task of discerning and then assisting the fallen angels among this collection, those least likely to enhance the foundational professional virtue of loyalty to the relief of patient suffering, seems a worthwhile challenge to the conscience of many medical students and health professionals. ConclusionBy so viewing an exhibition such as Bill Viola’s The Passions, it is hoped that one practical, normative outcome of the emotional resonances evoked in our students may be to encourage them to challenge the role of corporate multinationals in setting global public health policy, while at the same time appreciating their contributions to efficiency and innovation. They could then begin to play a medical regulatory version of Hermann Hesse’s eclectic, nation-ruling and character-shaping “Glass Bead Game” (from the Nobel Prize winning novel of the same name). In the novel, student monks in a fictional country of Castalia are taught to play an extremely complex game in which aspects of diverse intellectual traditions are interwoven. Strategic “Renaissance-type” thinking could suggest: Constitutional, lobbying and professional regulatory measures countering profit-driven moves to dismantle universal health services and medicines delivery systems9 in favour of user-pays health savings accounts10 and medicines savings accounts;11 Trade agreement provisions facilitating improvements in socially responsive, cost-effectiveness evaluation of allegedly “innovative” pharmaceuticals before government reimbursement;12 and Educational strategies assisting capacity building in this area by teaching students to have pride in Australia’s role in promoting the public good of cost-effectiveness evaluation by the Pharmaceutical Benefits Advisory Committee in the context of its social justice origins and the multinational corporate pressures upon it. 1 Chesham Street George Lambert, Chesham Street, 1910. Oil on canvas. National Gallery of Australia, Canberra. 2 Dolorosa Bill Viola, Dolorosa, 2000. Colour video diptych on two freestanding hinged LCD flat panels. © Bill Viola. Photo: Kira Perov. 3 Emergence Bill Viola, Emergence, 2002. High-definition video rear projection on a wall-mounted screen. Commissioned by the J Paul Getty Museum, Los Angeles. © Bill Viola. Photo: Kira Perov. 4 Observance Bill Viola, Observance, 2002. Colour high-definition video on plasma display mounted on wall. © Bill Viola. Photo: Kira Perov. Medieval devotional works were created in an intellectual climate that emphasised the instructional value of the vices, as well as the virtues. The traditional seven capital vices are: superbia (pride), ira (anger), invidia (envy), gula (gluttony), lusuria (lust), cupidita (greed) and accidia (sloth).7 Many works in Viola's The Passions likewise resonate with this tradition, particularly Observance (above) where such vices appear in expressions shared between those passing each other to observe a person who has died. Viola's work from this perspective might encourage medical students to present reflections as if these people were delegates of the World Trade Organization discussing enhanced regimes of intellectual property rights; or chief executives of a multinational pharmaceutical company considering the profit outcomes of a research and development strategy, or how to alter a nation's public health system to maximise their organisations' financial growth. 5 Five Angels for the Millennium Five Angels for the Millennium, 2001 (detail, from left to right: Departing Angel, Fire Angel and Birth Angel). Five channel video projection with stereo sound. © Bill Viola. Photo: Kira Perov. What imaginative “normative” resonances do these images have for medical students when loyalty to the relief of patient suffering is considered in the context of the challenges produced by corporate globalisation?

Thomas A Faunce BA/LLB, BMed, PhD

David J Tiller,* Rick McLean,† Bruce C Harris‡ * Head, Department of Renal Medicine, Royal Prince Alfred Hospital, Missenden Road, Camperdown, Sydney, NSW 2050; and Visiting Professor, School of Rural Health, University of Sydney; † Associate Dean, ‡ Program Coordinator, School of Rural Health, University of Sydney, Dubbo Campus, Dubbo, NSW. dtillerATmed.usyd.edu.au To the Editor: Your column in the 5 September issue of the Journal1 was exquisitely timely. Four days later, a seedling from the original Hippocratic tree from the island of Cos was planted in the grounds of a clinical school of the Medical Faculty of the University of Sydney (Figure) — not in proximity to the jacarandas of Camperdown, but rather to the river red gums near the School of Rural Health in Dubbo! The School of Rural Health is the newest of Sydney University’s clinical schools, having been funded as part of the Regional Health Strategy in 2000. The story of how the Hippocratic seedling came to Dubbo is wonderful. About 18 months ago, two of us (B H and D J T) were discussing what shade trees should be planted around the new clinical school (summer in Dubbo is hot), and the matter of the Hippocratic tree arose. We discovered that it was a European plane tree and made an initial approach to the National Library of Medicine in the United States (who, as stated in your column, had grown a tree from a cutting of the original), but this was unsuccessful. However, Dr John Boulas, a Greek-born Sydney-based urologist colleague was soon to depart for the Olympics in Greece and, as luck would have it, undertook to contact an urologist colleague in Greece who looked after the prostate of the mayor of Cos. This was duly done, and within a couple of months, two seedlings from the original tree arrived at customs in Sydney and spent 3 months in quarantine at the Royal Botanic Gardens. After that time, having been declared free of disease, one was brought to Dubbo to acclimatise. The official planting took place on 9 September and was officiated over by John Anderson, previous Deputy Prime Minister, who played a major role in the Australian Government’s commitment to fund the Regional Health Strategy in 2000, and the new NSW Minister for Health, John Hatzistergos, whose parents came from the island of Cos! To close the loop, both Mr Anderson and Mr Hatzistergos are University of Sydney alumni. The university’s motto (“sidere mens eadem mutato”) means “same learning under different stars”, indicating its links to the universities of Oxford and Cambridge. Perhaps the School of Rural Health motto should be “same learning under the same tree”! In any situation, the links to the history of medicine are firmly established, and medical students will have the opportunity to reflect on the tradition of medicine before their taking of the Hippocratic Oath or its modern equivalent. Wanted: a few more modern-day Hippocrates to teach under the tree. Apply within.

David J Tiller · Rick McLean · Bruce C Harris

Peter M Brooks Executive Dean (Health Sciences), University of Queensland, Royal Brisbane Hospital, Edith Cavell Building, Herston, QLD 4006. p.brooksATmailbox.uq.edu.au To the Editor: Van Der Weyden raises an interesting issue in his recent column From the Editor’s Desk.1 It has long been known that the collective noun for academics is “an absence of”! He is absolutely correct in pointing out that research is valued far more than teaching. That is the reality of current university funding and is at risk of becoming more so, given the research assessment exercise currently being introduced by the federal government.2 This raises the whole issue of profess-orial titles. In a world where elitism is considered not politically correct, we should perhaps dump these titles entirely. I have long yearned for a system like that in the United States, where an individual enters the academic stream at the level of Assistant Professor, progresses to Associate Professor and then Professor (finally being offered tenure after winning the Nobel Prize). This leads to the situation where the “professorial denominator” is not used — individual academics (like other staff) are introduced as “Doctor”. In Australia, many Associate Professors drop the “Associate”, and most “clinical” title holders seem very keen to add their academic titles to their private practice shingles and letterheads. I have often considered doing an economic analysis of the annual value of a title to a doctor’s practice (which I suspect is considerable), and charging appropriately. A decade ago, the then President of the Royal Australasian College of Physicians and myself, as Honorary Secretary, decided to replace professorial titles with “Dr” in all College mail-outs. This lasted about 6 weeks, with a veritable flurry of responses pointing out that we had failed to address these Fellows appropriately. What Van Der Weyden highlights are the real pressures currently on academic medicine, and the need for real debate in the medical community about the worth of academe and the absolute essential building blocks — research, learning and ser-vice — of any credible health system.

Peter M Brooks

Objectives: To determine the number of patients in our teaching hospitals who were, on any given day, both available and willing to see medical students.Design and setting: Repeated cross-sectional audit in four teaching hospitals in the greater Newcastle area of New South Wales (one tertiary referral hospital, two district general hospitals, and one hospital combining general medicine and surgery with specialised oncology services). Audits were conducted three times, 2 months apart.Participants: All adult inpatients in the four hospitals.Main outcome measures: Numbers of patients present and accessible to students, present but inaccessible, absent, or unfit to be seen for clinical reasons; numbers of patients who agreed to history-taking and physical examination by a medical student.Results: Of 1960 patients, 959 (49%) were present and accessible to students. Only 11% were absent, and the most common reason students could not see patients was that the patients were said by nursing staff to be unfit to see medical students (25%). Of those present and accessible, 70% said they would agree to provide a history, and 67% that they would agree to physical examination.Conclusions: Across all four teaching hospitals about 200–250 patients are available and willing to see medical students on any given day. This is too few to provide our current student population of 500 with extensive clinical experience.

Leslie G Olson PhD, FRACP · Suzanne R Hill PhD, FAFPHM · David A Newby PhD

The demand to implement clinical and educational strategies based on evidence has increased in the past two decades. Over a similar time frame, the problem-based learning (PBL) approach has been widely adopted by undergraduate medical schools, in spite of empirical reviews suggesting that its effectiveness may be limited. Students claim that PBL provides a more satisfying learning experience than traditional methods. While such an outcome is desirable, it is substantively less than the original promise of the approach. We hypothesise that the widespread adoption of PBL may be more a consequence of the approach meeting criteria for successful dissemination than of demonstrable positive educational outcomes. We suggest that greater effort should be taken to articulate and measure important undergraduate educational outcomes. Alternatives to the PBL approach should be actively considered.

Robert W Sanson-Fisher PhD · Marita C Lynagh PhD

Has academic medicine lost its leadership role? Many of us believe academic medicine is in crisis.1-3 Tugwell, Professor of Medicine at the University of Ottawa, has written of the need to “bring people together to debate whether the existing structure of academic medicine is still fundamentally sound and, if not, to propose alternatives to it”.1 Editor in chief of the Journal of the American Medical Association, DeAngelis, recently wrote that “the traditional 3-legged stool of academic medicine comprising education, patient care, and research is broken. The education leg is currently being held together by peanut butter and bubble gum combined with the unselfish persistence of faculty dedicated to teaching”.2 The other core roles are also under threat. Much medical research today is done outside academic medicine, for example in institutes of biotechnology and biomedicine. And most clinical service, even in teaching hospitals, is provided by non-academic doctors. Perhaps what really makes academic medicine unique and important and risks being lost is the “added value” or synergy that exists when the three traditional roles are combined effectively — that is, the extra value and quality of teaching provided by the best clinicians and researchers; the special relevance of research defined and driven by the needs of the healthcare system; and the innovation and excellence in service when it is informed by that research. Our view is that: We have lost sight of the reality that teaching the next generation of doctors is a core and essential activity of academic doctors, vested in us by society;4 We are failing to strike the appropriate balance in research, with too much emphasis on basic biomedical research at the expense of clinical, applied and health services research;3 We have forgotten the essential values of altruism and social responsibility;5 and We are at risk of becoming irrelevant to the healthcare system through a failure to drive innovation and excellence in clinical practice across the system, resulting in indefensible variations in practice and outcomes. In response to concerns such as these, in June 2004 a group of leading medical journals, including the Medical Journal of Australia, convened a working party of medical academics to promote and revitalise academic medicine. We met for 4 days near London to define an agenda for the next 12 months, and attended a plenary meeting with about a hundred invited stakeholders from around the world. Why is academic medicine failing?1-3 The reasons are multiple and complex. Loss of leadership must rate highly, with the accompanying loss of focus and vision. The values of academic medicine have similarly become diluted. A major concern, reported by all members of the working party, is the apparent decline in interest in academic medicine as a career. The world has changed profoundly in the past few decades, for example with the rise of patient interest groups, intense pressures on healthcare systems, and the ever-expanding availability of new technologies, but it seems the discipline of academic medicine has not changed with it. What is to be done? First, we agreed that an international campaign is needed about this issue, combined with a global debate. We need to acknowledge that there is a crisis and a need for change. The International Campaign to Revitalise Academic Medicine (ICRAM) is under way, with a website at www.bmj.com/academicmedicine. We want your views and participation. The working party believes we need a new vision for academic medicine. We need a clear definition of academic medicine and a clear iteration of our values — what we stand for and what we want to achieve. As part of this, the place of academic medicine within medicine, the healthcare system and society needs to be clarified. The working party acknowledged that the debate about academic medicine needs to be evidence-based wherever possible. Ioannidis and colleagues have published an initial synthesis of available evidence and defined a research agenda:3 Problems: What are the problems with academic medicine across different settings and countries? Capacity: What factors influence career choice and are responsible for the declining numbers of doctors choosing academic medicine as a career? Indicators: What are reliable indicators of quality, impact and outcomes in academic medicine research, teaching and service? Impact of industry: What are the relations between academic medicine and its funders, particularly the pharmaceutical industry, and how should they be optimally regulated? Patients: Does academic medicine work for patients?3 Five task groups have been formed to deal with the key issues of vision and values, training and careers, analysing the evidence, stakeholder liaison, and communication. The convenors of these groups meet monthly as a steering group for the working party. A series of regional and stakeholder advisory groups are also being formed to ensure we have broad input from a wide range of interests. Details will be posted on the website soon. With two articles recently published in the British Medical Journal, launching the campaign and presenting an initial analysis of the evidence,3,5 our work is well under way. We are drafting articles on a new vision for academic medicine, the role of academic medicine in global health, and training and career options. We recently met with the World Health Organization and the World Federation for Medical Education. A mechanism for receiving submissions to the campaign will be established. What does this mean for Australia? We are the two Australian members of ICRAM. Once ICRAM’s business plan is available, we intend to write to the Chief Medical Officer and to the Committee of Deans of Australian Medical Schools, formally introducing them to ICRAM and its work, and seeking their involvement. We hope to secure support for a national meeting to explore the issues on a national scale, and to develop strategies to respond. It is early days. The ICRAM working party cannot do this alone. We need engagement with, and involvement from, a wide range of professional bodies. We believe this is a vital task and are committed to it. We hope you will join us.

David Wilkinson DSc, FAFPHM · Robyn L Ward PhD, FRACP

What’s needed in medical education are new and big ideas, coupled with a dose of investment In the 18th century, doctors had no particular qualifications and their education was gained as an apprentice to a master. Maybe this wasn’t such a bad idea — students today find themselves increasingly on the fringe of a system that has lost its enthusiasm for imparting wisdom to its young people, despite this imperative being enshrined in the Hippocratic Oath. The UK’s General Medical Council still has high expectations of medical schools: early contact with patients; patient-centred communication skills; courses rich in ethics, culture and ethnicity; and more training taking place in the community. It champions curricula that produce caring, knowledgeable, confident and competent medical graduates who have a broad understanding of health and disease in individuals, their families and society. . . . emphasising teaching over research in their portfolio can be professionally life-threatening for academics But in the UK today there seems to be a growing gap between aspiration and action: the universities, the National Health Service (NHS) and the government don’t seem to support the laudable goals of the General Medical Council. While it is often difficult to measure the success of medical education, there is only so much neglect it can tolerate — squeeze it too hard and standards will drop. In both the UK and Australia, governments want more doctors trained, but the strategies do not extend much beyond numbers and throughput. There is money for new places in medical schools — in the UK, Labour has invested substantially in the NHS in recent years, and the number of students accepted in medical schools has increased from about 4800 in 1999 to almost 7000 in 2003.1 This has been achieved by increasing the size of existing schools and by establishing new ones, such as the University of East Anglia and the Peninsula Medical School in south-west England. Additional sites for medical training have been created in association with existing schools (eg, Durham with Newcastle, Derby with Nottingham). But there is a dwindling pool of both clinical and pre-clinical academics to teach the eager new recruits. Teaching seems to be moving off the mental map for doctors working in a health service that, they feel, has pushed them to the edge. The human side of medicine is what makes working in the NHS tolerable; it can be rewarding to spend time with patients and students without the need to race back to the lab to inject some more rats or write another grant application. Good relationships and appreciation of effort can help too — many consultants and general practitioners feel they are in exile within the NHS, doing cut-down versions of the jobs for which they trained. Teaching does not fare well in such an environment. We have new contracts for consultants and GPs that encourage careful tallying of hours worked and quality targets met. Many find this “policing” approach demoralising; it is only through professionalism, goodwill and belief in its value that teaching will flourish. Juggling clinical work, research and teaching is difficult enough. But when teaching lacks mechanisms equivalent to those that identify and reward excellence in practice and research, it is relegated to a distant third place. Disturbingly, emphasising teaching over research in their portfolio can be professionally life-threatening for academics. While two-thirds of the income of medical schools reflects the numbers of students they teach, the remainder is determined by scores in the Research Assessment Exercise (RAE).2 Several research-intensive medical schools approached the 2001 RAE by a thorough purge of dedicated teachers in order to boost the institution’s average rating for excellence in research. Despite being obliged, almost immediately, to rehire limited numbers of teachers to meet their education responsibilities, some of these same medical schools are already sharpening their knives for more academic cutbacks in the run-up to the 2008 RAE. The less ruthless medical schools emerged from the 2001 RAE with financial penalties and have since cast staff adrift more slowly. Nevertheless, it’s possible that this obsession with research-based income will implode. Sooner or later the General Medical Council will decide that things have reached such a point of neglect that medical education needs dedicated investment — not just in buildings, but in teachers and medical courses. In the meantime, the next generation of medical academics and teachers is shrinking. To train all the extra students in the system, the UK probably needs about 1000 more clinical academic posts by 2006.3 This won’t happen while the new NHS contracts attach financial rewards to service in preference to teaching. These problems are not unique to the UK. Australian medical schools face similar pressures, and teaching often comes out second best. The spirit of curriculum reform has led to more graduate entry, more problem-based learning, and now strategies to get medical graduates into rural and remote Australia. Yet, Australia is also short of graduates, and recent increases in medical student numbers will only partially redress the short-sighted cutbacks of the early 1990s. One hopes the Australian Health Workforce Advisory Committee’s push for a more integrated approach to workforce planning will produce a commitment not only to boost numbers, but to ensure appropriate funding of courses to maintain the high reputation of Australian medical graduates. Governments are becoming increasingly hard-nosed about the money they invest in training medical students, and there is a burgeoning international transfer market. Australian medical graduates are an attractive product in this global marketplace. Governments want their graduates to stay. The Scottish Executive, for example, questions why it should educate so many English students when they are inclined to return “south of the border” on graduation. This market mentality needs a few more rules; there needs to be an international commitment to high standards and agreements to maintain investment locally rather than trying to poach quality graduates trained at some other country’s expense. Despite the difficulties, there are some impressive developments in undergraduate education in the UK. The new medical schools are alive with enthusiasm and energy,4 and are pursuing models of medical education that build on previous innovation, such as Australia’s Newcastle model. Nevertheless, what’s needed in medical education are new and big ideas, coupled with a dose of investment. Where are the current icons in medical education? In the past the likes of Abraham Flexner argued passionately for practical and interactive education, while James Mackenzie introduced the novel concept of teaching by general practitioners. Without passionate and committed teachers, medicine will decline. Then, any number of state-of-the-art laboratories, industrial partnerships, novel genes and science parks won’t be able to rescue it.

David P Weller MPH, PhD, FRACGP, FAFPHM · Richard F Heller MD, FRCP, FRACP, FAFPHM · Konrad Jamrozik DPhil FAFPHM, MFPH

This is an extraordinary opportunity and very exciting, say the Deans of the new medical schools 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. What are the new schools and why are they needed?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. Courses and curricula: no need to reinvent the wheelThe 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. Delivering the course: do we need a full deck of cards?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. Clinical teaching: doing more with lessAvailability 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 technologyInformation 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: an international endeavourAssessment, 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. School-specific goalsNot 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. Research and the tripartite model of academic medicineAlthough 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.” ConclusionIf 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. Characteristics of five new Australian medical schools* Australian National University Griffith University Bond University University of Notre Dame Australia University of Wollongong First intake 2004 2005 2005 2005 2006 Type of course 4-year graduate 4-year graduate 5-year undergraduate 4-year graduate 4-year graduate Student places per year 92 88 ~65 80 80 Commonwealth- subsidised (HECS) 80 (includes 5 MRB, 11 BMP places)† 80 (includes 3 MRB, 6 BMP places)† 0 50 (includes 3 MRB, 7 BMP places)† 72 Fee-paying domestic 0 8 ~55 30 0 Fee-paying international 12‡ 0 ~10 0 8 * Information was not available from the University of Western Sydney or the proposed University of Notre Dame in Sydney. †Publicly funded places created under the Medical Rural Bonded (MRB) Scholarship Scheme and the Bonded Medical Places (BMP) Scheme carry a requirement for 6 years’ work in rural areas and areas of workforce shortage, respectively. ‡Approved places, not all filled in 2004. HECS = Higher Education Contribution Scheme.

Kerrie A Lawson PhD · Mabel Chew FRACGP, FAChPM · Martin B Van Der Weyden MD, FRACP, FRCPA

Objective: To assess the attitudes of final-year medical students to digital rectal examination (DRE) and their experience of performing DRE during clinical training.Design: Questionnaire-based survey.Setting and participants: All students in the final year of medical school at the University of Melbourne in 2003.Outcome measures: Agreement with statements about attitude to DRE; number of DREs performed and abnormalities palpated; and ratings of frequency of supervision and perceived barriers to performing DRE.Results: 222 of 256 students (87%) responded. Almost all (97%) believed that DRE is an essential requirement for a medical practitioner, and 94% that they should have the skill before graduating, while 92% said they had been taught how to perform it. The median number of DREs performed was two, with 17% of students performing none. Sixty-three per cent had palpated a prostate, 24% a prostate cancer, 19% a rectal tumour, and 11% faecal constipation. Half the students (52%) felt they could give a reasonable or confident opinion based on their DRE findings. The most often cited reason for not performing DREs was the lack of a doctor to act as a supervisor.Conclusions: A concerted effort is needed from academics, supervising doctors and students to improve medical students’ proficiency in performing DRE and confidence about their findings.

Nathan Lawrentschuk MB BS · Damien M Bolton FRACS, MD, BA

Medical simulation is a relatively new teaching modality suitable for medical education at all levels, although its long-term benefits have not yet been validated. Simulation allows the participant to practise diagnosis, medical management and behavioural approaches in the care of acutely ill patients in a controlled environment. Simulators have achieved widespread acceptance in the fields of anaesthesia, intensive care and emergency medicine. More recently, team training for pre-hospital and within-hospital multidisciplinary medical response teams has become popular. The increasing number and diversity of courses at “CASMS” parallels the evolution of simulation centres into regional clinical skills centres elsewhere. Such centres are likely to become a cost-effective means of achieving greater consistency in medical skill acquisition and may improve patient outcomes after medical crises.

Richard H Riley MB BS, FANZCA · Amanda M Grauze RN, GradDipEd(Higher · Neil H Trewhella CSM, BHSc (Prehospital Care) · Claire Chinnery BN, RN · Ross A Horley

A long and proud history of health education in the Fiji Islands started in 1885 with the founding of the Suva Medical School, which became the Central Medical School in 1929 and the Fiji School of Medicine (FSM) in 1961. Today, FSM provides training in medicine and a wide range of other healthcare disciplines, including dentistry, pharmacy, physiotherapy, radiography, medical laboratory technology, dietetics and environmental health. Students come not only from the Fiji Islands, but from all Pacific Island countries (a population of about seven and a half million people). A particular problem has been that formal postgraduate training and continuing professional development have not been available for its graduates, forcing many Pacific Island practitioners to undertake specialist training overseas, with many choosing not to return to the Pacific. Thus, the Pacific Island countries and FSM itself have been heavily dependent on transient expatriate practitioners for delivery of care and medical education. Valuable though the contribution of such expatriates has been, it cannot substitute for local graduates. To address these and other issues, a Fiji School of Medicine Development Plan was developed in 1994 and endorsed by the Government of Fiji. A major recommendation was that “an effective postgraduate training program, and preferably one utilising the resources of Fiji and the Pacific Island countries, is the key to the revitalisation of FSM.” This was followed in 1995 by a meeting on Yanuca Island in Fiji, sponsored by the World Health Organization, involving consultants and government representatives from all Pacific Island countries. This meeting recommended establishing diploma and masters courses in anaesthesia, internal medicine, surgery, obstetrics and gynaecology, child health and population health. The Fiji government then requested, in discussion with the Australian Agency for International Development (AusAID), that FSM be included in the bilateral program of assistance between the two countries. In May 1997, AusAID appointed the Royal Australasian College of Surgeons (RACS) to manage the 5-year project with a budget of A$5.5 million, in partnership with the Royal Australasian College of Physicians and its Division of Paediatrics, the Australian and New Zealand College of Anaesthetists, the Australian Society of Anaesthetists, the Royal Australian and New Zealand College of Obstetrics and Gynaecology and the Universities of Otago and Melbourne. The aim of the project was to establish a postgraduate training program at FSM, involving local curriculum development to make it more relevant, and to reduce (although probably not eliminate) the need for doctors to travel to other countries for specialist training. Each of the five disciplines was to offer a 1-year diploma, giving a theoretical and practical background sufficient for providing care in Pacific Island countries with populations too small to support fully trained specialists. This diploma would also act as the introductory year for a 3-year masters program for those showing particular aptitude, and who wished to proceed to full specialist practice in larger Pacific Island countries. Selection into the diploma program would require a minimum 3–4 years’ experience after graduating from medical school, and support from the relevant Pacific Island Country authority. Progression from the diploma to the masters program would depend on achievement of a high standard during the course and examination. The FSM faculty was strengthened by the appointment of additional staff in each of the five disciplines, one of whom was appointed Coordinator of Postgraduate Studies (W B). These were supported by long-term advisers from Australia or New Zealand to interact with local staff in each of the five disciplines. Advisers spent full-time attachments in Suva for 18 months to 3 years, depending on the state of development of the specialty. The project was launched on 5 May 1997. The appointment of long-term advisers and local counterparts followed rapidly, and teaching began formally in all disciplines in 1998. In anaesthesia, a pre-existing diploma established with the help of the Australian Society of Anaesthetists was adapted to the more practically oriented and problem-based format used in all five disciplines. In paediatrics and obstetrics and gynaecology, FSM was able to build on diplomas from the University of Otago, which had been offered through the distance mode. In surgery, informal postgraduate teaching and course development had commenced in 1996. The agreed format for the curriculum was a series of modules designed to provide detailed learning objectives, with core and reference materials to allow the trainees to adopt a problem-solving approach to learning and clinical practice. The content was clearly defined at the diploma level in recognition of the fact that this might be the only formal training for trainees, in particular, from the smaller Pacific Island countries, and emphasis was given to the need for life-long learning and continuous professional development. At the masters level, subspecialty teaching was provided by visiting medical staff from Australia and New Zealand, who spent 2-week periods at FSM for direct teaching and to help develop the modules. A specific requirement for each masters trainee was the completion of a research project, supervised by staff in the discipline and the Research Director at FSM. In Suva, trainees in the diploma and masters program undertook clinical duties at the Colonial War Memorial Hospital. Diploma candidates from other Pacific Island countries were able to undertake their initial studies in their own country, provided there were adequate local facilities and clinical and academic supervision, with the last three months of the course undertaken in Suva for intense supervision and preparation for the examinations. Masters candidates are all trained in Suva, with an additional 3–4 months on attachment in Australia or New Zealand. Distance learning for postgraduate education and continuing professional development is a major issue. In 2002, FSM identified “flexible learning”, a process that is learner-focused, and, with the help of the University of the South Pacific and Professor Ian Rouse of Curtin University, is developing a Resource Centre that will collate all paper-based and electronic-based resources, improve delivery of internal services and coordinate workshops on flexible learning for staff at FSM. Distance learning should become more widely available in the future, as more and more FSM-trained specialists in general return to their own environments. GraduatesIn 1999 the University of the South Pacific, a distinct entity which awards MB BS degrees to FSM graduates, approved the awarding of a Master of Medicine (MMed) degree after review by independent external reviewers, and subject to a further review in the final year of the first cohort (2001). This was completed satisfactorily in August 2001, noting that the programs were “soundly based and well balanced in terms of targeted acquisition of appropriate expert knowledge, technical capacity, life-learning skills and problem solving ability”. It was noted that the academic level of the MMed degree was rightly set at a level which was equivalent to other MMed degrees in the South-East Asian area. The diploma remains an award made by FSM itself. By the end of 2002, 74 diplomas had been awarded (anaesthesia, 16; internal medicine, 13; obstetrics and gynaecology, 8; paediatrics, 17; surgery, 16; community and hospital practice, 4) and 14 candidates had completed the Master of Medicine degree (anaesthesia, 1, internal medicine, 3; obstetrics and gynaecology, 4; paediatrics, 2; surgery, 4). Of these graduates, 68 with diplomas and 12 masters graduates were practising in Pacific Island countries. ConclusionsWithin 5 years the FSM postgraduate training project, established with funds provided by AusAID, has facilitated the development of a viable and now largely self-sustaining program for postgraduate medical education for the Pacific Islands. All strategies for implementation have been fulfilled, although continuing support from authorities and individuals from countries such as Australia and New Zealand will be necessary if these achievements are to be sustained and advanced. A memorandum of understanding is under discussion between FSM and AusAID to facilitate such support.

Gordon J A Clunie DSc(Edin), FRACS · Eddie McCaig DSM, FRACS · Wame Baravilala MRCOG, FRANZCOG

Objective: To compare the cancer knowledge and skills of interns in 2001 who graduated from graduate medical program (GMP) courses with those from non-GMP courses, and to compare the cancer knowledge and skills of interns in 2001 with those who completed a similar survey in 1990.Design: Questionnaire survey of recently graduated interns in a random sample of Australian and New Zealand hospitals. The questionnaire was designed to allow direct comparison with the 1990 survey, and was guided by the Australian Cancer Society's Ideal Oncology Curriculum for Medical Schools.Results: 443 interns completed the survey (response rate, 62%; 42 were excluded, leaving 401 surveys for analysis: 118 from GMP courses and 283 from non-GMP courses). Interns from GMP courses felt more competent than those from non-GMP courses at discussing death (P = 0.02), breaking bad news (P = 0.04) and advising on smoking cessation (P = 0.02), but less competent at preparing a patient for a hazardous procedure (P = 0.02). More GMP interns would refer a breast cancer patient to a multidisciplinary clinic (83% versus 70%; P = 0.03). Knowledge about cancer risks and prognosis was significantly less in GMP interns, but GMP interns rated their clinical skills, such as taking a Pap smear, higher than non-GMP interns. The GMP and non-GMP groups did not differ in their exposure to cancer patients, but compared with 1990 interns recent graduates had less exposure to patients with cancer.Conclusions: GMP curricula appear to have successfully introduced new course material and new methods of teaching, but have not always succeeded in producing doctors with better knowledge about cancer. Recent graduates have less exposure to cancer patients than those who trained 10 years ago.

Michael B Barton MB BS, FRANZCR · Sharon E Miles BAppSc(HIM) · Martin H Tattersall MD, FRACP · Phyllis N Butow PhD, MClinPsych · Sally Crossing BEc · Konrad Jamrozik DPhil, FAFPHM · Bin Jalaludin PhD, FAFPHM · Christopher H Atkinson MB ChB, FRANZCR