Year: 2006
Type: article
Abstract: If the success of the now time-independent and competency-dependent training programme conducted by the Faculty of Occupational Medicine (AFOM) of the RACP is anything to go by, then it may be timely to discard time as a facsimile of competency in other programmes of undergraduate and postgraduate medical education. The AFOM reform was a response to the Australian Medical Council accreditation report on the Royal Australasian College of Physicians (RACP). It has been in place long enough for some confidence to be derived from the experience. Trainees can sit any of the exit assessments at any time, in any order and as many times as needs be to show that they can meet the stated competencies. The latter are in continual reform to render them increasingly explicit and to meet changing perspectives of what an occupational physician should be able to do. The quality of the training is now measured by transit times (time from enrolment to graduation) and not by examination-specific pass rates. The process is very attractive to older trainees and especially those who have partly or fully trained outside Australasia. Time spent in a training scheme can only ever be a reasonable basis for assuming competency if there are sound master–apprenticeship relationships in place and if the medical student and junior doctor learning and workloads ensure a reasonable exposure to disease. Moreover, understandings of the natural and treated histories of those disease processes must be assured. These assumptions do not appear to be currently valid. There is a worldwide and an across-community interest in issues of medical competency and its relation to training and the design-financing of health services. Perspectives vary widely in scope, stance and sense of urgency.1–4 It is reasonable that the demand for a faster and cheaper supply of vocationally independent doctors is being led by Governments and health authorities. The current 10- to 15-year minimum period taken to achieve independent function by doctors is obviously too long in terms of addressing existing community needs. The consequent shortfall of local medical graduates has resulted in an increased reliance on overseas-trained doctors and has spawned concepts of nurse practitioners and physician assistants with general scopes of practice. It is interesting to note that the only strong evidence in support of the effectiveness and safety of the latter is derived from care that is at the least complex end of the clinical spectrum or that is overseen by physicians.5 One response in Australia to the demand for faster training has been the introduction of 4-year graduate-entry ‘undergraduate’ medical programmes. The accusation has arisen that these contracted programmes have been created at the expense of critical curriculum elements and especially within basic sciences such as anatomy. The campaign in this regard has been waged largely by surgeons through the media and appears to be anecdotally based.6 Nevertheless, it is clearly preferable that shortened medical education programmes of the future involve the accelerated learning of comprehensive curricula. The basic sciences need to be preserved in undergraduate curricula as scientifically predicated and evidence-based practice is one of the major reasons for the privilege our profession deservedly enjoys in the ‘health marketplace’.7 Importantly, the wider health-provider and consumer communities will need to be reassured by explicit assessments of publicly agreed and declared competencies. The issue of competency is very much to the fore in the ongoing debate about the utility of the first postgraduate years of medical practice. Our impression is that core competency is probably eroded during, and perhaps by, the first of these years (the traditional intern’s year). The problem is multifactorial in origin. The contributors include the assumption of shift work, which makes it difficult to see disease evolution, and by union and regulatory authority originated constraints on duties and the geriatric bias of patient groups in large urban hospitals.8 Even allowing for the effect of a workforce increasingly comprised of overseas-trained doctors whose first language is not English and the anecdotal nature of the complaints, it would seem to us to be only a matter of time before passing a professional exam, such as that used by the legal and accountancy professions, will be requisite for the progression of junior doctors from provisional to full registration. This additional ‘hurdle’ would be entirely in keeping with the competency orientation and dependency we are advocating. The AFOM experience shows that there are two fundamental barriers to introducing postgraduate time-independent training. These are agreeing to an explicit set of competencies and developing reliable ways of assessing those competencies.9–11 If recent comparisons of clinical cases and objective structured clinical examinations are taken at face value, then for one or two observers to confidently assess someone’s clinical competence (reliability greater than 0.8), approximately 10 long clinical case examinations are needed.11–13 On this basis, it is reasonable, if not a little cynical, to describe the current RACP Part One Clinical Examination as a raffle. There is an obvious argument here for iterative clinical assessment. These issues also apply to reform of undergraduate education, along with the problems of wresting control of curricula from secular and intuitively self-interested departments; undertaking the transition from the historical expectations of a medical graduate, say for example in obstetrics, to more contemporary perspectives will require careful management.14 We also do not underestimate the problem of changing the current annualized form of student funding to something based on performance milestones and especially on graduation. It will be crucial to meet that challenge. There are other lesser barriers, which include the reliance of hospitals on junior doctors to fulfil set periods of contracted service, although many of these hospitals are increasingly asking just what it is that the more junior of these doctors contribute. It will also be necessary to have accurate tracking systems in place and to use clinical logs as the basis of learning plans. Self-directed clinical learning must be nurtured by structured clinical experiences. Students will need greater access to those patients coming to hospital with ‘undifferentiated’ health problems, as compared to most in-patients, who, in addition to being very old, have a long list of identified disease processes. It is obvious that these in-patients are increasingly dissimilar from the ambulatory population that will form the majority of most graduates’ lifetime practice workloads. A shift to a competency-based, time-independent and accelerated learning of a comprehensive curriculum is certainly possible, and, in our opinion, desirable. It should also be possible to address health workforce issues through this reform and especially to shift the attraction away from careers in the procedural disciplines. In addition to meaningful alignment of remuneration with need, and to reward cognitive practice, this will also require a concentration on positive educational experiences and role models. The argument that training schemes in general medical practice will be chosen more often by graduates if there is an increased exposure to general medical practitioners (GPs) during the undergraduate years may be wrong. On the basis of our anecdotal data, an increase in exposure may be counterproductive in this regard if the additional time in general medical practice is negatively perceived. We intend to collect definitive data to test this hypothesis later this year. The problem of overwhelming that section of the GP community, which is willing and able to teach effectively, is likely to be compounded in New Zealand. The plan to require junior doctors to undertake some time in general practices, in addition to present-day medical students and general practice registrar commitments, will fail if it goes ahead without a very substantial commitment of funds to resource the practices and to upskill the GP teachers. As we have opined beforehand,15–18 we do not believe that the status quo is a tenable response to the health workforce demands of the next 15 years.19–26 The road ahead beckons, the road behind ceases. Cornelus Sanders’ allegory style Wakley Prize Essay of 2005 deserves our attention here.27 It is our opinion that only the use of disruptive innovations in health-care service and deliberate financially driven alignment of health need, utility and supply will enable current health access and quality to be maintained over that period,28,29 let alone to address inequalities for rural and indigenous communities. Abandoning slow and cumbersome education programmes for doctors would be a good start.
Source: Internal Medicine Journal
Authors: D. Gorman, J. Scott
Institution: University of Auckland
Language: English
Field: Medicine
Domain: Health Sciences
SDG: Quality education
Open Access status: bronze
OpenAlex ID: W2054806524