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Expanded settings: an answer to a training system at the brink?

Medical training, at all levels, is under pressure. Unprecedented numbers of medical students, chronic underfunding and public hospitals preoccupied with efficiency at the cost of training, have created an unsustainable medical education system. The evidence is already obvious. Despite significant efforts by both Government and health services, 244 medical graduates could be left without an internship by the end of 2012. If the status quo continues, Health Workforce Australia is predicting a shortfall of 404 first year vocational training places by 2015 and 1265 by 2025. These figures are a clear indication of a traditional medical training system at capacity. Innovation must occur if the full benefit of increased medical school enrolments is to be realised by the Australian community.

19 Aug 2012

Medical training, at all levels, is under pressure. Unprecedented numbers of medical students, chronic underfunding and public hospitals preoccupied with efficiency at the cost of training, have created an unsustainable medical education system.

The evidence is already obvious. Despite significant efforts by both Government and health services, 244 medical graduates could be left without an internship by the end of 2012. If the status quo continues, Health Workforce Australia is predicting a shortfall of 404 first year vocational training places by 2015 and 1265 by 2025. These figures are a clear indication of a traditional medical training system at capacity. Innovation must occur if the full benefit of increased medical school enrolments is to be realised by the Australian community.

The greatest untapped resource for medical training is expanded or non-traditional settings. To take examples from a procedural perspective, almost 50 per cent of laparoscopic cholecystectomies - and the majority of gynaecological procedures - are performed in private hospitals. Data concerning consultations is harder to obtain, but it is clear that at least an equivalent number of specialty consultations are conducted within private rooms, even without considering general practice. It is obvious that substantial scope exists for training within these settings.

Beyond the sheer volume of possible training experiences, the content of these experiences is also significantly different. Aspects of many specialties have poor exposure in traditional teaching settings, and access to expanded settings offers a more rounded learning experience for medical students and trainees. Some specialties are (almost) entirely privately based, such as dermatology and sports medicine, and training in these disciplines must occur within expanded settings.

Consent, indemnity and funding remain difficult problems to resolve, making the transition into expanded settings challenging. Trainees continue to be anxious about maintaining their employment entitlements and ensuring that their training is of a similar standard to that to which they are accustomed. 

Providing teaching, supervision and mentorship in new settings requires significant investment, not only in funding, but also in time and resources.  

The Specialist Training Program (STP), initially set-up and funded by the Commonwealth Government, has now been running for almost five years.  This successful program has established 105 funded positions in expanded settings for vocational trainees this year, in addition to 518 pre-existing positions. The Commonwealth has also committed to significant increases to this program in the future.

With the recent dissolution of the Enhanced Medical Education Advisory Committee, the body previously tasked with overseeing the STP, there is a risk that this valuable program could lose direction and fall by the wayside.  This seems a backward step, especially given the current situation.

A similar program, Prevocational General Practice Placement Program, offers valuable positions in general practice to pre-vocational trainees, providing experiences beyond the scope of those available in traditional teaching hospital settings.

While acknowledging the expansion in private settings achieved so far, significantly more is required. The challenge is now the timeframe. The clichéd ‘wave’ is already upon the health system. Examination and adoption of successful models, streamlining of accreditation processes and adequate funding are vital, but safeguards to maintain training quality must not be forgotten in the rush to increase capacity.    

Medical training in expanded settings is already a major part of the solution, but further expansion has to be supported. It is no longer appropriate for one half of the health system to shoulder the burden of the entirety of medical training.

 

 


Published: 19 Aug 2012