Medical education towards 2010: shared visions and common goal
Speech by John Horvath AO, Chief Medical Officer, to the Committee of Deans of Australian Medical Schools and Australian Medical Council, Canberra, 7 March 2005.
Slide 1: The Relationship between Policy, Pedagogy, and Practice in Australian Medical EducationGood afternoon ladies and gentlemen. It is a great pleasure to be asked to deliver a presentation at the 2005 Medical Education Conference and be able to address some of the key partners in medical education in Australia on such an important topic - the relationship between policy, pedagogy, and practice in Australian medical education.
Slide 2: Goals
"The system of medical education in Australia must be considered in relation to the health care system as a whole with which it is inextricably associated. It prepares practitioners to work in the health system, and must ensure not only that its graduates have the knowledge, skills and attitudes that are required, but also that they understand how the health care system functions and what responsibilities they have to it". (The Doherty Report, 1988, p29)The content of this quote rings true 17 years after it was written.
It brings to light just how inextricably connected are the three concepts of policy, pedagogy and practice in Australian medical education.
It is crucial that education and training continues to adapt, and also prepares those in it to adapt, to the needs of doctors, patients, the health system and society if it is to remain relevant. We here today must all remain committed to this goal.
Let me start by defining the concepts for you.
Slide 3: Defining the concepts of Policy, Pedagogy and Practice‘Policy’ incorporates all governments and stakeholders, however, I will refer mainly to the Australian Government’s health policy;
‘Pedagogy’ (or the art of teaching) refers to the medical curriculum, teaching theory and educational delivery in today’s system of medical education and training; and ‘Practice’ refers to the realities of practicing medicine in Australia, and the promotion of health outcomes for patients and prevention of illness.
So - how has Australian Government policy on medical education evolved to its current point?
Slide 4: A short history of medical education policy in AustraliaThe political context for medical education has changed markedly over the last quarter of a century.
Where once medical education was perceived to be the unchallenged domain of the universities, a more proactive role is now being taken by a range of organisations to help plan for an education and training model that produces an appropriately skilled and experienced medical workforce.
Slide 5: The Karmel Report (Expansion of medical education)The Karmel Report ‘Expansion of medical education’ was released in July 1973 by the Committee on Medical Schools. The Committee was set up to make recommendations to the Australian Universities Commission on the need for new or expanded medical schools in light of likely trends in the delivery of health care in Australia over the period 1971 to 1991.
It was felt that, in view of developments in the fields of medicine and patient care, a decision to establish additional medical training facilities should not be made without an expert enquiry into future supply and demand.
Whilst the Committee received many submissions concerning medical education in its widest sense, the central issue of concern was medical manpower.
Slide 6: The Karmel Report: Medical ManpowerTo provide you with a snapshot, the Report noted that in 1972 there were 8 medical schools which produced 878 graduates. Of these, approximately one-third specialised in general practice, and 50 per cent of the students continued their training in a different speciality.
There were approximately 18,000 medical practitioners in 1972 which is equivalent to one doctor to 721 persons. The Committee deliberated on whether this ratio was adequate for Australia’s needs for the present and for the future, and they determined that it wasn’t.
Slide 7: The Karmel Report recommendationsIn response to a perceived shortage of doctors for the future, the Report recommended an increase in the number of medical undergraduates, the establishment of new medical schools, and a community focus for medical education.
Responsibility for these recommendations was deemed to be that of the organisations involved in medical education - the universities, hospitals, professional colleges and postgraduate committees.
Besides funding additional tertiary places, there was no indication in the Report that any government, state or federal, should assume a role in assisting change.
The assumption that the content of medical education was the domain of the medical teaching institutions remained unchallenged.
Fifteen years later, in 1988, the Doherty Report was released. This was perhaps the first serious attempt made in literature to investigate and critically analyse the relationship between medical education and the health care system.
Slide 8: The Doherty Report (Australian Medical Education and Workforce into the 21st Century)The report Australian Medical Education and Workforce into the 21st Century, also know as the Doherty Report, was developed by the Committee of Inquiry into Medical Education and Medical Workforce and released in 1988.
It covered a wide spectrum of issues, including the selection and training of undergraduate, postgraduate and vocational students, curriculum setting, financing of medical schools, and workforce distribution.
Just over 100 recommendations were listed in the Report. To name just a few, these included: curriculum review by medical schools, self-directed learning, community involvement, maximal use of new technology and innovative student selection methods.
The Committee felt it very important that medical education and training delivery was re-structured in a way that would give students the knowledge, attitudes and skills needed to meet new challenges during their professional lifetime. This issue within medical pedagogy is still very much relevant today.
The Report was the first signal to government to play a greater role in medical education and training as it relates to medical workforce issues.
Slide 9: The Doherty Report recommendation 3(i)
'That the Commonwealth Government recognise the close relationship between, on the one hand, how medical care is delivered and financed, and, on the other, how medical practitioners are trained (medical education) and their number and distribution (medical workforce)’. (Doherty Report, 1988, iii)This recommendation, and its political ramifications, fuelled the Australian Government’s growing interest in medical education policy. It became increasingly obvious that government health policy, service delivery, medical education, and workforce are inherently connected.
To address these issues from a nationally coordinated perspective, the Report also recommended the establishment of an Australian medical workforce surveillance committee.
Slide 10: The Australian Medical Workforce Committee, The Doherty Report recommendation 11(i)
‘That an ongoing Medical Workforce Review Committee be established, with representation from bodies somewhat similar to those represented currently in the Australian Health Ministers’ Advisory Council and the Health Workforce Planning Forum of the Australian Health Ministers’ Conference’. (Doherty Report, 1988)The Doherty Report proposed that the functions of this Medical Workforce Review Committee would be to review the Australian medical workforce, analyse relevant workforce data, make recommendations on appropriate intakes to medical schools, and to establish links with bodies responsible for workforce planning for the health sector in general.
The federal, state and territory governments took this recommendation on board, and the Medical Workforce Committee began work in November 1989.
However, aside from the establishment of the Committee, which focused primarily on workforce numbers and distribution patterns, there was still little attention paid by governments to the questions of how medical practitioners are trained.
Slide 11: Context for national medical workforce policies - 1980sAlso in the 1980’s, governments were challenged with the development of policy to address new workforce issues. This is back in the day when there was no doctor shortage - in fact, there was a perceived oversupply in metropolitan areas of some of the medical and health professions, particularly general practitioners and pharmacists.
Health Insurance Commission records indicated that the number of GPs per head of the Australian population had increased by 15.8 per cent over the 1984-85 to 1989-90 period.
The unrestricted entry of overseas trained doctors entering Australia was also considered to be a contributing factor to the escalation of Medicare outlays.
Slide 12: The General Practice StrategyIn response to a perceived oversupply of GPs, the Australian Government introduced the ‘General Practice Strategy’.
The Strategy sought to address four key issues of general practice: quality, workforce, integration, and financing.
Slide 13: The General Practice Strategy - 2In terms of workforce, the Strategy focused upon oversupply and maldistribution issues.
To tackle oversupply, measures to control numbers of overseas trained doctors were implemented along with the introduction of vocational registration which then later led to the creation of ‘provider number’ legislation.
To address maldistribution, the Rural Incentives Program offered doctors grants and extra training to doctors who relocated to practice in rural areas.
Slide 14: The General Practice Strategy - 3The General Practice Strategy attempted to curb escalating Medicare outlays.
But at the same time, it used ‘education’ as a lever and sparked a movement towards more ‘targeted’ Australian Government health care policies.
Slide 15: The realities of health practice in AustraliaToday, the Australian Government sees itself as a major player in the delivery of health services - not just through funding Medicare, but also through targeted policies which seek to achieve improved outcomes in the areas of aged care, rural health, primary care, mental health, population health and prevention, and the health workforce.
A good example of the Australian Government’s increasing involvement in improving health outcomes is in the area of chronic disease management.
Slide 16: The Rise of Chronic Disease
During the last century the major cause of death in Australia shifted from infectious disease to chronic disease. Today chronic diseases make up more than 80% of Australia’s overall disease burden due to death, disability and diminished quality of life. Department of Health and Ageing 2004, A Mandate for Action on Chronic Disease Prevention, Unpublished draft document.51% of Australian adults in 2001 had one or more chronic conditions, which may have resulted in disability or death. As above.
As the Australian population ages, the burden of premature death, disability and diminished quality of life, due to chronic disease, will increase. This may be eased by implementing intervention strategies.
Slide 17: National Chronic Disease StrategyThe Australian Government’s National Chronic Disease Strategy aims to find better ways to prevent, manage and treat chronic disease, in the short, medium and long term.
There is a growing recognition that chronic disease management is not just about making a diagnosis and writing a script. Chronic disease management should include complex interchanges with families, the inter-disciplinary team within which treatment occurs, and giving the patient greater control through the self-management of their disease.
These new understandings into chronic disease management must be reflected in medical education and training methods. Today’s medical graduates must acquire a changed range of knowledge, skills and attitudes if they are to effectively manage people with chronic disease, including inter-professional skills and experience in the continuum of care.
We must be cognisant of this changing need, and work to provide our younger doctors with the appropriate skills and knowledge to deliver optimum patient care.
Slide 18: Rethinking medical training deliveryAs I have attempted to demonstrate thus far, there is growing recognition of the need to align medical education and training with the current and future health care requirements of the Australian community.
Once, education and service delivery were almost synonymous with one another but now they barely cross paths.
Slide 19: Lack of alignment between education and service deliveryStudents are still learning in an environment that is focussed on hospital teaching experiences, has a narrow doctor and organ specific training focus, and where impressing the supervisor and getting top marks is of upmost importance!
However, the changing realities of service delivery in Australia requires a student that is equipped and capable of dealing with many things, including working effectively as part of multi-skilled team, having the interpersonal skills to work in a variety of health settings, and whose primary competition is with themself – to deliver the highest quality services possible to their patients.
Slide 20: Rethinking medical training deliveryIt would be fair to say that the health care industry is one of the only industries where training has not kept pace with changing practises.
If the airline industry was to continue training pilots in DC-3’s then I’m sure this would not be good for public relations!
Workforce shortages experienced worldwide are an additional imperative for change. Smarter ways of delivering training and care need to be devised.
Slide 21: Where is medical education and training going?My colleague from the Department of Health and Ageing, Mr Brett Lennon, will be exploring the direction for medical education and training in greater detail at the Wednesday afternoon symposium, but I would like to say a few words also.
There no longer needs to be an adherence to the narrow confines of doctors, nurses and other health professionals. We have the opportunity to redefine who does what, by using a broader and more flexible training model which takes into account modern patterns of disease and care.
Indeed, most of the illnesses burdening today’s society are too complex to be addressed by one single health discipline, and are rarely addressed in the hospital environment alone.
The complexity of modern health care and technology necessitates that a variety of training methods are used, and that each training method has a clearly articulated learning outcome.
Slide 22: Continuum of CareBecause currently, we have a crisis on our hands – medical specialist trainees are no longer getting access to the continuum of patient care. At the heart of this problem is the lack of experiences that medical trainees are being exposed to through their medical training.
To illustrate my point, consider the current day treatment of a patient with a breast lump. JH to talk freely here.
Slide 23: Medical Specialist Training Steering CommitteeThese issues, among many others, are currently being explored by the Medical Specialist Training Steering Committee. The Steering Committee was established by the Australian Health Ministers’ Advisory Council in 2004.
The Steering Committee is assessing the current disconnect between specialist training and service delivery, by exploring opportunities for training to occur in settings other than public teaching hospitals.
The Steering Committee is using a model which was developed by its predecessor, the Medical Specialist Training Taskforce, to investigate the viability of providing training through a network of settings, including public hospitals, private hospitals, private practice, rural and regional settings, community based practices and non-clinical settings.
Slide 24: The Proposed Training ModelThis training model will have the following four major benefits:
- It will expand training to match the service delivery required by the community;
- It will improve the training opportunities and experiences available to trainees;
- It will improve the standards of care in the new training settings and throughout the Australian health system; and
- It will utilise the learning opportunities of a broader range of health care and training settings.
In this sense, medical education must assume that the individual will continue to learn and adapt to their profession’s constantly changing dynamics in respect of technology, patient needs, and service delivery.
Slide 25: Changes to the tools of the tradeFor example, I can confidently say that in the 30 plus years I was practising as a renal transplant physician, the tools of the trade have changed significantly. Nowadays, a renal physician needs an MRI, cat scans, ultrasounds, angiogram as well as a plethora of drugs.
The most important part of medical education is to prepare doctors for constant change – there are not many industries where in a space of 20 to 30 years all the tools of the trade are completely different.
In the foreseeable future we have major changes in diagnostic imaging, new neo techniques for chemical diagnosis, robotic surgery and drugs that target receptors and pathways. Indeed, what will be the MRI and CAT scan of 2030 for our current medical students?
Maybe we had all better watch start trek a lot more closely! Or, perhaps just listen more attentively to the symposium following afternoon tea, which will attempt to define this doctor of the future.
Beyond all else, we need to work now to provide medical education and training which resonates with the needs of our community and provides a foundation upon which doctors can continue to learn and apply their minds and learn new skills.
Slide 26: Medical education - our future challenges?The challenge for the future is to move away from the traditional focus of training the individual doctor, to one where the trainee understands their role in treating patients as part of a multi-skilled team.
The traditional Bachelor of Medicine is no longer relevant or desirable. We cannot expect that in this age of complex illness and multiple technologies a doctor upon graduating with their university degree knows everything. Instead, we must expect that the doctor will know where to find the answer to everything.
Slide 27: Specialist training - our future challenges?We must also shift our focus away from training the ‘super sub specialist’ and champion for the resurrection of the generalist. There are many advantages to well trained generalists, as we all know, they have the skills to treat the bulk of our patients.
JH to talk freely about trekking in Bhutan
Now what does climbing Mount Everest have to do with anything you may ask?
Consider that this mountain represents the structure of the Australian health sector. The peak of a mountain cannot hold a large number of climbers, there is just not enough room for a great number of people to converge together at any one point in time. But half way up the mountain, at the base camp, it is the hive of activity, there are a far greater number of individuals who reach and converge upon this part of the summit.
In terms of the specialist workforce sector, we have far too many people striving to reach the pinnacle and become ‘super sub specialists’. This places strain on the accessibility and appropriateness of doctors within our community.
We need specialists to align with the structure of the mountain, to have a greater number of generalists responding to the needs of the broader community, and far fewer numbers of super sub specialists practising in their narrow fields with their unique instruments.
Slide 28: So what do we want out of medical education?Fundamentally, we should be encouraging the development of a medical education and training model that sees that graduates are equipped, as a minimum, with the following core skills:
- Good, basic and rigorous science;
- The ability to work in a team and understand the role that they themselves, along with hospitals, GPs, and other health professionals play in the delivery of health care;
- The ability to work with a patient, family, or community; and
- The effective use of health resources.
Slide 29: The educational and training challenges that lie aheadIn delivering these skills, academia must ensure that independence is maintained and that education maintains its rigour.
But this also has to take into account the society’s needs and expectations in terms of medical service provision.
Governments need to respond to doctor supply and demand issues with the goal being to provide accessible health services in our community.
And, all of these activities must take place in the political reality of finite budgets and resources.
Psychiatry is a good example of how these tensions translate into practice.
Slide 30: Psychiatry: an example
Mental illnesses account for about 30% of the total burden of non-fatal diseases in Australia. (Mathers C et al 1999. The Burden of Disease in Australia. Canberra: AIHW).
This high burden of disease requires a large workforce, in an area which is often not “perceived” to be a good use of resources.
But the need to address mental health problems and mental illness in Australia has never been so desperate. Especially as psychiatry shortages exist in all geographical areas other than capital cities. (AMWAC 1999. The Specialist Psychiatry Workforce in Australia, supply and demand requirements and projections 1999 – 2010. AMWAC Report 1999).
The challenge for all of us is to rise above the immediate pressures and deliver an educationally robust cohort of graduates who can respond to societal needs.
Conclusion to presentationQuote: "They always say time changes things, but you actually have to change them yourself″" (Andy Warhol, The Philosophy of Andy Warhol (1928 – 1987).
We must all be more assiduous in facilitating change - medical education needs to evolve as patient care evolves. The AHMAC Medical Specialist Training Steering Committee is attempting to ensure that education and training anticipate and lead these changes.
The universities and medical colleges in Australia need to reciprocate by stepping up to the challenge of producing an education and training model that meets the needs of the community and reflects the nature of service delivery whilst still maintaining scientific rigour in training.
It is essential that all stakeholders view education and training as the foundation upon which doctors can develop as they proceed through their career. In this sense, medical education is an on-going process which must adapt to the profession’s constantly changing dynamics with respect to technology, patient needs, and service delivery.
I look forward to working with you all in the coming years to help address the challenges we face in this area. I thank the Committee of Deans of Australian Medical Schools and the Australian Medical Council for inviting me to speak here today.
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