Good morning.

It's a privilege to speak at this conference - which is a timely initiative of the ADF.

When I said I was speaking at an ADF function, somebody asked, "Why are you speaking to the Australian Defence Force?"

I replied that ADF was the Australian Doctors' Fund - and probably better known to some as the Australian Attack Force!!

Like the AMA, the ADF is an active and avid campaigner on behalf of doctors and their patients.

I will talk today about the AMA view on medical training.

As you all know, everybody has a view on medical training.

The Australian Government has a view on medical training.

The State and Territory Governments have their view on medical training.

The public hospitals have a view.

The private hospitals have a view.

We all know that the ACCC has a view. To borrow the title of a James Bond movie, it's probably "A View To A Kill".

Patients certainly have a view - one that must be heard.

Older doctors have a view - a view rich with experience

And younger doctors and doctors-in-training have a view - a view rich in energy and enthusiasm.

All doctors - young and old - must have an input to future medical training and future medical workforce needs.

As a profession we are united on that. And as a profession we have to keep reminding governments of that.

But I think today we are increasingly seeing evidence of a generation gap in attitudes to medical training.

The young are questioning the old, and the old are looking quizzically at the young.

Our challenge as a profession is to ensure Australia's future medical training approaches are a mix of the new and the old.

We need a blend of experience and enthusiasm - with a big dollop of reality.

And we need to set our future plans in an environment of unity within the profession, not confrontation.

There will be differences.

And there will still be a few skirmishes out the back behind the toilets.

But we cannot have public brawling over an issue so important to the health of all Australians.

That only defeats our purpose.

We must find common ground within the profession and build our ideas and policies together - our generation and the next generation.

And there is common ground - and plenty of it.

I think at the heart of everybody's view of medical training is the need to maintain high standards.

I think also that there is no argument that doctors must teach student doctors.

Medicine is an art.

Clinical experience is the heart and soul of that art.

Clinicians are a non-negotiable part of medical training.

Medical training is an empty vessel without clinical experience.

And how do you get clinical experience?

You get it through teaching by the bedside. With real patients. Taught by real clinicians.

You can't get that experience in a classroom alone.

You certainly cannot get that experience - that learning - over the Internet.

A medical student cannot ask the right questions if there is no clinician with them at the patient's bedside.

A medical student cannot get the right answers or the right instruction unless a clinician is there to guide them.

And this contact with the clinician must come to the student in the early stages of training.

The connection and wisdom will stay with them throughout their studies…and throughout their entire careers.

So it is my view that the role of the clinician is something that will be defended - must be defended - by this generation and the next generation.

And as our students become clinicians themselves, they must continue to learn throughout their medical career with other clinicians. The learning never stops.

A major concern I have about the current state of medical education is a lack of commitment to the basic sciences.

I'm talking about anatomy, physiology, biochemistry, histology and pharmacology.

These sciences are integral to medicine and medical education.

As medicine is an art, it is equally a science.

The basic sciences must remain part of our profession and an essential part of our medical training.

They always have been and always should be basic 'tools of the trade' for each and every doctor - now and into the future.

There is a saying that goes 'if it ain't broke, then don't fix it'.

I don't think it applies 100 per cent to medical training, but I do think we should take stock of all the good bits before we come to an agreement about the bad bits that do need fixing.

Australia has a world-renowned system of medical education.

Australian qualifications are held in high regard throughout the world and our graduates have little problem getting work overseas.

We have a standard of healthcare that is envied throughout the world.

Yes, it has its problems but no one would or should lay the blame for these at the feet of the profession or the skills of our doctors.

Australia's doctors serve their patients diligently despite many pressures and obstacles.

There are politicians who put short-term political gain ahead of the long-term benefits of the health system.

There are over-zealous bureaucrats - and a lot of them. Especially in the public hospital system.

There is always inadequate funding.

We have workforce shortages.

We have crumbling infrastructure.

Despite this, our hardworking docs keep holding the system together.

Putting patients first - always. They are trained to do it and do it well.

That's one bit of medical training that will never change.

The medical profession has a strong, independent tradition - which is fundamentally linked to excellence in medical education.

Part of that strong independent tradition is having a say in training.

Sure, we must work with other stakeholders, but at the end of the day we must set the standards.

Others with a say have different standards to ours.

The ACCC, for example, does not understand that perfect competition is not a solution to complex workforce issues.

I am encouraged that ACCC boss, Graeme Samuel, has a more flexible attitude to the unique nature of our profession than his predecessor…at least in our early meetings.

Governments of both persuasions - and both State and Federal - believe they and their bureaucrats know more about medical practice and medical training than the medical professionals do.

So much so that they continue to create systems to employ and direct doctors.

Systems that rob us of our independence.

Systems that rob patients of choice.

But we resist and will continue to resist…as we must do with medical training.

Nevertheless, the reality is that workforce shortages, community expectations and political pressure are conspiring to lessen our influence over medical training.

The implications for quality and safety are obvious.

A training agenda that is driven by bureaucratic control and tight budgets will push quality and safety to the end of the hospital waiting list.

Policy makers in Government are increasingly looking for alternatives.

The problem for doctors and patients and the health system is that they could be seduced by wacky promises of a production line of doctors or medical technicians or assistants…just so long as it comes in under budget…and they don't talk back.

And this is not a fantasy.

Regulation is the 'in' thing in the education sector as well as the health sector.

The Higher Education sector has learned very quickly that full fee paying courses are a lucrative source of income.

I have no doubt that they see an untapped potential in postgraduate medical training.

All they need are a few willing state governments who will help them to deliver the clinical settings for training.

Our response to this challenge must be intelligent and patient focused.

We have to ensure our next generation of doctors gets the best possible training in the best possible environment…without it costing the earth.

A medical career must remain open to the brightest students, not the richest students.

Graduate Education

There has been an explosion in medical knowledge.

Medical students have much more to learn than ever before.

With an ageing Australian population, they will have to deal with patients with increasingly complex treatment needs.

There have been concurrent significant changes to Medical School curricula as Universities grapple with the problem of properly equipping students to face these challenges.

As I said earlier, there has been a shift of focus away from the core sciences.

Instead we are seeing a shift to problem-based learning.

This is not unique to Australia. Medical schools all over the world are heading in the same direction.

The Australian Medical Council oversees the accreditation of medical schools and its guidelines give Universities a significant degree of freedom in the development of curricula.

The AMC guidelines do not favour problem-based learning over the more traditional teaching model - although they do require that there should be an appropriate mix of teaching methods.

They encourage diversity, which is an important part of advancing medical training.

But what effect is this having?

Well, it depends on who you talk to.

Some say that the pendulum has swung too far and that students are emerging from medical school with significant gaps in their knowledge - particularly in anatomy.

Others believe that these students are carrying forward more knowledge than ever before - and they are much better qualified to manage patients.

Problem-based learning may be seen as advantageous in preparing for a specialist career in some specialties.

But in others, such as surgery, it may be seen as a step backwards.

It's a debate we have to have.

With my comments on the basic sciences and the role of clinicians, I think my position is clear.

It's no secret that there is widespread frustration at the direction taken by medical schools.

A word of caution, though.

It seems the only way this debate can be resolved is for the profession to examine this issue objectively.

We must be prepared to look beyond past practices and to acknowledge the very different challenges a medical school student faces today.

We all know at the AMA that our Doctors-In Training are quite vocal in expressing their views about training.

Perhaps we older heads need to listen a bit more.

So too the tertiary institutions need to understand that they need to engage the medical profession to set the direction of medical curricula.

They must gain a better understanding of the skills that are needed to prepare a junior doctor as they embark on their post-graduate training career.

How much attention is being paid to ensuring that university, PGY1 and PGY 2 years and vocational training ultimately complement each other?

Very little, I'd say.

One thing is for certain: if medical schools are letting our students down, then it will ultimately be the Medical Colleges who will need to pick up the pieces.

Teaching Hospitals

A major impediment to quality training today is the erosion of the quality of teaching in the public hospital system.

We are seeing Australian icons - our great teaching public hospitals - being left to decay.

The administrators are putting so-called 'service delivery' ahead of traditional priorities such as quality and the 'teaching hospital' function.

Our teaching hospitals are not history book traditions: they are living traditions and national treasures.

But instead of being protected and nurtured, what are they getting?

Funding cuts.

Bed closures.

Cutbacks to resources for supervision and training.

Ever growing workloads.

Poor rostering practices.

The bureaucrats are cutting the time needed for quality medical education in our once-great teaching hospitals.

There is a dangerous lack of clinical involvement in hospital decision-making.

This, my friends, is a recipe for disaster in medical education.

We have to get though to the hospital administrators, the bureaucrats they are destroying overnight an asset that takes generations to build.

Medical training must be looked upon as an investment in the nation's future, not a line item in the hospital financial statements.

A key part of the future for medical training is the expansion of specialist training into private clinical settings.

There has been a fundamental shift in the management and delivery of healthcare in this country.

We have seen greater management of health care within community settings.

We have seen decreasing lengths of stay in hospitals.

We have seen an increased role by private hospitals.

There have been many new technologies and techniques.

While, at the same time, our public hospitals have been neglected.

Teaching hospitals are dealing with an increasingly narrow range of conditions and they are not providing many trainees with the training or clinical exposure they need.

Public hospitals are largely focused on acute care, whereas chronic care is where the main game really is today.

Informed thinking is getting behind the principle that medical training should take place in both the public and private health care systems.

Yet, four years after the Australian Health Ministers' Advisory Council first established a working party to examine the issue, we have seen bugger all progress.

We have seen a working party replaced by a taskforce that was replaced by a steering committee.

What's next? A Royal Commission?

It's not that hard.

We do not have to make wholesale changes to the medical training system to progress this concept.

It can be delivered with relatively little change to existing systems.

There are small pilot programs operating in areas like dermatology, physician and surgical training that are already yielding positive training results.

Yes, there is no doubt that expansion of training into private settings will have an initial impact on public hospitals, but not lasting.

We have to plan for that and ensure adequate throughput through the complementary public/private training streams.

The biggest impediment will be, of course, the old Commonwealth versus State funding blue. Who pays? You pay?

I think it's time our governments outgrew this old vaudeville routine.

Medical Colleges

But what of the role of the Colleges?

The proud tradition of medical colleges is fundamental to the quality of medical training in Australia.

They set and maintain the standards for specialist training.

But some in the community still see the Colleges as clubs or secret societies.

Others fail to understand what the Colleges actually do.

We have to change this unwarranted perception. The Colleges need to sell themselves much better.

The Colleges must explain to the public the role they play in protecting patient safety and providing high quality medical care.

The Colleges must improve the way they interact with each other and explore the opportunities that exist for them to co-operate more closely in the delivery of training.

There has been some movement at the station.

The Committee of Presidents of Medical Colleges has re-established the education subcommittee.

Their agenda specifically includes Recognition of Prior Learning and portability of training.

This is a major step forward by the Colleges and a direct and positive response to lobbying from junior doctors.

The inability to change from some vocational training programs to another and receive at least some credit for training already undertaken is a significant problem.

Trainees in these circumstances are often faced with the prospect of remaining in a training program that might not suit them any longer - either for professional or personal reasons.

Or they can start again in another discipline with little or no credit for work and training undertaken so far.

Both scenarios do not make any sense.

There must be greater communication between Colleges and trainees.

Trainees should have a say in College decision-making processes.

They must be consulted on training programs, examinations, fees and charges, and general college policies.

There is inconsistency on this issue and it is a constant source of disquiet among the AMA's junior doctor community.

Trainees are not just the future college fellows. They are the contemporary consumers of the Colleges' most valuable service -training.

Trainees strongly support their Colleges. The Colleges must return that support, with interest.

Rural Australia

Just before finishing up, a few quick words about rural medical training.

Modern Australia has seen banks and post offices and other crucial services disappear from country towns and communities.

Medicine has been following this trend.

The result has been incredible pressure and stress on the doctors and health professionals who remain.

We still haven't seen a proper response from governments to the medical workforce crisis in rural and regional Australia.

We have seen unfunded bonding of students, though. But that is another speech for another day.

We can't let medical training bypass rural Australia.

Rural communities must be provided with the right facilities to give rural students a shot at entry into medical school.

Junior doctors must have access to a robust and quality training experience in these areas.

The evidence shows that people who are from rural areas, or who are exposed to country practice early in their medical training, are far more likely to go on and practice medicine in rural areas.

Technology, rural clinical schools, skills centres, and outreach programs all present rich opportunities to enhance the standard of health care in rural communities.

We want young doctors to be given the support to stay in rural communities because that's where they want to be.

Helping Indigenous Communities

The same goes for Indigenous communities.

We are seeing individual communities now taking ownership of their own issues locally and this is yielding some positive results, including in health.

To see improvements in Indigenous health we need a bigger Indigenous health workforce.

Indigenous students need to be able access fully funded University places and more money needs to be committed to pre-medicine programs and support units.

Conclusion

As I am passionate about fixing Indigenous health, I am passionate about my profession.

I have great friends in the medical profession. I even married a doctor. That's how passionate I am.

I want to see the privilege that was handed to me handed on to others.

I want to be sure that future generations of Australia have access to quality affordable medical care.

As a society, we have to look after the doctors we've got. We must keep them in the profession and attract others back into the workforce.

Australia has truly great doctors. But we need more of them. More great ones.

The way to do that is to train them properly. I hope this Conference provides a blueprint to satisfy this and the next generation.

Thank you.