1. Preamble
The AMA recognises that public hospitals, complemented by general practice, have been and continue to be the cornerstone of medical training in Australia. An adequately resourced public hospital system provides a rich and diverse learning experience for medical students and junior doctors. The AMA believes that this environment should be further developed and strengthened over time.
Over recent years, it has become evident that clinical training will expand from the traditional settings of the public hospitals and move into the private sector and into community settings. The privatisation of outpatient clinics, the focus on acute care in public hospitals, and decreasing lengths of hospital stay mean that medical students and junior doctors have limited access to the variety of conditions that are managed primarily in the private sector, and are missing out on being involved in the entire patient journey.
Additionally, the massive increase in medical student numbers has highlighted the need for more capacity for training- as students and then as junior doctors once these students graduate.
The AMA supports the expansion of medical training into expanded settings beyond the traditional teaching hospital model. These settings are a largely untapped resource. The experience of general practice training shows that the private sector can play a very valuable role in medical training.
2. Background
Many studies and reports have been undertaken in Australia deliberating the possibility of expanding the training of junior doctors. In 2002 the Phelan report noted that the reliance of the current system on primary training in public teaching hospitals has resulted in limited experience available to trainees in access to certain types of medical conditions that are primarily managed in the private sector.1
In 2003, further issues in relation to the current training capacity of the teaching hospitals were highlighted in a report of the Medical Specialist Training Taskforce (MSTT) that confirmed the necessity to provide training in expanded settings such as smaller public hospitals, private hospitals, private practices, community based practices and non-clinical settings to ensure that the training being provided matched the current and long term service delivery requirements of the community.2
In October 2006, a report by the Medical Specialist Training Committee (MSTC) to the Australian Health Ministers Advisory Council supported the expansion of medical training settings to ensure improved training opportunities and experiences available for junior doctors as well as increasing the capacity for training.3
In response to workforce shortages, the Commonwealth Government has also embarked on the most significant expansion of medical student places that Australia has ever seen. Compared to 2006, by 2012 the number of graduates from medical schools will double.
Australia must generate significantly more training places if the quality of our doctors is to be maintained. By 2013, 3400 intern places will be required, compared to the 1622 that are currently available. Similar increases in vocational training places will also be needed.4
3. Prevocational Medical Training
Prevocational medical training commences on entry into the workforce, with supervision and training almost entirely provided in public hospitals. Traditionally comprising of large tertiary teaching hospitals, and hospitals in rural, remote, or outer metropolitan areas, they provide important opportunities for medical education through the involvement of academic research, and clinic al experience in a learning environment.
The early prevocational years represent an important phase in the training of doctors to the high standards that have been a hallmark of medical practice in Australia. It is vital that teaching remain the central focus in the early postgraduate period for public hospitals and other training settings that may be developed in the private sector. Employing hospitals must have a commitment to the teaching and welfare of doctors-in-training.
It is important to continue to support public hospitals to maintain their significant role in prevocational medical education and training. In this regard, expansion of training settings needs to complement the public hospital training.
4. AMA Position
In 2007, AMA National Conference supported the introduction of a system to facilitate the training of medical specialists in expanded settings, particularly the private sector. Delegates overwhelmingly supported the proposition that this must be based on expanding the exposure of junior doctors to a wide variety of patients, clinical presentations and settings, and the focus of changes must be on the quality of the training of junior doctors.
AMA National Conference recommended that the AMA work with other stakeholders and governments to promote the benefits of private sector training to consumers, private practices, private health insurers, private hospitals and medical defence organisations.
The AMA recognises that from an educational perspective there is significant merit in encouraging an environment where medical students, prevocational doctors and vocational trainees are able to learn from each other. Training in alternative settings should, wherever practicable, support this approach.
The AMA supports the introduction of a scheme to facilitate training in alternative settings, conditional to incorporation of the following principles:
- Arrangements for training in private settings must respect patient choice by ensuring that all patients treated by junior doctors are informed about the role of trainees in their medical care and freely consent to this.
- Private practices must be resourced appropriately to take on a training role. Resources should be provided by government and should be focussed on infrastructure, educational resources, support for the acquisition of teaching skills, IT resources, human resource management support and the like.
Junior doctors’ entitlements and working conditions must be protected- Junior doctors must not be financially disadvantaged.
- Medical indemnity arrangements must not disadvantage or impose extra costs on medical students, junior doctors or their supervisors.
- Training positions must be accredited by the relevant accrediting authority to ensure that the high quality of training is maintained.
- The system for training in the private sector must ensure that income generated by the activity of the junior doctor together with government or other subsidies fully compensate the practice for losses incurred by taking on a training role.
- There must not be any reduction in services at public hospitals as a result of junior doctors moving into the private sector- Public teaching hospitals should continue to play the central role in the training of junior doctors, and should be appropriately resourced.
- There must be professional support for supervisors, medical students and junior doctors, along with equitable access to educational resources.
References:
1. Peter Phelan Consulting, Medical Specialist Education and training: Responding to the impact of changes in Australia’s health care system. A discussion Paper (Prepared for the AHMAC Working Party to Research Issues Relevant to Specialist Medical Training Outside teaching Hospitals), February 2002, p 13.
2. Medical Specialist Training Taskforce, Systematic Framework, Appendix B, p.35 located in the Report by the Medical Specialist Training Steering Committee, Expanded Settings for Medical Specialist Training, October 2006.
3. Report by the Medical Specialist Training Steering Committee , Expanded Settings for Medical Specialist Training, October 2006, pg 37.
4. AMA Media Release, Medical Training must be Core Component of Health Care Agreements, 8 March 2007.