Medical training in expanded settings - 2012. Revised 2015

1.1.The AMA supports medical training in expanded settings in line with the following principles:

(a)Training must respect patient autonomy by ensuring that patients are informed about, and consent to, the role of trainees in their medical care.

(b)Public hospitals will continue to play the central role in medical training. There must not be any reduction in services at public hospitals as a result of training expanding into the private sector and other settings.

(c)Governments must appropriately resource expanded settings to provide medical training.

(d)Trainees must not be financially disadvantaged by undertaking training in expanded settings. Entitlements and working conditions must be protected and maintained across all training settings.

(e)Medical indemnity arrangements must be clear from the outset and meet the needs of trainees, supervisors and facilities.

(f)Training positions must be accredited by the relevant authority to ensure that a high quality of training is maintained.

(g)There must be professional support for supervisors and trainees, along with equitable access to educational resources.

(h)The contribution of practitioners to teaching and training should be appropriately recognised.

2.Definition and scope

2.1.For the purposes of this position statement, expanded settings are defined as private or community settings beyond the scope of traditional public teaching hospital settings.  Trainees are defined as medical students, prevocational and vocational trainees. Although at different training levels, the principles of their training needs are similar. This document does not address vocational training in the specialty of general practice.

3.Introduction

3.1.Medical education and training in Australia occurs across a diverse range of settings in both the public and private health sectors. This includes public teaching hospitals, and increasingly private and community settings that provide training opportunities to meet the current and long-term health care needs of the community.

3.2.Public hospitals, complemented by general practice, will continue to be the cornerstone of medical training in Australia. These settings must be adequately resourced and supported to ensure that they provide high quality healthcare as well as an optimal learning experience for trainees.

3.3.Training in expanded settings is now recognised as an important adjunct to the public teaching hospital model, benefiting both the trainee and the setting in which the training occurs. It enables clinical training relevant to future practice that may not otherwise be available in traditional settings.  

3.4.The growth of training places in expanded settings increases training capacity and is one available avenue for expanding clinical training within the Australian healthcare system. 

4.Consent

4.1.Patient consent needs to acknowledge the presence of trainees and their involvement in the procedural aspects of patient care. Experience shows that most patients consent to and enjoy being part of the teaching experience.

5.Training and accreditation

5.1.Training in expanded settings enhances the education and training experience, fosters career development and increases training capacity. All training places must be accredited prospectively by the appropriate credentialing body to ensure the quality of training is maintained. Postgraduate medical councils and medical specialist colleges play a key role in ensuring that the high quality of training is maintained in expanded settings. Information sharing may be necessary to ease the administrative burden of accreditation as placement numbers grow. Consideration must also be given to resourcing the accreditation of additional facilities and positions and addressing how these costs can be recouped in a fair and transparent manner.

5.2.Expanded settings training positions must provide trainees with the appropriate depth and breadth of clinical experience, caseload and involvement in care relevant to their stage of training. This can be achieved by establishing partnerships between new expanded settings and traditional public teaching hospitals, and maintaining access to the established teaching facilities. 

5.3.Trainees in expanded settings must not be disadvantaged in terms of their training progression and ability to complete program requirements. New placements must complement existing rotations and training should be coordinated across settings to ensure a high standard of training is received irrespective of location or stage of training. Mapping learning outcomes against an agreed standard or curriculum during the accreditation process will ensure the placement meets core-training requirements relevant to the stage of learning. 

5.4.Evaluating training placements is essential to determine the value of the position and the quality of training and supervision provided. The development of a standardised exit survey tool to assess the quality of training would enable gaps in policy, process and practice to be identified and addressed. Assessment of positions that lie vacant due to a lack of trainee demand should also occur, and funding redirected to other training positions if appropriate.

6.Supervision and support

6.1.Appropriate supervision is essential for patient safety and a quality training experience. All expanded settings must be adequately resourced and supported to ensure they have adequate supervisory capacity, particularly in settings where teaching and training activities may not have traditionally occurred. This includes funded time to provide teaching, training and mentorship and to undertake training to provide this support.   

6.2.The diversity of expanded settings highlights the value of establishing clear learning and supervision plans, including the role of the trainee and a description of the minimum level of supervision that is required. College and training institutions must ensure sufficient resources are allocated to orientate and support trainees and any new supervision models must have ongoing and robust evaluation. 

6.3.Supervisors and trainees should have access to the same level of educational and academic resources and activities in expanded settings that exist in public hospitals. Where practical, these may include academic meetings, case reviews, research and other quality assurance activities, and infrastructure to provide access to e-learning materials.

6.4.The potential for trainees to feel professionally isolated from mainstream programmes is an important consideration. Educational and support programs, such as video-conferencing and on-line training platforms, that enable trainees to maintain contact with their peers, colleagues and mentors, and access other training networks, are important to enhance the experience for trainees in these positions. 

7.Recognising the contribution of practitioners to teaching and training

7.1The honoured duty to pass on knowledge and skills from one generation to the next is an important part of the medical profession’s history and future development and will generally guide the decisions of individual practitioners regarding suitable recompense for teaching and training in expanded settings.  

7.2The AMA considers that practitioners should be appropriately recognised for teaching and training through honoraria, academic titles, funding for practice infrastructure, access to resources/facilities and the like. Where practitioners undertake teaching and training on behalf of an organisation that operates for commercial gain, this recognition should not preclude them from seeking appropriate rewards for such services. 

7.3It should also be acknowledged that doctors in training working in appropriately supervised positions in private practice may be able to generate sufficient activity to compensate the practice for any costs incurred in providing training and supervision.

8.Entitlements and indemnity

8.1.Trainees must not be financially disadvantaged when working in expanded settings. To mitigate the risk of this occurring, employment arrangements should maintain public sector wages and conditions, including unbroken service, for the purposes of public sector entitlements.

8.2.Medical indemnity protection is not always clear and has the potential to impact on medical training. To allay this risk, there should be no difference in the indemnity provided to trainees and supervisors across public and expanded settings. It is essential that medical indemnity arrangements are clarified at the outset and are conveyed to all practitioners.

9.Funding and governance

9.1.Despite Government funding of training in expanded settings, there is a complex interplay of factors impacting on the ability of facilities to provide ongoing training. Significant costs are incurred with medical training from the actual provision of training and from lost efficiencies relating to the training process. Current funding does not always cover the entire cost of the training position, and the fee-for-service funding model in private settings does not accommodate the provision of medical education. These factors significantly impact on the willingness of institutions and private practitioners to provide training.  

9.2.Equitable access to significant, dedicated and reliable funding for training positions in expanded settings is essential if positions are to be established with no financial detriment to the institution, supervisor and trainee. Funding must provide for full cost-recovery of providing high quality medical training, and must be indexed to guarantee the long-term sustainability of placements in expanded settings. The institution and practitioner must be compensated for the complete cost of participating in training.   

9.3.Ongoing identification of expanded settings for training must continue, considering the capacity for clinical and non-clinical education, supervision, case mix, clinical exposure and the requirements of training standards. Coordinated recruitment processes for positions within expanded settings may facilitate trainee movement more easily across settings.

9.4.It is essential that the scope and quality of training provided in individual expanded settings training positions are monitored on an ongoing basis. Monitoring should include feedback from trainees and supervisors and needs to be considered when reviewing ongoing funding of individual positions. Transparent, accountable mechanisms must exist for reassigning funding from positions that are not utilised or fail to deliver quality training. These mechanisms must clearly outline the responsibilities between Federal and State Governments, with appropriate funding flowing accordingly between the two.