In the past 10 to 20 years the delivery of specialist medical health care (and health care in general) in Australia has changed significantly and continues to change, with a growing private and community sector and widespread closure of ambulatory clinics in large public hospitals. Over the same period worldwide there have been substantial shifts in the focus of medical specialist training, these include an increasing emphasis on competence and competencies; a substantial increase in the importance of interdisciplinary teams; a change in the balance between training and service delivery, and a move from viewing training as an end-point, to a continuum of 'lifelong learning' where specialist medical practitioners (with the assistance of their specialist college) are responsible for their on-going medical education and professional development throughout their professional life. It is logical to assume that the delivery of health care internationally, and in Australia, will continue to change over the coming decade.
Expectations that shape the requirements of training and trainees' experiences and expertise have also changed. Training continues to be substantially based on an apprenticeship model and the link between training and service delivery remains crucial. However, trainees are working in an environment in which knowledge and skills are changing rapidly, they are required to learn new skills and to constantly up-date their skills, whilst meeting optimum standards of care. It is no longer possible for a medical specialist to consider their specialty in isolation from the wider health or social community. Some of the complexities of the changes of expectations are reflected in the non-technical competencies which the Australian Medical Council (AMC) requires for accreditation of each specialty training program. These wider responsibilities of the medical specialist in the health care of the community were described by the CanMEDs 2000 Project and elaborated on in CanMEDs 2005 (RCPSC 1996; 2005). In line with changing community expectations, medical specialist responsibilities have been extended beyond the requirements of clinical expertise and professionalism to encompass non-technical competencies such as communication; collaboration; management and leadership; health advocacy; and scholarship and teaching. In the last decade, since the original publication of these competencies, other expectations, particularly cultural competence, have been added.
In addition to those broad competencies, the World Health Organization (WHO) has identified that, in the coming decade and beyond, there will be a rapid shift in balance between acute and chronic health problems. This shift will require that the skills of health professionals will need to expand to meet these new challenges. WHO identified five 'new competencies': patient-centred care (organising care around the patient’s health); partnering and greater collaboration between health professionals and with the patient and their community; quality improvement and safety; greater use of information technology to monitor patients over time and across medical disciplines; and taking a public health perspective.
Within each medical specialty training program the knowledge and skill requirements are also continuing to expand. Wherever they are working in Australia, each medical specialist is expected to maintain the currency of their knowledge and skills within their discipline. To meet these expectations trainees require opportunities to be exposed to the most advanced approaches. Because this information is frequently in addition to, rather than replacing earlier knowledge and skills, such expectations bring with them the potential to extend training requirements.
To address the challenges facing medical specialist training, specialists and training providers are changing their thinking about education. Other challenges can be, and are being, met by harnessing opportunities created by the changing health care settings, changing demographics of illness, and changes in the skills and knowledge required for evidence based health care and a patient centred approach. Current programs are being built on and expanded and there are further opportunities to increase flexibility in approaches to training and education.
Just as training settings, understandings of education, and requirements of training are changing, there is clear evidence that the expectations of trainees are changing. Increasingly there is a proportion of specialist trainees who move into medicine as postgraduate (rather than undergraduate) students, meaning that they are more mature and possibly more focused on their desired profession. There are changes in the balance between male and female trainees in most medical specialties. There are also changes in trainees’ expectations around the balance between work and ‘life’ (AMA 2001; AMWAC, 2003).