There are a variety of drivers for change that will impact on specialist medical training in the coming years. The types and settings of training and the number of trainees are two which directly influence training.
3.1 The changing health delivery environment
It has become increasingly clear that the location and provision of specialist medical training needs to change. Colleges now recognise that if specialist medical training remains exclusively within public teaching hospitals, it may limit opportunities for training because, as the role and capacity of public teaching hospitals is changing, they are becoming less appropriate settings for some aspects of vocational training and some requirements for training are not being met. An example of this phenomenon was identified by Phelan (2002) who stated that surgical trainees need to experience a broader range of surgical procedures than those seen in larger metropolitan hospitals. The medical conditions of patients admitted to public teaching hospitals have increased in number and complexity while the length of stay is becoming shorter. As a result, opportunities to learn about the management of less complex conditions and the provision of continuity of care are decreasing. Specialist colleges are already seeking solutions to these changes by moving their trainees into a wider range of settings. This diversification of settings in which training is increasingly being undertaken is aimed at both providing better training experiences by reflecting the current and future health care needs of the community, and training specialists in the full range of settings in which services are delivered.In the past, public hospital outpatient clinics have provided excellent and efficient learning opportunities, especially for more advanced vocational trainees. However, in many parts of Australia public hospital outpatient clinics are disappearing as patients are transferred to private settings. Patients with less complex problems are rarely seen in such clinics, they are cared for in general or private office practice. To accommodate these changes and still provide the opportunities necessary for training, specialist colleges have been adapting their training approaches to be more flexible, shaping training requirements around a ‘fit for purpose’ approach, and have begun to incorporate opportunities offered for learning in a variety of non-traditional settings, including community health centres and academic medicine.
3.2 The shortage of medical specialists
At the same time as changes are occurring in health delivery, there is growing concern in the community about the shortage of medical specialists and, according to the research of the Australian Government Productivity Commission, this problem will increase rather than diminish into the future. If Australia is to generate a sustainable workforce of medical specialists, training needs to be more efficient.Accommodating the increased numbers of trainees whilst maintaining and improving standards requires changes in the delivery of specialist medical training. At the system level, this will require improved communication between the increasing number and diversity of stakeholders. Historically, different institutions have influenced and controlled different parts of the system. This stakeholder-driven strategy has created a robust and stable training system. As roles, relationships, responsibilities and accountabilities of key stakeholders change there is opportunity to enhance governance mechanisms particularly in areas of overlapping responsibilities between stakeholders.