4. A review of specialist medical training programs

Objectives for a review of specialist medical training programs
4.1 Method of surveying specialist medical colleges
4.2 Results
4.3 Diverse settings in which medical specialist training does or could occur
4.4 Learning Goals - commonalities across settings and between colleges
4.5 Educational infrastructure and resources required in each setting

Objectives for a review of specialist medical training programs

In light of changing training needs and changes in the health delivery environment, the objectives of Reference Group 3 were to review specialist medical training programs. Specifically their brief was to:

1. Explore the educational imperative for training in settings other than public teaching hospitals, by seeking information from each colleges on the average proportion of training time required in each setting of the proposed training model;
2. Identify the learning objectives related to each setting, for each specialty;
3. Specify the infrastructure and resource requirements required in each potential setting to support the learning objectives, bearing in mind that the proposed training model recommends a networked approach to training settings. (This assessment was to anticipate collaborative resourcing arrangements between specialties and colleges);
4. Identify overlaps between the learning objectives, training settings and opportunities for standardisation and collaboration between colleges. Top of page

4.1 Method of surveying specialist medical colleges

The consultation process

To assist in their discussions the Reference Group sent two letters to the medical specialist colleges requesting information on current and potential training across the range of settings, and the learning goals that would apply to each setting. Six questions were included (April 2005) (see Box 1).

It was noted that the information that was collected would be made available to Reference Groups 1 and 2 to inform their assessments of implications for service delivery in public hospital settings and also the costs and benefits associated with training in all settings.

Box 1: Questions sent to the Specialist Colleges in letter 1

1. For earlier and later years of training, and for each speciality and, if applicable, sub-specialty; what preferred proportion of training time could be completed in the following settings:
   
   • public hospitals
     
   • private hospitals
     
   • private practices
     
   • community based settings
     
   • rural and/or remote settings (specifying hospital or practice)
     
   • non-clinical settings
   In addressing this question, please articulate any exclusions to the types or settings for training which may apply to specialty areas or stages of training. Please note that this question will inform Reference Group 2's assessment of training time in settings other than public hospital environments, and does not assume an apprenticeship (time-based) method of learning.
   
2. What learning goals would apply to each of these settings? Such goals could relate to key competencies such as those defined in CanMEDS 2000.
   
3. What particular infrastructure and resources would be required in each of these settings, to enable them to provide effective training?
   
4. How would the accreditation of any of the above settings be substantially different to your current accreditation practices?
   
5. What current experiences are already offered to your trainees in private settings?
   
6. Would these training settings have implications for the Australian Medical Council Standards and Procedures for the accreditation of training programs?

Analysis

The responses from the colleges were collated to provide comparative information on current and optimal training across settings (within each college), and on educational goals for each setting (between colleges and across settings).

The specialist colleges which responded to the letters are listed in Appendix D. Tabulated and graphed results of all college responses to the second letter are available in Appendices E and F.Top of page

4.2 Results

Whilst some of the colleges interpreted the questions differently, the results demonstrate that they are already recognising the potential of diversifying training opportunities and intend to increase the proportion of training in settings other than public hospitals (Appendix E). Already in their training programs colleges recognise that one hospital cannot provide all the clinical experiences required by trainees, and that a richer and more varied clinical experience can be gained through working in a variety of settings. The colleges therefore expect trainees to rotate through a variety of hospitals which will provide complementary experiences. They also recognised the potential benefits of training outside of hospital settings and although training opportunities currently available outside public teaching hospitals may be fairly limited, as demonstrated below a number of innovative examples had been implemented.

4.3 Diverse settings in which medical specialist training does or could occur

Public Hospitals

Public hospitals are at present the main settings for vocational medical specialist training, providing important opportunities for learning. Public hospitals include large tertiary teaching hospitals and those in outer metropolitan, rural or remote settings. Traditionally, public teaching hospitals provided strong educational infrastructure, often supported by academic involvement, and concentrated clinical experience in a supportive learning environment. Smaller public hospitals, often in outer metropolitan and rural areas, provide less differentiated services than larger teaching hospitals. Training in these environments is particularly suited for trainees in the early part of their experience and for more senior specialty trainees who have chosen to become generalists. The development of Rural Medical Schools has strengthened training in a number of regional hospitals by providing an academic base that is particularly valuable for specialist education. So whilst there are clear arguments for facilitating training outside public hospitals, these remain invaluable training resources that need continuing support to maintain their highly significant role in postgraduate medical education and training. Top of page

Private Hospitals

Examples of specialist training in private hospitals

1. ANZCA have three training programs in private hospitals. At Westmead Private Hospital (NSW) trainees rotate for periods of three months from the public hospital; Noosa Private Hospital is part of a network of public and private hospitals providing rotations for three or six months; and the trainee at Gosford (public) Hospital is involved in one list per week at a satellite private hospital to gain experience in procedures which are not available in the primary site.
   
   
2. In WA, RANZCR have three training positions which are entirely based in a private hospital. All trainees also have experience in a rural hospital which provides both public and private care. Trainees benefit from these experiences because of the wider case-mix. Accommodation is provided for trainees whilst they are in the rural setting.

Private hospitals provide important alternative training opportunities. A small number of private hospitals are of similar size to and have similar or better clinical resources than public teaching hospitals. Many of these are already used for medical training and an increasing number support specialist training. There is however a need to develop and support educational infrastructure in these environments. Smaller private hospitals are more common and often care for a different spectrum of illness than public hospitals. These hospitals offer valuable opportunities for training in a broad range of procedures, some of which are now uncommon in larger public hospitals. In the survey many of the colleges identified private hospitals as being able to contribute to trainees’ clinical experience and case-mix, as well as training in technical skills, whilst some also acknowledged the potential contribution in the area of private ambulatory care.

Examples of specialist training in outer metropolitan private hospitals

1. Currently the placements in this program within the RACP include 2 adult medicine placements in NSW and 4 in Victoria, plus 2 paediatric placements in Victoria.
   
   
2. RACS has 5 trainees in a similar program (4 full-time and 1 part-time) with posts in NSW, Queensland and WA.

The Australian Government has also established a set of training pilots to place trainees from a range of medical specialties in the Outer Metropolitan Specialist Trainees Program, thus facilitating private practice placements for specialist trainees. The program aims to develop and implement effective and sustainable models for specialist training in private practice whilst providing training opportunities for specialist trainees outside teaching hospitals. Built into the model are mechanisms to address issues such as indemnity and fee management.Top of page

Private practices

The training opportunities in private clinical practices are wide, ranging from office based consultative work to large, well-resourced diagnostic groups providing sophisticated diagnostic imaging or pathology services. By undertaking training in these settings, trainees will be provided with a comprehensive education, which should complement the clinical experience received from hospitals. Training in these settings will prepare trainees for working in private practices as specialists. An increasing number of trainees in dermatology, pathology and diagnostic imaging are offered training opportunities in private practices.

Examples of specialist training in private practices

1. ACD have had training in private practices in NSW, Queensland and NT. These rotations vary from one day per week to full-time for six months, or half-time for 12 months. An evaluation of this program indicated that the posts are effective in meeting course objective and have a high level of satisfaction from trainees, patients and supervisors.
   
   
2. RANZCO has full-time posts in private practices in rural NSW and another in an urban setting in Victoria. Each post is part of a network and provides training for four trainees (three months each) per year. There is potential to expand this scheme to include posts in Tasmania and Queensland.
   
   
3. All RANZCOG trainees spend 6-12 months in rural practice during which time the trainees are involved in clinics which are managed through private practices. It is estimated that, at any one time, approximately 10 trainees are involved in this kind of experience, plus another 5 in the sub-specialties of ultrasound and reproductive endocrinology and infertility.
   
   
4. RANZCP has training in three private practice clinics (Victoria, NSW & Queensland). They noted that at some of these settings trainees need a four-eight week orientation in order to prepare them for working in the new environment.
   
   
5. The Royal College of Pathologists of Australasia (RCPA) have 30 trainees in private practice in NSW, Victoria, Queensland and WA (20 under a scheme funded by the Commonwealth Government and 20 directly funded by private laboratories). The RCPA has a requirement that each trainee must spend a minimum of two years in one or more public pathology laboratories.Top of page

Community-based team practice

Community-based team practices often care for patients with special needs, such as the very young, the elderly, the disabled, the dying or those with mental illness. These practices provide opportunities for experiencing team-based clinical care of chronic rather than acute illness, not readily available in hospital settings. They also provide opportunities for health promotion, prevention (particularly secondary prevention), early identification and early intervention. For this reason block periods of time in community-based health services have already become an important part of training in geriatrics, psychiatry, paediatrics and child health. RACP identified that there is a dual relationship between the competencies in the relational domain (eg communication skills) and community training settings. Communication skills and the capacity to relate to people from all cultures and backgrounds are important for all medical specialists, especially those who work in multi-disciplinary environments, such as community-based team practices.

Examples of specialist training in community-based team practices

1. Trainees from RACP (paediatrics) have a number of sessional placements including community health care centres, Aboriginal Medical Services and child protection agencies. In one such rotation, trainees combine hospital-based specialty ambulatory care at the Royal Children's Hospital Melbourne (RCH) with community clinics, in particular geographic locations on site with child and family teams. Through these experiences they gain better understanding of children's and families' health issues in a community context, of health and other resources available in the community, and of multidisciplinary team work. They also maintain links with their professional peers, and continue to benefit from the education/training/research infrastructure at the RCH.
   
   
2. ACEM has accredited several special skills posts in NSW, NT, WA and Queensland for training experience. These posts, called ‘retrieval services', are with organisations such as the Royal Flying Doctor Service. All ACEM trainees are required to have 18 months in non-emergency department training and can have a maximum term of six months in one of these posts.

Home-care is another clinical setting which is gaining increasing usage for people who are chronically, or terminally ill.

Example of home-care as a clinical setting

1. Palliative Medicine (PM) trainees are required to do three mandatory training terms, one of which is training in a community setting (outreach or homecare service). The aim of this term is for trainees to gain experience, under supervision, in the provision of palliative medicine consultations in the domiciliary setting and ambulatory care clinics. PM has two and a half registrars in the service. They visit patients at home or in hostels and nursing homes at the request of the specialist, or by GP referral. It is a team approach to these visits, with the registrar being accompanied by the community nurse or occupational nurse. Alternatively the registrars may do joint visits with the community consultants.Top of page

Non-clinical settings

Clinical settings remain the most frequent settings for practical training. However the colleges acknowledge that valuable learning can occur in non-clinical settings, such as tertiary institutions, clinical skills laboratories and scientific and clinical meetings. The use of simulated learning environments compliments clinical environments and may reduce the patient risk of the novice student. Thus, simulated learning environments can be used to increase trainees’ skills and confidence, whilst providing trainees with thorough and comprehensive feedback and supervision.

The current diversification of training settings has demonstrated the educational value of broader experiences than those encountered solely in public teaching hospitals. With a broader patient mix, a wider range of medical conditions, and exposure to more speciality supervisors in a wider range of health settings, trainees are better able to understand links and commonalities between settings and specialities, as well as the significance of holistic and multi-disciplinary healthcare. The colleges recognise that the level of teaching and supervision may be superior in some settings, the range of clinical experience superior in others. However, it is the summation of experience that is important.

Examples of specialist training in non-clinical settings

1. As part of the non-emergency component of their training, ACEM trainees have the option of working in laboratory environments, such as toxicology or forensic medicine, or in simulation centres.
   
   
2. As part of their first year of training, all RACS trainees are required to successfully complete the three day ASSET course, developing basic surgical skills.

All specialist medical colleges recognise that the time spent in diverse settings by trainees needs to be increased, with an equivalent reduction in the proportion of training in public metropolitan (training) hospitals (see Appendix E). For some colleges the proposed reduction of time in metropolitan public hospitals is quite substantial, for example ACD (from 88% - 50%), RANZCR (1) (80% - 50%), and RANZCP (55% - 25%). However, the majority of colleges proposed a reduction of 10-15%.

Most colleges stated that they expect the reduction in training in metropolitan public hospitals will result in a small increase across the alternative settings. However, some colleges, such as the ACEM (from 5% -18%), and ACD (0% - 10%) project that their greatest increase will be into public rural hospitals, whilst RANZCR indicated they were expecting a substantial change in the balance of their training programs towards private ambulatory care, both metropolitan and rural (5% - 30%). For all of the other colleges the greatest increase in projected training settings is into the metropolitan private hospitals (RANZCP 2% - 25%) and into private and/or community ambulatory care (metropolitan and/or rural) (generally between 5% - 10%). RANZCP also indicated that they were anticipating a shift from community (28% - 10%) to private ambulatory care (0% - 20%). ACD (2% - 10%), RACS (4% - 8%), and RANZCOG (rural) (2%-5%) were the only groups that indicated that they anticipated an increase in training in non-clinical settings.Top of page

4.4 Learning Goals - commonalities across settings and between colleges

All of the specialist colleges that used CanMEDS 2000 as their frame of reference to answer the question about learning goals identified that a range of those educational goals can be met in more than one setting (see Appendix F). Their responses indicated that all of the competencies could be developed in a range of settings, to varying degrees. A few colleges, such as RACP, believed that all the CanMEDS 2000 roles applied in every training setting.

There was variation in the number of competencies that correlated with each of the training settings, suggesting that certain learning environments tend to be favoured as being more appropriate and applicable than others. The settings that correlated with the highest number of educational goals across the colleges were public and private hospitals, and private ambulatory care. The settings that correlated with the lowest number of educational goals across the colleges were rural and community ambulatory care (this figure may be at least partially because some colleges do not use those settings).

The competencies that were aligned to the highest number of training settings were medical expert/clinical experience/case-mix, communicator, collaborator, manager, scholar and professional. The competency of technical/procedural expertise was indicated as being delivered in the least number of training settings, possibly indicating that it is not able to be taught in some settings.

Some colleges did not provide data in the requested form stating that they found it very difficult to separate the competencies by setting because, for example, as ANZCA stated 'CanMEDS competencies are taught "holistically" and 'whether in metropolitan or rural public hospitals, or private hospitals, a trainee on any given day, in the course of their duties working with a specialist anaesthetist, may accumulate knowledge, skills, attitudes and behaviours enhancing their learning and development' across all of the competencies.

From this data, the committee concluded that in the future, all trainees should have some exposure to private and/or community-based settings at some stage of their training, the appropriate proportion being integrated within the total accredited training program as determined by each college.Top of page

4.5 Educational infrastructure and resources required in each setting

The colleges identified six main resource and infrastructure elements which need to be provided to facilitate the provision of effective training, adequate exposure and experience for trainees to develop competence. They are:

• appropriate supervision, teaching, and feedback, plus training for less experienced supervisors
• protected time for supervisors and trainees
• professional support
• equitable access to educational resources
• recognition by institutions and managers of the value of training to service provision and quality
• provision of setting specific physical infrastructure requirements where needed

Accreditation of settings and programs

In relation to accreditation of settings it was noted that standards for accreditation of private settings need to be explicit, these should be met in current training sites as well as new ones, and that alternative training settings will be judged against established and acceptable standards to ensure they provide adequate training opportunities. Largely this means that they should be the same as the standards used for existing training settings. However, as many private settings would not have been accredited for training before, there may be some matters which require increased attention in the early implementation phase. The colleges provided a number of examples of where there will be need for further consideration including:

• availability of supervision
• quality of supervision (including the impact of fee for service, peer review/audit/clinical governance)
• trainee access to procedures (including data on clinical throughput, trainee records/ logbooks)
• industrial conditions that are conducive to training
• education facilities

In relation to the AMC standards and procedures for the accreditation of training programs RANZCR was the only college that envisaged that there may possibly be changes at some time in the future. However, they stated that such proposals for change are more likely to come from the consequences of ACCC reviews than from changes within programs in relation to training requirements or settings.