5. The educational framework for proposing an expanded specialist training environment

5.1 Principles for effective education and training in expanded settings for training
5.2 Issues to be addressed
5.3 Enhancing Partnerships
5.4 Supervision

Based on the information gained, the committee concluded that, in order to maintain the standards and experiences required to train a medical specialist, the colleges are already changing their thinking about training requirements and training sites, and that they will need on-going support to maintain the way in which training, and the system itself is evolving.

Four of the most significant changes which have taken place over the last decade have been the introduction of the language of competencies, with an associated broadening of expectations of what it means to be a medical specialist; the expansion of training into non-traditional settings; increased cooperation between the specialist colleges and between all of the stakeholders; and changes to the provision of supervision for trainees.

Diversifying training across a range of settings will bring four major benefits to trainees, specialist medical practitioners, the training settings, and the community:

• for trainees there will be improved training opportunities and experiences available to them. This is essential because in at least some of the specialties the minimum is currently not being reached. Besides broadening their experiences to ensure that they are better equipped to carry out the role of an independent practitioner wherever they are employed, it will also expand their horizons and understandings of the roles of their chosen specialty, and broaden their understanding of the health care system.
  
  
• both trainees and medical specialists will benefit because training will become more targeted. It will create opportunities to expand training to match service delivery and community needs, more closely aligning the provision of high standard, multi-discipline patient care with community expectations
  
  
• patients will benefit because there will be more specialists working in rural public hospitals, private hospitals, community and private ambulatory centres, and also to some extent in non-clinical settings. It will improve access to standards of care in the expanded range of training settings and throughout the Australian health system
  
  
• within the defined healthcare networks the expanded settings will extend the current training capacity through increasing the capacity to take in more trainees without increasing pressure on public teaching hospitalsTop of page

5.1 Principles for effective education and training in expanded settings for training

The follow principles have been set out to guide the expansion of training into the range of different settings as proposed by the colleges:

• Specialist medical colleges will continue to provide effective and integrated training, education and certification to medical specialists. Such training, education and support will encompass both the organised institutional education that occurs at the beginning of specialists’ careers and the forms of 'lifelong learning' that occur in different training settings
  
  
• Specialist medical colleges will continue to define the requirements for training and accreditation of training settings in collaboration with other stakeholders
  
  
• Where appropriate for the enrichment of trainees' experiences, training will occur in a range of new and different training settings (including private, community, rural, elective and emergency settings)
  
  
• Training will address all of the required competencies as defined by the specialty
  
  
• The varying education needs of specialist medical trainees - between disciplines and at different stages of training - are recognised and accommodated. For example, exposure to an increasing breadth and depth of case mix provides trainees with opportunities to undertake graded responsibility in decision making, and to participate in all aspects of professional responsibility
  
  
• Trainees will be provided with a stable professional environment and receive appropriate levels of professional and educational support throughout their training
  
  
• In addition to the specialty specific training, opportunities will be taken to provide training in the generic competencies through interprofessional collaboration. For example, the program which is currently being trialled in hospitals in Victoria and NSW, the National Patient Safety Education Framework, was developed as a joint project between the Centre of Innovation in Professional Health Education, in the University of Sydney, and the Australian Council for Safety and Quality in Health Care. This project is designed to provide training (in multidiscipline teams) in patient safety and care for all health care workers from support staff (Category 1), to clinical and administrative leaders (Category 4) (UofS & ACSQHC, 2005)
  
  
• A wide range of different education and training delivery methods will be combined to most effectively utilise both methods and settings according to the trainees' stage of training and speciality
  
  
• Trainees will be provided with equitable and flexible access to training opportunities, including portability of training and recognition of prior learning
  
  
• The possibility of shortening training time will be explored (more targeted training, provision of common learning opportunities, focusing training on competence, and recognition of prior learning may all provide avenues for saving training time)
  
  
• Trainees will receive training whilst fulfilling service delivery commitments
  
  
• Trainees will be provided opportunities to undertake research and pursue scholarship and contribute to the teaching of others
  
  
• Lifelong learning principles will be incorporated into specialist medical training
  
  
• All settings involved in specialist medical training are to be equipped with the necessary infrastructure (including indemnity) and resources required for training.Top of page

Training in settings other than public teaching hospitals

1. RACP identified important learning goals for consultant physicians and paediatricians working in settings other than public hospitals
   • Gain experience in diagnosis and ambulatory care management of patients with complex chronic multisystem disease. The aim with such care being to keep patients as well as possible and to minimise hospitalisation. For example:
     1. heart failure with co morbidities of hypertension and renal disease, or
     2. chronic obstructive lung disease with co morbidities of diabetes and angina, or
     3. a child with developmental disability and associated recurrent respiratory infections.
   • Develop skills in multidisciplinary team care with community-based health professionals ( as compared to hospital teams) eg:
     1. cancer care,
     2. palliative care,
     3. visiting nurse services,
     4. home support services.
   • For Paediatric trainees it is essential that they gain understanding of referral processes and can liaison with local resources which impact on child health and development e.g:
     1. maternal and child health services,
     2. early intervention services,
     3. social welfare services,
     4. school nursing,
     5. preschool and school educational services.
        
        
2. Because of changes of case-mix in the public hospitals it is now necessary for trainees in many of the surgical specialties to have some of their training experiences in private settings in order to be competent to perform some of the most common operations. For example:
   1. varicose veins,
   2. vasectomies,
   3. knee reconstructions and
   4. plastic surgery.

As indicated in the results of the surveys, the specialist medical colleges have recognised that the generic competencies can be developed across a wider range of setting than those that they are currently using for training. Some sectors now provide training opportunities that others do not.

The expansion of training into settings other than public training hospitals is not unique to Australia. Since 1995 some 50 articles have been published commenting on, or outlining the need for, expanded training opportunities. The majority of these reports have emanated from the USA with a smaller number from Canada and UK.

Through the diversification of settings the following current challenges to ensuring full and appropriate training will be met:

• Trainees need to experience a broader range of procedures than is seen in large metropolitan hospitals (and/or public teaching hospitals)
  
  
• There is limited ambulatory experience in many training hospitals particularly specialist trainees in adult medicine, paediatrics and child health, and the various disciplines of surgery
  
  
• 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 the medical conditions of patients admitted to public teaching hospitals become more complex, opportunities for trainees to learn about the management of less complex conditions are decreasing
  
  
• Patients with less complex medical problems are rarely seen in public hospital outpatient clinics, but are cared for in general or private office practice
  
  
• Patients with common mental health disorders are usually treated in private and community-based practices

In addition, it is anticipated that through expanding training into non-traditional settings, whilst at the same time maintaining the centrality of the public teaching hospitals for training, it will be possible to increase the number of trainees in each medical specialty providing an overall increase in specialist trainees across all training settings.

The examples outlined by the colleges demonstrate ways in which training is already expanding into non-traditional settings. As the proportion of trainees in different settings increases, this process needs to become more formalised. The committee suggests that, to maintain accreditation and standards, and to ensure equity for trainees, the most appropriate process will be the establishment of accredited training networks. The committee anticipates that this will take a variety of forms and will, in most instances, probably develop around pre-existing formal or informal hospital networks. Some training hospitals have already created network arrangements with other hospitals (non-metropolitan and/or private) to provide wider training opportunities for the trainees they employ. Such networks could be used as a basis for establishing expanded networks by widening them to incorporate the diversity of settings which will be involved in training.

Examples of existing networked training arrangements

1. There are informal networks such as that of St. Vincent's Hospital in Melbourne which enable trainees to move between metropolitan and rural settings.
2. In Perth, plastic surgeons work in a network which includes training in both public and private hospitals because certain elements of their training, such as cosmetic surgery, are not available in public hospitals.
   
   

It is anticipated that each network will include at least one public training hospital which will continue to provide a large proportion of medical specialist training. Depending upon specialist training needs, the trainee's level of experience, as well as the type of setting, patient numbers and case-mix, and geographic relationships, trainee rotations may be allocated as a block period of time, or a proportion of each week. To ensure that trainees have the most effective training opportunities, and also that the settings gain the most efficient use of all of the trainees they employ, each network will need a designated 'Director of Clinical Training' who will oversee the movement of trainees between the different settings and the quality of their experience. This role is considered to be central to the effectiveness of the network as a training environment and to the maintenance of high quality training.

The network will need to have governance structures that take into account the different accreditation requirements of all of the different specialties and establish clear guidelines to support trainees in each setting within the network. It is anticipated that it will be the network that will be accredited, rather than each setting. This means that not all resources will be required in every setting. Rather it is expected that the full compliment of training requirements will be available for trainees within the network. In some situations a post may require individual accreditation, particularly where competence can only be assessed following repeated exposure and training for a particular procedure.Top of page

5.2 Issues to be addressed

There are a number of issues that will need to be resolved to ensure that the diversification of training settings does not impact negatively on the quality of service offered in those settings, or on the quality of training. At the system level it is essential that safeguards are put into place to make certain that:

• High quality training in public teaching hospitals is not compromised by more diverse training
• Teaching and infrastructure in public teaching hospitals is maintained, if not bolstered
• The process does not exacerbate inequalities in access to care between public/private or metropolitan/rural
• Potential patients (both public and private) are educated about the benefits provided by trainee involvement in their treatment

At the same time specialist medical colleges will need to:

• More specifically define the goals for training, and develop precise curricula and detailed educational objectives for the various settings
• Ensure that appropriate training is provided for supervisors
• Develop mechanism for providing regular, confidential feedback from trainees to their college on training quality and whether the required range of clinical experience is obtained.Top of page

5.3 Enhancing Partnerships

Besides the proposed expansion of training into settings other than public teaching hospitals, the committee came to recognise the need for, and the potential for, enhanced partnerships. The concept of enhancing partnership functions on two levels. One relates to improved relationships between specialist colleges, and the other to recognition of the inter-dependence of trainees, supervisors, hospitals, administrators, jurisdictions, colleges, universities, CPMEC and the AMC.

Specialist medical colleges have, and will continue to play, a significant role in maintaining the standards of training within their specialty through the development of curricula the accreditation of training settings, assessment and endorsement for Fellowship. In addition Colleges are responsible for providing continuing professional development for the life time career of Fellows. Until very recently each college has taken a separate and autonomous approach to these activities. However, increasingly it is becoming possible to identify areas for potential co-operation and collaboration.

There are a number of collaborative initiatives that are either taking place, or have been identified, which will contribute to the standardisation of curriculum and on-going cooperation between the medical specialist colleges. For example:

• Committee of Presidents of Medical Colleges - Australia (CPMC) Education Committee (2005) established a network of college educators who will meet three times a year to discuss and explore issues of common interest across the medical specialties
  
  
• CPMC (2005) project to collect information from the colleges about their modules and current training courses that have the potential to be offered across the wider medical training community
  
  
• CPMC (2005) also collected information about the ways in which the different colleges currently recognise prior learning. The underlying proposition for this project is to smooth the progress of trainees’ movement across specialties
  
  
• AMC (2005 & 2006) organised combined college workshops on assessment issues
  
  
• One of the recommendations from the ACCC (2005) review of the RACS 'Criteria for Accrediting Hospitals' was that the college would work with other bodies (including other colleges) that undertake accreditation of the educational support provided by hospitals, to develop common accreditation criteria and processes for meeting educational support requirements.

One example of initiative originating from a college was the invitation from RACP (2005) to representatives from different colleges, faculties, and chapters to participate in a workshop to discuss the development of curriculum addressing adolescent health. From that workshop there is a proposal to write one module that can be shared by other specialties, and another in which the contributions of the different specialties to this area of health is collated together.

The generic competencies offer another area of obvious overlap in performance requirements and the possibility for sharing of resources. For example, RACS has modules on their website which set out the objectives and performance criteria in the areas of Professionalism and Ethics; Health Advocacy, and Communication. Such curriculum material is readily available to other colleges to use as they deem appropriate for their specialty.

Some of the above initiatives require very few, if any, additional resources to establish, participate in or contribute to, and/or to maintain. However, because each college budget is developed around internal administration and expenses, other inter-college collaboration requires support and/or resources that are not readily available within the colleges.

The other area where the value of enhanced partnerships is increasingly being recognised is between the numerous stakeholders involved in specialist medical training - all of which have key roles in the management and coordination of specific and individual training programs across colleges, sectors and jurisdictions. The increased representation of jurisdictions (JRs) on college committees, and greater consultation between the colleges and the JRs in recent years are examples of improved partnerships between these organisations.

To successfully implement the expansion of training there is need for increased collaboration across and between governments; jurisdictions; public and private hospitals; community-based health settings; and the colleges. The number and variety of stakeholders who will be involved in the proposed expansion of specialist medical training indicates a need for greater coordination and cooperation between the stakeholders. Due to the complexity this will entail in the future when there will be additional and more diverse training settings, clear definition of roles and areas of responsibility need to be developed. Such definition is necessary to facilitate and maintain collaboration and communication, provide adequate resources, infrastructure and supervision, and to limit the amount of administrative overlap required to maintain high quality training. However, whilst coordination of the interests of the stakeholders is essential, the implementation of the training framework should be flexible, to allow for differences between specialities and jurisdictions, and should avoid increased layers of complexity and/or administration.Top of page

5.4 Supervision

High quality supervision is essential for high quality training. In expanding the training of medical specialists (both in number and variety of settings) the inter-connected issues around recognition of current public supervision, provision of supervision in non-traditional settings, and training of supervisors, all need to be addressed.

Historically, supervision in public teaching hospitals has been undervalued and rewarded in non-monetary ways as a pro bono activity through the colleges. Now, with increasing pressure in training hospitals to meet the demands for service delivery, the supervision/training component is becoming more difficult to achieve without due recognition of the importance and contribution of such roles within the hospitals. This may mean that in the future, supervision, even within those traditional settings, will need to be properly recognised and remunerated, leading to a substantial increase in wage costs for supervisors.

Expanding specialist training into non-traditional settings will mean that additional supervisors will need to be recruited. Whilst specialists who choose to work in the public training hospitals have accepted that part of their role is in supervising trainees, this is not the case for specialists who work in the other settings that are proposed in the expanded network model. Not only are the specialists in those settings unaccustomed to the role and expectations of supervision, in some cases they may be reluctant to take them on.

The changes to training proposed in expanding and networking training environments mean that supervisors (both current and new) will need to be trained. The number of current and potential supervisors who may need to be trained is unknown. Such training is needed in order to ensure that supervisors in each of the specialties are properly informed and is able to incorporate the changes into their training and assessment approaches. Training will therefore need to include:

• the impact of the new, competency based curricula
• the most effective ways in which to incorporate training into work-based practices
• providing feedback and support for trainees
• how to best utilise opportunities for multidisciplinary learning
• assessments of competencies and the changes to assessment that are required
• changes to work based, in-training assessment
• how to determine underperformance and identify procedures to assist a trainee in addressing defined deficiencies
• how to adapt supervision according to the context and the level of development of the trainee, (and, in some instances)
• how to carry out remote supervision

The Expanded Specialty Network Model for training offers opportunities to develop new and/or additional approaches to supervision. Having trainees working in non-traditional settings may require, in some instances, a more flexible approach to supervision, including the possible use of distance/remote supervision. Depending on the context and level of training, such approaches can provide opportunities for trainees to move into decision making and taking some level of responsibility before graduating, providing a period of transition to independent practice, whilst still having the oversight of a supervisor. The committee anticipates that in an accredited training network, supervision and assessment issues for trainees working in different settings will be managed within the network as a whole, which is the reason that the previously mentioned 'Director of Clinical Training' is considered to be such a key role.

There are already some effective examples of distance supervision including the RACP hospital based supervisors for local community-based trainees in the RCH example outlined above, as well as the use of metropolitan based supervisors for physician and paediatric trainees in remote settings such as Port Hedland and Broken Hill.