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Sounding a wake-up call for postgraduate medical education

Australia’s international reputation in education has been taking something of a hammering lately. Attacks on overseas students have generated bucketloads of adverse publicity, and the uncertain future facing many international medical students is another issue that won’t go away anytime soon.

Professor Bruce Robinson, dean of medicine at the University of Sydney, thinks one solution may be to broaden the range of services involved in providing postgraduate medical education. There are, of course, many reasons why this might be useful – especially if it means more graduates wanting to work in general practice or in disadvantaged areas.

He writes:

“The recent difficulties for international medical students, who after as many as seven years of study have found themselves scrambling to secure postgraduate training positions, have been stressful for all concerned and not helpful to this country’s reputation for education.

The students’ much publicised problems, though, have served one useful purpose. They have been a wake-up call for state and commonwealth governments, medical schools and the profession on the need to overhaul postgraduate medical training.

Without reform we are destined to see the events of the past months – students graduating but not sure they will be able to secure an internship – repeated with increasing severity in the years ahead.

With the number of medical graduates due to more than double in the next two years, local as well as international students will soon struggle to secure postgraduate training positions. Within three years, the numbers of young graduates without internships could be in the hundreds.

Just as important, without reform of postgraduate education and training, we will not be preparing young doctors well for the realities of modern health care and for the medicine most will eventually deliver.

Postgraduate medical training has traditionally taken place in the country’s public hospitals. There is absolutely no way that under-resourced public hospitals can accommodate the increasing numbers of graduates looking for internships in the years ahead. Nor should they.

Changes to the way medicine is practised, the growth in the private hospital sector, and the shift from people being treated in hospitals into ambulatory care settings all necessitate rethinking the intern role.

Patients today spend shorter periods in hospitals, they are increasingly diagnosed and treated in general practices and specialist rooms. When students and young doctors see patients in hospitals for short periods but are then not involved in continuity of their care, they are missing a fundamental part of good medical practice. Without spending some of their training in community settings, in general practice and with specialists, trainees risk not seeing the full range of health delivery.

Changing patient management strategies, which are now more likely to include other health professionals such as physiotherapists and nurses, are also not well reflected in the public hospital-based postgraduate training we now provide.

One of the factors that has restricted change to postgraduate training has been an overly bureaucratic and traditionalist approach by governments and some in the medical profession. But if we are serious about providing better education experiences for our young doctors, we need to think more broadly and develop programs that more fully reflect modern medicine.

Instead of focusing all postgraduate training efforts in public hospitals, we need to be looking at options in the public and private systems, in general practices, specialist rooms and health centres, including Aboriginal medical centres.

Private hospitals now play only a minor role in medical education and training, but in our discussions we have found highly experienced members of the profession working in the private sector who are happy to engage in training young doctors.

We should also consider international opportunities. International training, especially in countries in our region, offers invaluable new perspectives and cultural experiences that foster more enlightened practical doctors. Many Australian health professionals work internationally and are willing to assist in training young doctors.

The Health and Hospitals Reform Commission, in its recent report, made a number of recommendations on postgraduate training, including the development of a new framework with clinical training available across all health settings, both public and private, and involving hospitals, primary health care and community settings.

With the new graduates emerging, there is real urgency to this endeavour.

To take the brightest students, ask them to commit to at least seven years (in the case of Sydney Medical School) of intensive study but then not provide them with the postgraduate opportunities they need to become the doctors they have the potential to be – and that the community needs – is wasteful and unacceptable.

It is imperative that we review and moderate the clinical training we provide, so we can accommodate the higher numbers of graduates but also allow it to occur in settings that make our young doctors ready and relevant to contemporary medical practice.”

• This article first appeared in The Australian’s Higher Education Supplement of 14 Oct. It is reproduced with the author’s permission.

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