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Govts ponder internship overhaul

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Medical students in the final year of their degrees may be required to undertake prevocational training as part of two-year transition to practice arrangements under contentious changes to internships proposed by a Council of Australian Governments review.

The review, commissioned by the Australian Health Ministers’ Advisory Council, found that although the current internship model was not broken, changes in health care and the way hospitals operate meant it “no longer fits the purpose of meeting the long-term health needs of the community”.

In particular, the inquiry reported that many medical graduates were leaving university highly qualified but with limited experience in providing actual patient care and “no baseline of work-ready capabilities they are expected to meet”.

Hinting at the possibility that medical graduates could face an entrance exam for internships, the review suggested graduates be required to satisfy “entry requirements that reflect…expectations of work-readiness” before commencing.

It said the current internship model in most cases provided for little experience outside of public hospitals, and was increasingly falling short of what was required because it gave graduates only “limited exposure to the full patient journey and range of patient care needs which are important in developing well-rounded doctors”.

Instead, it has recommended that the current one-year internship be replaced with a two-year ‘transition to practice’ model in which the first year would continue to serve as a prerequisite for general registration, while the second could include entry into vocational training.

“We believe a two-year timeframe is more realistic to provide diverse experience, build a strong general foundation and more adequately prepare graduates for vocational training,” the review said, noting that the “vast majority” of doctors currently complete a second general year that is unstructured and poorly aligned with the next stage of training.

More radically, it suggested that the two-year model include the final year of medical school and the first year of postgraduate training, though it acknowledged that this was a profound change that should initially be piloted across a range of medical programs and health service settings before being embraced.

Less controversially, the review said there was a need to improve the supervision of interns, to shift the basis of assessment to a demonstration of specific capabilities and performance, and to ensure that clinical experience is gained in a wide range of settings.

AMA President Professor Brian Owler said he was “delighted” the review had taken up the peak medical group’s suggestions for improved supervision and assessment, as well as expanded prevocational experience in community, private and other non-traditional settings.

The push to expose interns to a wider range of experiences has come as figures reveal an increasing proportion of final-year medical students come from the nation’s capital cities – a trend at odds with hopes to address the rural doctor shortage by increasing the number of aspiring doctors coming from country and regional areas.

A survey by the Medical Deans of Australia and New Zealand found 76 per cent of final year students last year came from capital cities, up from 67 per cent in 2010.

There has been a growing effort to recruit more students from the country in the expectation that a higher proportion are likely to go on to practice in rural areas.

While approving plans to increase the breadth of intern experience, Professor Owler said there were “question marks” over the suggestion that the two-year transition to practice be split between university and the workplace.

“The AMA is yet to be convinced that there is any evidence or need to support such a radical change,” he said.

The AMA President said the fundamentals of the current intern system were sound – a view backed by the review’s conclusion that the existing milestones for medical registration should remain unchanged.

He said it was pleasing that the review had heeded the AMA’s call that changes be made incrementally and based on evidence, including its adoption of the AMA’s suggestion for an annual National Training Survey.

The review’s findings and recommendations have been referred to a working group comprising representatives from the Medical Board of Australia, the Australian Medical Council, and all State and Territory Postgraduate Medical Councils.

Professor Owler said the working group should also include doctor in training representatives, and involve extensive stakeholder consultation.

Adrian Rollins