THERE has recently been a move to bring medical education under a centralised umbrella. With this comes a move to increase the powers of the Australian Health Practitioner Registration Agency, expanding it from just regulation to medical education.

The rationale appears to be aimed at standardising medical training, with a view to reducing aspects of education to common denominators that can then be used to justify training people who are not doctors to do jobs that doctors currently do, fragmenting training into small parts.

This is an exercise in cost reduction, which undermines the current central role of the doctor in providing medical care. It will not work because it is not dealing with the root cause of why we are in the state we are in.

I understand why people who are not doctors would think that fragmenting medical education and care could be a good idea. They see doctors providing the same services over and over and think that other people could be trained, in a shorter period of time, to do each one of these services. Therefore, they might be persuaded to provide the service for a fraction of the cost of a doctor, especially as the government will be paying the bill and this will be their only way of making a living from it. Rather like a factory conveyer belt, only the commodity is people.

As the demand for medical services has risen, appointment books have become more crowded and operating lists have grown longer to try and meet that demand. Looking from the outside, it may seem logical to think that these new recommendations would be a reasonable next step.

The trouble with this way of thinking is that it fails to take into account the fact that medical care is already too fragmented, and this fragmentation has come at a cost, particularly to the patients for whom we care. If anything, we need to move back to restoring medicine and medical education to its true whole, rather than looking to fragment it further.

At present, the family doctor is the one who holds all the fragments of medical care together for our patients. They refer to the specialists, coordinate all the information from the specialists, translate what the specialist said in two minutes back to the patient, and care for the patient as a person, making sure they are not missing the forest for the trees. Of course, this essential role is also being undermined due to the pressures of time and money, with doctors spending less and less time with each patient. But it does exist and is recognised as such.

It is now, apparently, being suggested that this central role is not needed, and that you can teach anyone a small amount of information in a short time and teach them to do one particular procedure or provide one particular aspect of medical care, and we could have people who are not doctors providing health care at a fraction of its current cost. Even suggesting such a solution shows a complete lack of understanding of what medicine is.

My father was a country GP in a group practice and he did practically everything – delivered babies, gave anaesthetics, took out appendices and set broken bones. He counselled individuals and families, gave lifestyle and relationship advice, and ministered to them at the end of their lives. There were not many people he had to send to the city for further care.

Medicine was much more simple and straightforward then. Many of the drugs we use now were not available then. But also, they were not needed so much. Life was more simple and straightforward too. People ate well, they exercised regularly (walking or cycling to school and work and playing sport) and they went to bed at a reasonable hour and rose with the sun.

In my lifetime, this situation has changed dramatically. Illness and disease have become more complex, multisymptomatic and multifactorial. The changes in our diet and lifestyle have had a dramatic effect on our health. The addition of high-fructose corn syrup to our diets and the peddled myth that fat is bad and sugar is good are just two factors that have led to an epidemic of obesity and related problems, such as diabetes and heart disease. The reduction in fresh whole food and clean water as our dietary staples, the reduction in exercise, and the increase in sedentary lives looking at screens have all added to our problems.

People are getting sicker at a younger age from lifestyle-related diseases, and we are now better at treating early-stage disease, while neglecting to modify the lifestyle behaviours that led to the disease in the first place. This is leading to an overwhelmed health care system, including in the bodies of the health care practitioners who are trying to treat all of us.

But the way forward is not to farm out individual procedures to try and reduce the burden of cost and increase service delivery. This will only increase the fragmentation of health care and the division between its practitioners and set up turf wars and price wars, all at the expense of the patients we are here to serve, as it fails to treat them as a whole person.

Most of us go into medicine because we care about people and want to care for them. Our current system of medical training no longer has this care as its primary focus though, either for us as carers or those we are training to care for.

If we truly care about dealing with the current epidemic of illness and disease, the way forward is very clear, although perhaps not easy.

We should be the beacons of light that inspire others to care for themselves, and we are not, because we don’t. Our medical training does not offer self-care and if anything it encourages the opposite – that we should care for people at our own expense, until we have nothing left to give – which is why we are currently experiencing an epidemic of anxiety, burnout and depression in the medical system.

It is very simple to learn to care for ourselves again, not in a tick-box way, but from the inside out. The tools of self-care are time-honoured common sense: eat fresh clean food, drink clean water, exercise regularly in a way that honours the body, go to bed early when you are tired, and in all aspects of life, deeply honour the body that carries you through it.

People like me, who have reconnected to this living way are open and willing to share it with anyone who will listen, and with the tools of communication we have available to us now – the internet, social media etc – it would not take forever to roll out a simple self-care program for health care practitioners and it would not cost the earth.

What it would take is a willingness to see that this is indeed a major part of the problem, and a willingness from us as health care practitioners to be a reflection of true self-care by living it ourselves, rather than the current model that operates from “do as I say, not as I do”.

We as practitioners have an enormous influence and reach. We see many people, every day, who come to us when they are vulnerable and open to change. If we were living and working in a loving caring way, that would offer them the living example that such a way is possible and the inspiration to reconnect to this lifestyle for themselves.

Doctors need to play a central role in health care, rather than being marginalised and devalued even further by these new recommendations.

Reducing the subjects we learn to a one-size-fits-all basic level for all health care professionals and shattering medicine into small pieces that we then teach in piecemeal fashion will leave nobody with a detailed overall understanding of the human body and how it works, or an overall knowledge of the person the body belongs to. This will not deliver the kind of medicine I want to be caring for me when I grow old and frail. How about you?

For too long we have been complacent in thinking that we can just do our job and go home and relax and everything will be okay, but it won’t be if we do nothing. We need to stand together, speak up and out.

We must choose to care for ourselves and each other and to stand together as a whole body of practitioners when it comes to issues such as the fragmentation of medical education which threaten to destroy our profession and the way it is practised. True change can only come from within. It starts with us.

Dr Anne Malatt is an ophthalmologist who works in Bangalow, northern NSW.


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9 thoughts on “Stop fragmenting medical education

  1. Anonymous says:

    Dr Malatt had better be careful she is not brought before the AHPRA Inquisition.

  2. Marcus Aylward says:

    Fine sentiments which are hard to contest, but which butt up against a reality of increasing sub-specialization within medicine, both as the knowledge pool increases and as patient expectation (with medico-legal risk as a fellow traveller) demands that only the best is good enough. Care is thus increasingly episodic and fragmented.
    As a GP today Anne, your father could no longer practise as he did: a holistic approach now may equate to a less medical expert approach. One might need patient consent for that.

  3. Dr Karen Price says:

    As a GP I find Marcus Aylwards comments curious. On what standing of expertise does he have to make a judgement that providing holistic care is less than expert care. He seems to have a poor regard for the specialty of family medicine. I am wondering how he feels able to comment in such a manner? Does he have lived experience of General Practice or specialty training in it? Am I reading that curious comment incorrectly ?
    I would reference his comments to the large body of literature on the best health care systems in the world are based on a strong and vigorous primary care sector.

    Start here.

  4. Anonymous says:

    High Fructose Corn Syrup? In Australia? Try again Doctor.

  5. David Henderson says:

    This proposal is serious threat to the professional practice of medicine and ultimately to the quality of health care in Australia. The proposal is not justified in any way other than it extends the range of regulation to medical education and training as laid out in the National Regulation and Accreditation Scheme, which has given us AHPRA and by the claim that it will introduce efficiency into the health system.

    The major threat in these proposals is that it will eventually give control of the professional medical knowledge to a government via an agency, probably AHPRA. Government bureaucracies are not known for their progressiveness or innovation and it is likely that curriculums and training programs will become rigid and fall behind world standards. This is evident in the intention to limit knowledge to that which is considered appropriate by the government, not only making learning conform to government policy , but explicitly limiting knowledge and training to that perceived by the agency to be appropriate to the roles of health professionals. There is a serious proposal to review pre-registration internship and some aspects of post graduate training, which is one of the great strengths of the Australian system, with a view to eliminating it. The opinion is that graduates should be ready for practice, as GPs, psychiatrists, cardiac surgeons? These proposals show a significant lack of knowledge of medical education and training and the increasing requirements for more knowledge in everyday medical practice. They are the direct opposite of the need for continued innovation and development that characterises the competitive contemporary world. There is no doubt that poor and/or ignorant practice is more expensive than the reverse. I recently treated a young and previously healthy young person who had suffered serious neurologic damage by cervical manipulation, regardless of the fact that this is a recognised complication. The cost to that person and to the system far outweigh the costs that appropriate treatment would have generated.
    I am sure that Professor Woods would be outraged if it was considered that a graduate would be suitable for a senior position in a health economics department.

    The other and probably more serious threat is that these proposals will transfer control and “ownership” of medical knowledge to the government. In any professional organisation or service there is a tension between management, which controls the resources and the professionals who deliver the services to people. The professionals have knowledge that the management does not possess and this allows the professionals to provide services according to their knowledge and experience. This situation is very different from the situation in public or private bureaucracies, where the knowledge is owned by the management and workers act according to the rules and regulations dictated by the management.

    Governments and bureaucrats, who have different imperatives from doctors see the health system as messy, as indeed it is. They would like to see a bureaucratic system, where doctors are employees, bound by rules and regulations, protocols and practice guidelines and unable to deviate from the commands of the management. But the “messy system” has delivered a standard of health care that is high by international standards. Freedom of thought, professional discretion, I.e. the ability to read according to knowledge, diversity and ability to communicate and discuss principles and practices have contributed to a “system” we can be proud of. Professor Woods’ proposals will not improve it.

  6. Gil Anaf says:

    Dr Malatt’s argument is articulated well, including (or especially) the need to be united and on the front foot. It may not be widely recognised, but there is an arguable case to be made that the profession of Psychiatry succumbed to this fragmentation type of policy years ago. The Govt argued that psychiatrists were an expensive resource, and that much of what they routinely did could be outsourced to lesser paid workers. This was / is the so-called “consultancy model” of psychiatry, where psychiatrists “consult” and then refer on to others, while “overseeing” treatment (by GPs, psychologists etc). Patients routinely complain that mental health services have never been in such a mess. My own view is that it is due to this same policy setting Dr Malatt warns about. Governments love it when they see a mess they can then blame someone for – because all the while, care decreases along with costs, since effective care is seen as a cost rather than an investment. I’m sorry to say, in my view, psychiatrists fell for it. I doubt being regulated by AHPRA is in any way a good way to go when it comes to training.

  7. Marcus Aylward says:

    Dr Price has taken exception to my comments on holistic care and wonders about my ‘standing’. Opinions can be offered without deference to ‘arguments-from-authority’, and ‘lived experience of General Practice’ is not an exclusive accreditation to allow comment.
    If she will allow my error in not acknowledging ‘holistic care’ as a specialty in its own right, then she might also acknowledge that ‘comprehensive’ care as practised by Dr Malatt’s father is no longer realistic.
    The role of the family physician has changed, and that provision of holistic care more often now also involves appropriate referral to specialists – unless she is suggesting that GPs can achieve equal outcomes in cataract surgery, colonoscopy, knee replacements, laparoscopic cholecystectomy etc.

  8. Anne Malatt says:

    Hi everyone,
    Marcus, I am not for a moment suggesting we return to some mythical ‘good old days’ where the GP does everything…we lived in a small country town and my father just happened to be interested in and excellent at surgery. The point I was making was that it was possible then, because people lived more simply and illness was generally more straightforward, and that in my opinion, our way forward is to start dealing with the collective problems we face by looking at our lifestyles, not by further fragmenting medical education and practice, and especially not by allowing it to be taken over by a government bureaucracy.
    But while we continue to undermine and criticise each other and focus on tiny details to pick on, rather than looking at the big picture, that is what may well happen…

  9. Graeme Ness says:

    As a Patient who was a chaplain in a major hospital, I know the need for doctors to look after themselves. If they don’t, how can they care for their patients? The old argument that a doctor should be able to function efficiently for many hours in one stretch, suggests a system that would have truck drivers banned from the roads for breach of regulations. In the past, doctors have appeared to believe that they are stronger.
    I react strongly against the idea of a bureaucrat determining what a doctor can do to care foe her/his patients. The well trained doctor who sees his patient as a whole person, is far more likely to produce the best results for their patients. You only need to see what Governments have done to Centrelink, making it harder for people to access the system, as they have fragmented the process, waiting hours on the phone to talk to someone; or rely on an on line system system system, which might work, but might not respond properly for months to see what could happen to doctors and medicine.

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