Review of medical intern training: improving quality and co-ordination
The medical internship is a cornerstone of Australia’s system of high-quality, generalist medical education and is a longstanding practice in medical education systems worldwide.
In the past five years the internship has come under significant professional, educational and political attention with the creation of registration standards, national accreditation frameworks, consistent assessment processes and outcome statements. As a consequence, what constitutes the essential internship experience is much better defined now than in the past.
However, a hallmark of a healthy medical education system is one that looks continually to improve quality of its graduates, and is responsive and accountable to the needs of the profession and the community.
At the Standing Council on Health meeting in April, the nation’s Health Ministers ordered a review of medical intern training to examine the current model and consider potential reforms. This is a significant opportunity for recommendations to improve the quality and coordination of medical training in Australia.
First, in the wake of increasing numbers of medical graduates and a desire for these graduates to embark upon generalist careers, now is the time to examine opportunities for, and barriers to, training in expanded settings.
In recent years there has been much progress in achieving a better balance of training interns inside and outside of the clinical departments of the various Royals and Saints. Interns currently have the opportunity to complement their essential medical, surgical and emergency medicine terms with general practice and, in some pioneering centres, system improvement and academic terms.
The loss of the Prevocational General Practice Placements Program, abolished in the May budget, is a significant setback to this progress. Promisingly, some State governments have committed funding to maintain placements supported by PGPPP funding.
While there are limits to the experiences that can be delivered outside of the inpatient teaching hospital setting — medical and surgical inpatient terms are very difficult to deliver in a manner that provides the experiences required for the development and consolidation of safe and comprehensive medical knowledge — there is clearly benefit in delivering training to as many interns as possible in community, academic, system improvement and other non-traditional settings.
The second target for the review should be the coordination and governance of the medical training system – specifically, the interaction between medical school, internship and further training.
The rapid growth in medical school intakes and the subsequent challenge to place increasing numbers of interns and prevocational and vocational trainees in quality positions, clearly illustrates the need to better coordinate each stage of training. The consequences of failing to train sufficient graduates to meet the future needs of our health system are significant and well documented.
Concentrating on the ‘intern crisis’, a dangerously simplistic answer would be to ‘solve’ the problem by abolishing internships and moving to a US-style system of progression from medical school directly to vocational training.
While perhaps attractive to advocates of shortened training pathways, the inevitable negative effects on generalist skills and the fragmentation of patient care significantly outweigh any benefits.
The review needs to examine governance of the training pipeline and recommend reforms that give teeth to policies that are based on the best available national workforce planning data. The long-awaited National Training Plans are essential for the effective coordination of our medical training system.
In the meantime, accepting that government and non-government bodies across multiple jurisdictions each manage various parts of the medical training system, data collection and the allocation of trainees must be improved through nationally coordinated systems for application, offer and acceptance of prevocational positions.
Phase one of the review was due to start in the second half of this year. The AMA Council of Doctors-in-Training will be active in advocating for it to make the most of its opportunity to improve the quality of Australian medical training.