ACADEMY OF CLINICAL EDUCATORS UNIVERSITY … · ACADEMY OF CLINICAL EDUCATORS UNIVERSITY OF NEWCASTLE Doherty to NRAS: A 30-year Review of Medical Education from an AMC Perspective

ACADEMY OF CLINICAL EDUCATORS

UNIVERSITY OF NEWCASTLE

Doherty to NRAS: A 30-year Review of Medical Education

from an AMC Perspective

Ian Frank AM

Chief Executive Officer



INTRODUCTION

• AMC major role development of standard for medical education since establishment (1985)

• 30 years at AMC – 27 as Chief Executive

• Previously 12 years University of Adelaide – 6 as Assistant Registrar (Medicine) – Faculty Executive Officer

• Career bookended by Doherty Report (1988) and Woods Accreditation Services Review (2017)



DISCLAIMER

Views, reflections and opinions expressed

are mine and not necessarily the

official position of the Australian Medical Council



PRESENTATION

• Changing Context of Medical Education – Then and Now• Doherty Report 1988• Milestones in Medical Education

– Graduate Entry Challenge– Medical Workforce and New Schools– Off-shore medical courses– Advent of the M.D. Degree

• Accreditation of Specialist Training• Medical Education under NRAS• Woods-Carver accreditation system review• Future Challenges for Medical Education



1988

• 10 Medical Schools

• All direct entry (matriculation)

• All Bachelor Degree programs

• All Commonwealth funded positions

• Duration: 7 x 6 year /3 x 5 year

• Course structure:

8 x pre-clin science/clinical

2 x integrated courses

• Approximately 1200 graduates per year



1988

• 10 Medical Schools

• All direct entry (matriculation)

• All Bachelor Degree programs

• All Commonwealth funded positions

• Duration: 7 x 6 year /3 x 5 year


8 x pre-clin science/clinical

2 x integrated courses


2017

• 21 Medical Schools -39 Programs(+ 2 NZ)

• 14 direct entry – 25 graduate entry

• 18 Bachelor/18 Masters/3 Combined

• Mixture of Govt. funded and full fee

• Duration:– Bachelor 9 x 4yr/1 x 4.5yr/5 x 5yr/3 x 6yr

– Masters 1 x 3yr/13 x 4yr/2 x 5yr/2 x 6yr

– Combined 1 x 4yr/2 x 5yr


- All integrated programs

- Variety of clinical settings




BACKGROUND TO AMC / PRE-HISTORY

• Decades prior to 1970’s no significant changes in medical education in Australia

• 1973 Karmel Report finds medical education inward looking not responding to community needs – concerns with student selection

• Two new schools established – Flinders (1972) and Newcastle (1978)

• Commonwealth funds community medicine and clinical pharmacology

• Narrow settings for clinical training (1980’s SA experience – reluctance to move out of major teaching hospitals)

• Decision to establish the AMC – an accreditation not registration decision – GMC withdraws from overseas accreditation when UK joins EU



DOHERTY REPORT 1988

• Commissioned by Minister Blewett 1987 – reported in 1988• Recommendation not implemented BUT major impact on medical education• Multi-disciplinary team – chair by Professor Ralph Doherty – PVC Health Science

UQLD• Wide ranging recommendations for undergraduate, pre-vocational and specialist

training, including:– Regular curriculum review – Self-directed learning– Community involvement– Expanded settings for clinical training– Innovation in student selection

• Defined knowledge, skills and attitudes to prepare student for life-long learning• Controversy over 2 year internship proposal – only one State supported (NSW)



SPECIFIC EXAMPLES OF DOHERTY RECOMMENDATIONS• Innovation in medical education

5(i) The Medical Schools be encouraged to develop innovative programs, including development of curricular material and staff development, to foster an inquisitive and self-directed approach to learning

• Assessment and medical education

5(vii) Assessments be designed to reinforce educational objectives…..

• Team-based training

6(xi) Strategies to develop team approaches to patient care with other health care professionals be identified and such approaches become a core component of the training program. The trainee should understand how such health professionals work in hospitals, community settings and private practice



INITIAL AMC ACCREDITAION PROCESS• First accreditation UQLD March 1988 led by Professor John Hamilton

• GMC Accreditation Guidelines used - Doherty Report outcomes not available

• Key principles of AMC approach to accreditation:

– Quality improvement not just quality assurance

– Diversity of medical education critical

– Universities and Medical Schools must retain academic independence

• Critical component AMC accreditation process:

– self assessment by Medical School prior to accreditation

– accreditation becomes external validation of self assessment

– Medical School has ownership of process



INITIAL AMC ACCREDITATION PROCESS

• U QLD not unqualified accreditation – conditions imposed to address concerns identified by AMC team

• Major concern for Council and the President – who was Director General of QLD Health at the time:

I came to the conclusion that if the council didn’t maintain standards it had set at the start for national accreditation, then we could forget the whole thing. I felt that we had to establish the standards and implement those standards without flinching from the difficulties we encountered into this foray into the unknown.

(Dr. Peter Livingston AO Foundation President 1985 -1988)



MILESTONES IN MEDICAL EDUCATION – AMC PERSPECTIVEGraduate Entry Challenge

• New AMC accreditation guidelines 1992 (Larkins 1991-95) incorporate Doherty findings• Consortium 3 Medical Schools – Flinders / Sydney / Queensland propose graduate entry

into integrated curricula – based on problem-based learning • Major challenge for AMC – new curricula and programs not fully developed – required

multiple reviews by AMC before full accreditation gained.• Accreditation outcomes:

– Flinders accredited 1995 (commenced 1996) -Sydney accredited 1996 (commenced 1997)

– Queensland – accreditation team found University not ready for graduate entry program – following extensive consultation accredited to commence 1997 –further AMC review until full program implemented.

• Challenged AMC to respond to new developments and major curriculum re-structuring.• Graduate Entry Proposals – sees greater collaboration between the schools on

curriculum development and student selection (GMSAT)



MILESTONES IN MEDICAL EDUCATION – AMC PERSPECTIVE

Medical Workforce and New Medical Schools

• 1997 AMC considers proposal for new Medical School at James Cook University –first new school in 25 years – complex accreditation – new course commenced 2000

• 2000 Government debates medical workforce:

– Failing recruitment to rural and remote areas

– Indigenous health issues

– 2002 report of Australian Medical Workforce Advisory Committee – projected deficit in Australian trained practitioners



MILESTONES IN MEDICAL EDUCATION – AMC PERSPECTIVEMedical Workforce and New Medical Schools

• Commonwealth relaxes restrictions on numbers – proposals for new schools increase:– The Australian National University 2003– Griffith University 2004– Bond University (first private university) 2004– Wollongong University 2006– University of Western Sydney2006– University of Notre Dame Australia

• Fremantle School 2004• Sydney School 2007

– Deakin University 2007• Rapid expansion new course presented challenges to AMC – need to change processes

to accommodate phased implementation of new programs.




Off-shore Medical Courses

• Early proposals for AMC to accredit off-shore courses by Australian Universities rejected

• Medical Deans vocal in opposition- concern automatic registration of graduates if off-shore courses accredited

• Post-2000 major advances in medical education globally – global standards for basic medical education developed by World Federation for Medical Education (WFME) adopted by AMC


from and AMC Perspective

MILESTONES IN MEDICAL EDUCATION – AMC PERSPECTIVEOff-shore Medical Courses

• 2005 Monash approached AMC with proposal for the delivery of its medical course in Malaysia through Monash Malaysia campus

• Course not differentiated from Monash Australia programs• Clinical training in Australia• Involvement of Monash staff in Malaysian program

• After review by Council Monash off shore program approved 2006• Subsequent off shore programs approved:

• UQLD / Ochsner Health Louisiana USA 2010• Macquarie University / Apollo Health Hyderabad India 2017

• Each proposal different challenges to ensure clinical training appropriate to Australian context




Advent of the MD Degree

• 2005 Melbourne University major change to degree structure focus on professional and Masters programs - “Melbourne Model”

• Proposal for Master degree program entry qualification for medicine and award Doctor of Medicine (MD) – internationally recognized qualification

• 1995 Australian Government introduced Australian Qualifications Framework (AQF) national policy for regulated qualifications – administered through Commonwealth and State Education Ministers – implications for new education programs:

– Level 7 – Bachelor Degrees broad knowledge skills for professional work

– Level 9 – Masters Degree – specific knowledge and skills for research professional practice and further learning

• Now AQF and AMC accreditation requirements had to be met




Advent of the MD Degree

• Melbourne MD program accredited to commence 2011

• Triggered a rush to convert existing programs to Masters Degree (MD) programs -18 Masters and 3 Combined Bachelor/Masters submitted for accreditation

• Challenges include:

– Capacity of programs to support expanded research component

– Potential trade off – research vs clinical training

– Greater problem for 4 year degree conversion than 5 or 6 year degree conversions

• Was the push to the MD educationally justified or marketing strategy?




Accreditation of Specialist Training

• 1999-2000 demise of NSQAC – AMC asked to develop new specialist recognition process

• Accreditation of specialist training component of new recognition process–adopted by AMC 2001

• Voluntary participation by existing Specialist Colleges until NRAS 2010

• New process based on Medical School accreditation principles and CanMEDScompetencies

• Impact of ACCC intervention – saw benefit in AMC accreditation

• Early accreditation findings on assessment – disconnect between curriculum planning and assessment

• Involvement of trainees critical part to specialist accreditation



MEDICAL EDUCATION UNDER NRAS

• NRAS implemented 2010 – following recommendations of 2005 Productivity Commission:

– Single national registration system for 10 registered health professions (extended to 15 now 16 professions)

– Single legislative framework for all professions – accreditation of education and training programs now regulated – includes basic / prevocational and specialist training

– AMC required to report on accreditation against approved standards



MEDICAL EDUCATION UNDER NRAS• Prior to NRAS AMC adopted Graduate Outcomes Statements developed by

Medical Deans – included in approved accreditation standards for NRAS:– Graduate Outcome Domains:

• Science and Scholarship• Clinical Practice• Health and Society• Professionalism and Leadership

– NRAS Accreditation Standards1. Context of the Medical Program2. Outcomes of the Medical Program (Graduate Outcomes)3. Medical Curriculum4. Learning and Teaching5. Assessment of Student Learning6. Monitoring and Evaluation7. Students8. Learning Environment



MEDICAL EDUCATION UNDER NRAS• Standard 8: Learning Environment:

– Physical Facilities– Information Resources and Library Services– Clinical Supervision– Clinical Learning Environment (example of detailed standards):

• Sufficient patient contact to prepare for clinical practice and appropriate to outcomes of program

• Diversity of clinical settings and clinical experience• Culturally competent health care• Actively engages other health professionals

• Major additional requirement under NRAS – Section 50 monitoring– Must set conditions to ensure program meets standards– Must terminate program if standards not met

• AMC now sets conditions on accreditation of programs - 340 possible conditions covering all standards



WOODS ACCREDITATION SYSTEMS REVIEW

• Health Ministerial Council commissioned review of NRAS – erroneously found cost of accreditation processes excessive - initiated further review of accreditation systems.

• Mike Woods formerly 2005 Productivity Commission and Peter Carver formerly Victorian Department of Human Services appointed to conduct second review

• Draft Report recommends:– Accreditation standards developed by Accreditation Councils– Standards signed off by new Board within AHPRA – 10 member Ministerial

appointments– Greater regulation and central control of processes

• Health Professions oppose proposed changes – seen as further reduction of involvement of health professions in standards of training

• Report now with Health Ministers



FUTURE CHALLENGES TO MEDICAL EDUCATION

• Team-based Practice And Training

– Universities in position to take lead

– Engagement of other health professions

– Needs engagement of jurisdictions/health services

• Medical Workforce Issues

– Disconnect between graduate numbers and specialist training

– Dangers of a “Lost Tribe” developing if appropriate training and development opportunities not available

– Potential of negative impact on peer relationships due to intense competition for specialist training



FUTURE CHALLENGES TO MEDICAL EDUCATION

• Commercialisation of Medical Education

– Major change in funding model – high dependence on fee paying students

– MD experience

– Potential impact on integrity of assessment – negative assessment outcomes challenged

• Student / Trainee Wellbeing

– “Sleeper” issue for clinical education

– Change in community attitudes to bullying and harassment

– Potential negative impact on engagement of clinical supervisors and teachers

– Imperative to engagement of students and trainees in solution



CONCLUSION

A Personal PerspectiveMedical Education will continue to thrive and respond to the many challengesthat it will face, not because governments or bureaucracies will be able to seethe solutions to the problems, but because of the quality and commitment ofthose involved in providing medical education and the remarkable studentsand trainees that take up the profession of medicine.



Thank You

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ACADEMY OF CLINICAL EDUCATORS UNIVERSITY … · ACADEMY OF CLINICAL EDUCATORS UNIVERSITY OF NEWCASTLE Doherty to NRAS: A 30-year Review of Medical Education from an AMC Perspective