Over the next three years in Australia, some significant changes will occur to the medical training system here. One of these important changes will be to the Australian medical internship system or, more correctly, the prevocational training system. The prevocational training system in Australia covers the first two years after graduation from medical school. In this post, I will summarise the case for change for the medical internship in Australia. And in a later post, I will provide an overview of what those intended changes will be.
TL:DR
The medical internship system in Australia has been largely unchanged since the 1990s when accreditation bodies were formed to oversight internships, and it was determined that completion of an internship required satisfactory completion of a 12-month provisional year experience, including mandatory core rotations in medicine, surgery and emergency medicine. Since that time, much has changed in the internship or prevocational training space: our healthcare systems and needs have changed markedly, as has the broad approach to medical education and training.
Stakeholders have concurred that the current system is not fit for purpose as it does not provide enough supervision, feedback and assessment and lacks focus on crucial issues such as the professional development and wellbeing of interns; skills in communication, feedback and patient safety; exposure to non-acute and community type experiences; and leaves a large group of doctors, the resident or PGY2 doctors, unsupported with no training or accreditation authority to protect their needs and interests.
Prevocational Training in Australia.
The two years following medical school graduation are generally agreed to be the prevocational medical training period in Australia (and New Zealand). This definition is somewhat arbitrary for a couple of reasons.
Firstly, historically, the medical internship in Australia has been given a special status as a provisional year undertaken after graduating and before being granted general registration.
According to Geffen (2014) the internship was gradually introduced by state and territory medical registration boards between the 1930s and 1970s in Australia. It was initially “intended to be a period of apprenticeship with little formal educational structure when junior doctors progressed under supervision from ‘knowing’ to ‘doing’.”
It is for this reason that the Australian internship system is largely off-limits to anyone other than a graduate from an Australian (or New Zealand) medical school.
IMG doctors can generally not apply for intern programs or internships in Australia. Rather than try to intern in Australia they should generally look for resident medical officer jobs.
Secondly, the immediate period after an internship in Australia has also evolved. Before the reforms to General Practice Training in the 1990s, a doctor could work as a general practitioner after gaining their general registration.
Since the advent of vocational registration for general practice and its recognition as a specialty in its own right, we have seen the postgraduate year 2 (PGY2) period evolve into a largely hospital-based year and sometimes extend into a PGY3, PGY4, PGY5 or more period before doctors being able to enter specialty training.
The prevocational medical councils also have had a variable stance on supporting PGY2 doctors. Leading to a concern about a “lost tribe” of trainee doctors who are not protected or supported by an accreditation or training body.
The Current Status of Internship in Australia
The nature of the medical internship in Australia has mainly remained the same since the 1990s when I completed my own medical internship.
Beginning in 1982 with the Postgraduate Medical Education of Council, bodies were formed in the States and Territories to accredit hospitals to be allocated interns to ensure that the interns were well supervised and that the care they were involved in was safe (Geffen, 2014). By 2000 all States had a form of prevocational medical education council with the 2 Territories being served by other State councils.
Around this time, the nature of the modern internship in Australia took shape. The internship experience and assessment process revolved primarily around the satisfactory completion of 5 rotations of 10 to 11 weeks duration. Within these rotations, each intern was required to complete a term in a medical unit, a term in a surgical unit and a term in emergency.
This intern experience has continued to the modern day with few modifications. Some jurisdictions have trialled a 4 term system and some prevocational councils have extended their accreditation approach through to the PGY2 resident year. Requirements to attend an educational program have been brought in. But the key requirements to complete internship and be able to move on to general registration, i.e. completion of a satisfactory 12 months with core rotations in medicine, surgery and emergency have remained.
So What Is Wrong with the Status Quo of Internship in Australia?
In 2014 in recognition of growing concern about the fitness for the purpose of the Australian intern system the Council of Australian Governments – that’s all the State and Territory and the Federal Government commissioned a review of internship in Australia.
The final report in 2015 made a case for change for internship in Australia. There were inconsistencies in the quality of training across different states and territories, leading to disparities in the level of competency and preparedness of interns.
Problems with workload and professional development for current Interns
The report identified high workloads and long working hours experienced by medical interns, limited opportunities for professional development and a lack of focus on essential communication and handover skills, which are needed to ensure safe and effective care of patients.
Interns being exposed to the wrong sorts of experiences
The report also noted that general practice is a critical area of need in Australia, given the aging population and the high prevalence of chronic diseases and that the current internship system failed to focus on chronic disease management and community-based care, which is where the bulk of health care is provided in Australia.
The internship period is when most trainee doctors select a specialty to focus their careers on. So by focusing the internship experience on acute and specialised medical and surgical care, interns were not adequately exposed to several specialties where there was a need for more trainee doctors, such as general practice, general medicine and psychiatry.
Problems with assessment, feedback and supervision in Internship
The report also highlighted the lack of adequate supervision and feedback in the internship program and that the current assessment process lacked standardization. The report also highlighted the need to improve the quality and consistency of feedback provided to medical interns to help them identify areas where they need to improve and to support their ongoing learning and development.
Indeed when I was the Medical Director of the Health Education and Training Institute between 2012 and 2016, we were aware that the current supervisor rating reports for interns provided very little discrimination in rating interns’ performance and were not identifying underperformance (Bingham, Crampton 2011).
Furthermore, the report recommended that the assessment process should be redesigned to focus more on the development of skills and competencies, rather than just the acquisition of knowledge. The report suggests that this could be achieved by adopting a more competency-based approach to assessment, which would involve defining the key skills and competencies that medical interns should possess upon completion of the internship program and assessing their progress towards these goals throughout the program.
The suggestion is that improvements to the assessment process were necessary to ensure that medical interns receive the support and feedback they need to develop their skills and competencies and provide high-quality care to patients.
What About PGY2 Doctors?
The final report also briefly discussed the postgraduate year two (PGY2) training and highlighted concerns regarding the current system. Specifically, the report noted a lack of consistency in the structure and content of PGY2 training across different states and territories in Australia. The report recommends that the PGY2 training program should be standardized across the country and that there should be a focus on ensuring that doctors receive appropriate supervision, feedback, and opportunities for professional development during this period.
The Medical Training World Has Moved On.
Suppose you are a medical student and you are reading this post. In that case, you are probably thinking that the current internship system in Australia is pretty archaic and very dissimilar to how you are taught and assessed as a student.
And indeed, much has changed in other countries in this time. Internship programs in the United Kingdom, New Zealand and Canada are examples of programs that have successfully addressed some of the challenges faced by the Australian system.
For example, the United Kingdom has implemented a foundation program, a two-year training program for medical graduates that includes rotations through various clinical specialties, as well as a focus on developing generic skills such as communication, teamwork, and leadership.
Canada has been even more radical in this time by dispensing with the internship altogether.
Finally, New Zealand has implemented a competency-based internship program that focuses on the development of specific skills and competencies rather than just the acquisition of knowledge.
There is much that Australia can learn from these international examples, and a more innovative and flexible approach to medical intern training is needed to ensure that medical graduates are well-prepared to meet the changing needs of patients and the healthcare system.
Even within Australia, we have seen major reforms to medical school and specialty training. In particular, a focus on more frequent feedback and greater, lower stakes in-training assessments. Adopting the same competency-based model that the Final Intern Review Report recommends.
Conclusion
It would be foolish to hold on to a system designed in the 1990s for a much different world than today. Especially when so many stakeholders have advocated that the system is no longer fit for purpose. Much has changed both in healthcare and the health and well-being needs of our nation. There have also been many changes to education and technology at this time.
Bringing Resident (PGY2) doctors under an accreditation system will go a long way to ensuring that fewer trainee doctors are left exposed to the whim of hospitals, providing “service” jobs and working unsafe rosters. There will still be other “unaccredited trainees” and SRMOs remaining who also require a body to protect their needs and interests. But. this step is a much-needed reform.
A change to the philosophy (pedagogy) of internship training and assessment has the potential to bring improvements to patient safety, the satisfaction and well-being of interns and intern preparedness.
A positive for the suggested change in model is that most other components of the Australian medical training system have adopted competency-based medical education already. So the approach and tools will be familiar to most.
I wholeheartedly agree that we need better to align the career aspirations of medical graduates with population needs moving away from expensive models of patch-up acute care to community-based preventative and primary care. Exposure to non-traditional intern rotations, including working in chronic care and community care, will hopefully help to sway the minds of some.
But it is essential to recognise that the intern or prevocational training system is only one piece in a much larger medical training system, many components of which have an investment in maintaining the status quo model of health care delivery.
The devil lies in the details of the proposed changes and their implementation.
References:
- Geffen, L. (2014). A brief history of medical education and training in Australia. Medical Journal of Australia, 201(S1). https://doi.org/10.5694/mja14.00118
- Wilson, A., & Feyer, A. M. (2015). (rep.). Review of Medical Intern Training: Final Report. Council of Australian Governments.
- Bingham, C. M., & Crampton, R. (2011). A review of prevocational medical trainee assessment in New South Wales. The Medical Journal of Australia, 195(7), 410–412. https://doi.org/10.5694/mja11.10109
