Medical education in Australia

Medical education in Australia includes the educational activities involved in the initial and ongoing training of Medical Practitioners (doctors) in Australia. Medical education begins in Medical School; upon graduation it is followed by a period of pre-vocational training including Internship and Residency; thereafter, enrolment into a specialty vocational training as a Registrar eventually leads to qualification and recognition as a fully qualified Specialist Medical Practitioner (such as that of a General Practitioner or Consultant Specialist).

The education and training requirements of medical practitioner from starting medical school to completing specialist training typically takes between 9 years to 14 years (or more) assuming full-time study and work, and dependent on the specialty choice and satisfying in-training requirements:

1. Medical school | 4 to 6 years
2. Internship | 1 year
3. Residency | 1 to 2 years (or more)
4. Registrarship | 3 to 6 years (or more)
5. GP or Specialist or Hospitalist | ongoing Continued Professional Development (CPD)

Medical education in Australia is facilitated by Medical Schools and the Medical Specialty Colleges, and is regulated by the Australian Medical Council (AMC) and Australian Health Practitioners Regulatory Agency (AHPRA) of which includes the Medical Board of Australia where medical practitioners are registered nationally.

Medical School

Entry into medical school and its successful completion allows the graduate to become recognised as a medical practitioner (doctor) and commence their post-graduate pre-vocational training. The aim of medical school is to teach basic medical knowledge and clinical skills to prepare the prospective junior doctor for safe and competent practice upon commencement of their internship. It remains one of the most highly competitive university programs to apply for.

Internship

Internship is a period of mandatory supervised general clinical experience. It allows medical graduates to consolidate and apply clinical knowledge and skills while taking increasing responsibility for the provision of safe, high quality patient care. Diagnostic skills, communication skills, management skills, including therapeutic and procedural skills, and professionalism are developed under appropriate supervision. Internship also informs career choices for many graduates by providing experience in different medical specialities including general practice, and providing a grounding for subsequent vocational (specialist) training.^[5]

The Medical Board of Australia has established the Intern Registration Standard. It defines the supervised intern (provisional registration year) training requirements that must be completed in order for graduates of Australian and New Zealand medical programs accredited by the Australian Medical Council and approved by the Medical Board of Australia to be eligible for general registration.^[6]

Graduates of these programs of study are required to hold provisional registration and to satisfactorily complete 12 months of supervised practice as an intern before being eligible for general registration. Whereby, general registration indicates that the practitioner has the skills, knowledge and experience to work as a safe entry level medical practitioner able to practise within the limits of their training.^[6]

Interns are required to perform satisfactorily under supervision in the following terms:

• at least 8 weeks that provides experience in emergency medical care
• at least 10 weeks that provides experience in medicine
• at least 10 weeks that provides experience in surgery
• a range of other approved terms to make up 12 months (minimum of 47 weeks full-time equivalent service).^[6]

There are usually four or five terms in an internship (between 10 and 12 weeks duration). Interns are required to complete three core terms in medicine, surgery and emergency care and other (non-core) rotations make up the balance of the intern year providing opportunities to explore additional areas of medicine and surgery, anaesthesia, psychiatry, paediatrics and less acute care such as rehabilitation medicine, palliative care, geriatrics and general practice.^[6]

Internships are positions facilitated and funded by both State Governments and the Commonwealth (federal) Government. In 2016, there were 3314 state-funded intern positions and 100 Commonwealth funded intern positions. With the increasing number of medical graduates, there have been concerns about the number of available internships.^[7]

Applications for internships are typically coordinated by the relevant State Government's Health Department through an annual recruitment campaign. Applicants have the opportunity to preference the district and/or hospital(s) they wish to be employed at, and are selected based on a combination of a ballot-based and merit-based system. The Australian Medical Student Association provides a yearly Internship Guide to help guide medical graduates in their application process, as well as providing general information about the different State and Territory Health systems and clinical opportunities available at the various hospitals.^[8]

Residency

Residency, for most doctors in Australia, is typically a further one or two years following internship spent working in the hospital (or occasionally, in community health settings) to gain more clinical experience in a range of settings with increased levels of responsibility. In contrast to medical education following the United States system, internship and residency in Australia are considered pre-vocational terms where doctors have yet to formally commence their training in a specific speciality.^[9] While some specialist medical colleges accept entrants after successful completion of internship or postgraduate year 1 (PGY-1), most prefer applicants to have completed at least a further 2 to 3 years (or more) of pre-vocational training at the level of a resident (PGY-2 to PGY-3 or more) in order to have gained sufficient additional clinical experience prior to applying for a specialist training program. Clinical rotations and terms are at the preference of the resident (and dependent on the availability of the health service); there are no mandatory terms to fulfill; for example, if the resident has aspirations to pursue enrolment in surgical speciality training, they would preference and request more rotations in the various surgical specialties (for instance, Neurosurgery, Cardiothoracic, or Urology), versus if the resident had interests to pursue emergency medicine, he would probably benefit from further rotations in the various critical care specialties (that is, ICU, ED, or Anesthetics).^[10]

During residency, these clinicians are known by a variety of terms, including but not limited to:

• Resident Medical Officer (RMO) or Senior Resident Medical Officer (SRMO);
• Junior House Officer (JHO) or Senior House Officer (SHO) or Principal House Officer (PHO);
• Hospital Medical Officer (HMO); or,
• Trainee Medical Officer (TMO).^[10]

Residents typically have general registration with the Medical Board of Australia; that is, having successfully completed internship in Australia.^[6] Whilst the Medical Board no longer requires performance reports to be submitted directly to them, it mandates and delegates the responsibility to the relevant hospital administration, post-graduate medical councils and speciality colleges, to ensure the continual support, education and teaching of their residents (and registrars) as well as ensuring routine performance reviews and term reports from senior clinicians supervising their practice.^[11]

Applications for residency is similar to that of internship, and is coordinated by the relevant State government through an annual recruitment campaign. Applicants have the opportunity to preference the district and/or hospital(s) they wish to be employed at, and are selected on a merit-based system which typically includes a review of the applicant's resume, interview, and referee reports.^[12][13]

Registrarship / Speciality Training Programs

Registrars or "trainee specialists" are doctors formally enrolled in a speciality (also known as 'vocational') training program. After completing internship and one or more additional years as a resident and meeting the pre-requisites for the relevant speciality college, doctors can apply for admission to a recognised medical speciality training program. This is the necessary training to obtain fellowship of one of the recognised specialist medical colleges, and allows a doctor to practice medicine independently and unsupervised in that relevant speciality field, and with this access to an unrestricted Medicare provider number and Medical Board specialist registration.^[10]

Selection into a speciality training programs are based upon merit and are highly competitive. Nowadays, most colleges require applicants to have previous clinical supervisors submit referee reports, and fulfil a number of criteria in their curriculum vitae which typically involve scoring the candidate in four domains:

1. Demonstrated clinical experience at the level of a resident or unaccredited registrar relevant to the speciality applied for
2. Academic excellence in addition to the basic medical degree including research publications and higher educational degrees
3. Pre-requisite completion of recommended workshops or courses, and if any, entrance examinations or assessments
4. Extra-curricular activities and merits that demonstrate a well-rounded individual ^[14]

Applicants with satisfactory CV are invited to partake in interviews or assessments that typically assess adequate medical knowledge to commence speciality training and explore psycho-socially if the candidate if suitable for the speciality.^[15][16]

Registrars pay an annual enrolment fee to be part of the speciality college (in addition to fees for exams and courses). In order to qualify for election to fellowship and specialist recognition, most specialist colleges have clinical, practical and exit exams, in conjunction with other assessments to assess the full range of skills and behaviours required as a doctor, such as communication and team work. Specialist training programs and examinations are administered by the individual colleges and vary between three and seven full-time years to complete, depending upon the speciality you choose. Part-time training is available to most specialities, and dual-speciality-training is optional and streamlined for some specialities. Vocational training for most medical specialities is undertaken in a public teaching hospital, however it increasingly includes rotations in private hospitals, regional, rural and community health settings. The exception is general practice, where doctors undertake most of their training in designated private general practices in a community setting.^[10]

Registrars are nonetheless employed and remunerated by the hospital at which they work for; and thus, are still required to submit an application for a position through the recruitment campaigns coordinated by the relevant State government's ministry of health. That said, some colleges help allocate employment and allocation to various training sites and hospitals to streamline the traineeship and employment obligations, whereas some colleges leave this entirely to the discretion of the trainee.^[10]

In Australia, the Australian Medical Council has recognised 16 medical speciality colleges responsible for the continued education, training, and accreditation standards of their respective specialities:

Hospitalists / Non-Vocational & Non-Specialist Doctors

In Australia, there is a subset of doctors which decidedly work as non-vocational non-specialist clinicians, who have completed prevocational training and usually some further (formal or informal) specialty vocational training. The reasons for this are varied, some of which include:

• doctors who do not have any intentions of specialising as a conscious career choice;
• doctors who do not or did not meet the requirements for specialty training;
• doctors who are intending to specialise in the future but not at this moment;
• doctors who have completed specialty training in a field (typically General Practice) but have decided to seek (additional or primary) employment as a non-specialist clinician;
• doctors who are concurrently in the process of specialising but additionally working as a non-specialist clinician elsewhere usually in the capacity of a temporary locum tenens.

Whilst not specialists per se, these clinicians are nonetheless experienced and senior in their years of medical practice. Depending on their scope of practice, they typically work with a reasonable degree of independence and autonomy, in addition to supervising junior medical staff; that is, themselves having completed an internship and typically worked at the level of a senior resident or registrar for at least several years thereafter.^[18]

These clinicians are known by a variety of terms, including but not limited to:

• Career Medical Officer (CMO)
• Senior Medical Officer (SMO)
• Multi-skilled Medical Officer (MMO)
• Hospitalists or Non-Vocational / Non-Specialist Hospital Doctors
• Non-Vocationally-Registered General Practitioner (Non-VR GP) ^[19]

These clinicians are typically employed in a variety of public and private hospital settings on a contractual or salaried basis. The responsibilities and renumeration of non-specialist hospitalists are usually comparable to somewhere between registrars and consultants, dependent on their place of employment. Despite the common trend for clinicians to specialise nowadays, non-vocational clinicians have an important role in fulfilling shortages in the medical workforce, especially where there is an area-of-need or after-hours where specialist coverage or accessibility is unavailable. These clinicians and employed across Australia in a variety of environments which include Community Clinics, Medical & Surgical Wards, Intensive Care Units and Emergency Departments. Nonetheless, these clinicians work closely and continually consult with the relevant attending specialists on-call; that is, final responsibility and care for the patient ultimately still rests with the attending specialist.

It should be noted that General Practice is now formally a speciality of its own with formal vocational specialist training. That is, those wishing to practice as a GP without vocational specialist registration can only do so in designated areas-of-need (such as that of rural townships) and at the compromise of only been able to invoice for non-specialist Medicare rebates. The exception to this are those who were grandfathered as already working as GPs prior to 1994. Non-specialist doctors are issued a restricted Medicare provider number.^[20]

The Australasian Society of Career Medical Officers (ASCMO) and Australian Salaried Medical Officers Federation (AMSOF) are organisations that represent this group of medical practitioners. Despite been non-vocational and non-specialist clinicians, they are still required to meet continuing professional development requirements and frequently attend courses facilitated by these organisations and the hospitals to keep their practice and skillsets up-to-date alongside their vocationally trained colleagues.

Consultant Specialists & General Practitioners

Upon completion of the prescribed specialty training program by the relevant medical specialty college, doctors are awarded a fellowship of that college and eligible to register and be recognised as a specialist with the Medical Board. These clinicians are considered to have satisfied all the necessary education and training requirements to become qualified for that specialty. Those with specialist registration are allowed to practice independently and unsupervised in their area of expertise, which in effect allows them to pursue private practice. Specialist clinicians are eligible for an unrestricted Medicare provider number that allows clinicians to bill rebates from Medicare for services delivered to patients, privileges for hospital admissions and private health fund billings, where most patients in Australia are a mixture of publicly covered Medicare and privately insured through a health fund. Whilst most specialist clinicians take the opportunity to pursue private practice, many of them (with the exception of a majority of GPs) continue to work at least part-time as salaried employees in the state public hospitals. There is also an opportunity for specialists partake in hospital administration to take-up committee or managerial positions, such as director of their department or the hospital or health service, as well as been actively involved in the education and supervised training of their junior colleagues.

Specialists are typically now recognised by their specialty profession name; for example, Radiologist, Pathologist, Haematologist, Nephrologist, Neurologist, et cetera. Physician broadly refers to those who specialise in any of the internal medicine sub-specialities. Surgeon broadly refers to those who specialise in any of the surgical sub-specialities. Doctors which have completed their specialist training are known by a variety of terminology, including but not limited to:

• Medical Director
• Consultant
• Staff Specialist
• Visiting Medical Officer (VMO)
• Senior Medical Officer (SMO)
• GP-Specialist or Vocationally-Registered GP (VR GP)

As of 1995, General Practice in Australia has been formally recognised as specialists by the Medical Board with its own vocational training pathway; its specialised role in health care is that of providing primary medical care to the community and comparable to that of specialist family physicians as in the United States and Canada; that is to say, a properly trained and qualified GP should be able to independently diagnose and treat a wide variety and range of illnesses in the primary care setting prior to referral to their specialist colleagues. That having been said, the term 'specialists' more colloquially and traditionally refers to clinicians qualified in a specialised field of medicine outside of the scope of General Practice. Medicare also makes this delineation for the purposes of appropriately allocating referrals, rebates and billing amongst "non-VR" GPs versus "VR" GPs versus Specialists. Medicare requires that patients attend their GP as their primary point-of-care, and in order to access Specialist care, the GP has to initiate and provide a referral.

Specialists (including VR GPs) are required as part of their specialist registration to partake in activities throughout the year ensuring their continued professional development (CPD) which is monitored and facilitated by their respective specialty medical college.

Additionally, while there is no requirement to do so, some clinicians at this stage of their career may consider further education (that is, if they have already not done so):

• Higher research or education degrees (such as Masters or PhD) or co-joint academic position at a university
• Fellowship placements (such as a neurosurgeon spending a year as a fellow in paediatric neurosurgery)
• Sub-specialisation (such as an emergency physician sub-specialising in toxicology)
• Second specialty qualification (such as an anaesthetist attaining a second-qualification to become an Intensivist)

Continuing Professional Development (CPD)

Continuing professional development (CPD) ensures clinicians remain up-to-date and evidence-based in their medical practice.

Medical practitioners with specialist registration, and those with general registration enrolled in a formal speciality training program, must continue to meet the CPD requirements set out and logged by their relevant speciality college. Medical practitioners with general registration (who do not have specialist registration) must continue to complete a minimum of 50 hours CPD per year to be facilitated at their own discretion and a logbook to be kept in the case of an audit or disciplinary action. For medical practitioners with provisional registration or limited registration, that is interns or international medical graduates, the Medical Board's standard more clearly sets out the requirements to ensure their CPD is linked to their training position and/or supervision plan, that is until the clinician is eligible for general or specialist registration.^[21]

Education of hospitalists, registrars, residents and interns, is typically arranged on a regular basis by the hospital at which these clinicians work at and are facilitated by the staff specialist clinicians. The forms of education can include but not limited to:

• Formal lectures and teaching sessions
• Informal bedside teaching
• Research and clinical trials
• Morbidity and mortality ("M&M") meetings
• Grand Rounds
• Clinical skill workshops and courses
• Journal club
• Simulations
• Committees
• Audits

Education of GPs and Specialists, in addition to non-specialist invested members including trainee registrars or non-vocational hospitalists, is typically facilitated by the relevant specialty medical college. Most specialty colleges use a points-based system to keep track of the clinician's CPD obligations for each year, with each specific activity attracting a certain number of points (for instance, attending a conference is worth 3 CPD points, whereas reading a journal article and completing the online quiz may be worth 1 CPD). There are certain education modules that are mandatory for specialists and their trainee-registrars, and others which are optionally recommended to be completed at the preference of the clinician. In addition to the above hospital-based education, the forms of education can include but not limited to:

• Subscription to journals including online educational resources
• Participating as an attendee or instructor at workshops and courses
• Conferences or seminars
• Academic appointment

See also

• Medical Schools in Australia
• Category:Schools of medicine in Australia
• Category:Teaching hospitals in Australia

References

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