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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

Doherty to NRAS: A 30-year Review of Medical Education from an AMC Perspective

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)

Doherty to NRAS: A 30-year Review of Medical Education from an AMC Perspective

DISCLAIMER Views, reflections and opinions expressed are mine and not necessarily the

• fficial position of the Australian Medical Council

Doherty to NRAS: A 30-year Review of Medical Education from an AMC Perspective

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

Doherty to NRAS: A 30-year Review of Medical Education from an AMC Perspective

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

Doherty to NRAS: A 30-year Review of Medical Education from an AMC Perspective

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

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

• Course structure:
• All integrated programs
• Variety of clinical settings
• Approximately 3400 graduates per year

Doherty to NRAS: A 30-year Review of Medical Education from an AMC Perspective

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
• f major teaching hospitals)
• Decision to establish the AMC – an accreditation not registration decision – GMC

withdraws from overseas accreditation when UK joins EU

Doherty to NRAS: A 30-year Review of Medical Education from an AMC Perspective

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)

Doherty to NRAS: A 30-year Review of Medical Education from an AMC Perspective

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

Doherty to NRAS: A 30-year Review of Medical Education from an AMC Perspective

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

Doherty to NRAS: A 30-year Review of Medical Education from an AMC Perspective

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)

Doherty to NRAS: A 30-year Review of Medical Education from an AMC Perspective

MILESTONES IN MEDICAL EDUCATION – AMC PERSPECTIVE Graduate 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)

Doherty to NRAS: A 30-year Review of Medical Education from an AMC Perspective

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

Doherty to NRAS: A 30-year Review of Medical Education from an AMC Perspective

MILESTONES IN MEDICAL EDUCATION – AMC PERSPECTIVE Medical 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.

Doherty to NRAS: A 30-year Review of Medical Education from an AMC Perspective

MILESTONES IN MEDICAL EDUCATION – AMC PERSPECTIVE 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

Doherty to NRAS: A 30-year Review of Medical Education from and AMC Perspective

MILESTONES IN MEDICAL EDUCATION – AMC PERSPECTIVE Off-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

Doherty to NRAS: A 30-year Review of Medical Education from an AMC Perspective

MILESTONES IN MEDICAL EDUCATION – AMC PERSPECTIVE 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

Doherty to NRAS: A 30-year Review of Medical Education from an AMC Perspective

MILESTONES IN MEDICAL EDUCATION – AMC PERSPECTIVE 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?

Doherty to NRAS: A 30-year Review of Medical Education from an AMC Perspective

MILESTONES IN MEDICAL EDUCATION – AMC PERSPECTIVE 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 CanMEDS

competencies

• 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

Doherty to NRAS: A 30-year Review of Medical Education from an AMC Perspective

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

Doherty to NRAS: A 30-year Review of Medical Education from an AMC Perspective

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 Standards

• 1. Context of the Medical Program
• 2. Outcomes of the Medical Program (Graduate Outcomes)
• 3. Medical Curriculum
• 4. Learning and Teaching
• 5. Assessment of Student Learning
• 6. Monitoring and Evaluation
• 7. Students
• 8. Learning Environment

Doherty to NRAS: A 30-year Review of Medical Education from an AMC Perspective

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
• utcomes 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

Doherty to NRAS: A 30-year Review of Medical Education from an AMC Perspective

WOODS ACCREDITATION SYSTEMS REVIEW

• Health Ministerial Council commissioned review of NRAS – erroneously found cost
• f 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

Doherty to NRAS: A 30-year Review of Medical Education from an AMC Perspective

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

• pportunities not available

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

Doherty to NRAS: A 30-year Review of Medical Education from an AMC Perspective

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

Doherty to NRAS: A 30-year Review of Medical Education from an AMC Perspective

CONCLUSION A Personal Perspective

Medical Education will continue to thrive and respond to the many challenges that it will face, not because governments or bureaucracies will be able to see the solutions to the problems, but because of the quality and commitment of those involved in providing medical education and the remarkable students and trainees that take up the profession of medicine.

Doherty to NRAS: A 30-year Review of Medical Education from an AMC Perspective

Thank You

ianf@amc.org.au