Post-graduate Medical Council of Victoria

Post-graduate Medical Council of Victoria

Submission to the Productivity Commission Health Workforce Review

July 28th, 2005

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Introduction to the Postgraduate Medical Council of Victoria
The Postgraduate Medical Council of Victoria (PMCV) supports medical workforce development, management and planning in Victoria through the training, accreditation and professional development of hospital medical officers and international medical graduates.  PMCV is funded through a service agreement with the Victorian Department of Human Services which provides for its core staffing and operational expenses.  Additional program and project funding is received through the Department of Human Services, the Medical Practitioners Board of Victoria and the Medical Training Review Panel (MTRP).
The Council’s activities include:
•	Supporting the well-being and personal and professional development of hospital medical officers (HMOs);
•	Conducting the computer matching process that allocates junior medical staff to hospital positions; 
•	Promoting and facilitating HMO education and training;
•	Developing and maintaining an efficient and effective accreditation process;
•	Identifying and acting upon issues affecting the medical workforce;
•	Supporting the integration and credentialing of international medical graduates working throughout the Victorian healthcare system;
•	Communicating and collaborating with stakeholders in support of the Council’s activities.
In order to achieve these aims, PMCV must liaise closely with universities, hospitals, practices, medical boards, health departments, professional colleges and the wider community.  
The comments that follow specifically relate to the medical practitioner component of the health workforce and focus on the needs and aspirations of junior (pre-vocational) medical staff.

Structure of the Postgraduate Medical Council of Victoria
PMCV comprises a Board, Committee, PMCV Office and five major sub-committees that oversee its activities and projects.  Senior staff and committee chairs would welcome the opportunity to discuss the contents of this submission in more detail with representatives of the Productivity Commission Health Workforce Review (See Appendix 1). 

Medical Director

PMCV Committee

PMCV Office and Project Staff

International Medical Grad. Sub-committee

Education Sub-committee

Medical Clinical Educators

HMO Managers Sub-committee

Accreditation Sub-committee

Medical Education Officers

Workforce Sub-committee

Executive Officer

Postgraduate Medical Council of Victoria Board

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Size of the Medical Workforce
The growth of the Victorian medical workforce is not keeping pace with retirement from the profession and increased service demands.  Victorian Department of Human Services modelling has identified the following numbers of additional medical trainees that will be required annually to maintain the workforce and meet service demands:

Anaesthesia	8
Emergency Medicine	5
General Practice	43
Geriatric Medicine	10
Obstetrics and Gynaecology	11
Ophthalmology	7
Psychiatry	10
Pathology	25
Rehabilitation Medicine	4
Surgery (all specialties)	22
Thoracic Medicine	3	    
		           Source: Department of Human Services – Service and Workforce Planning Division

There are insufficient local medical graduates available to fill the current quota of intern positions in Victoria, requiring recruitment of additional staff from interstate and overseas. 

It is clear that there needs to be a significant increase in the production of local medical graduates through the establishment of new medical schools and/or the expansion of existing schools in Victoria.  For the foreseeable future, it will also be necessary to supplement local graduate numbers by welcoming international medical graduates at prevocational, vocational and specialist levels to work in the Victorian healthcare system.

Training and Development of the Medical Workforce
Additional medical graduates embarking on pre-vocational and vocational training will necessitate a substantial investment in resources for their training and supervision in the hospital sector.  The establishment and funding of new positions, job design to ensure an appropriate balance of teaching and service requirements and accreditation of all positions by the Medical Practitioners’ Board and relevant  Professional Colleges is critical.
PMCV has considerable expertise and experience in the accreditation of hospital posts at Intern and HMO2 level.  Survey teams comprising senior medical staff, medical administrators and HMO representatives review and make recommendations regarding the accreditation of these hospital positions.  

A rigorous and effective accreditation system for hospital positions is fundamental to maintaining the quality of pre-vocational medical training. 

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Training and Development of the Medical Workforce  cont’d.
Given the long lag time between entry into medical school and the commencing practice as a fully qualified general or specialist practitioner, the impact of additional medical school places will not be felt for many years.  Each phase of training (undergraduate, prevocational and vocational) should be reviewed in order to identify opportunities for compression of training time without compromising the quality or intensity of training. 
It has been suggested that the trend towards graduate entry into medical schools may further lengthen overall training time depending on the nature and duration of the undergraduate courses. 

Common foundation programs across a number of healthcare disciplines (including medicine, nursing and allied health) may help to streamline pre-clinical training and also break down some of the existing boundaries between professions.

Distribution of the Medical Workforce
It is well recognised that across Victoria and throughout Australia there is a maldistribution of medical practitioners between city, suburban, regional and rural settings.  Access to general practitioners is becoming more difficult in rural and regional communities.  Most major medical specialties are also under-represented in the country with very high demand and particular needs in disciplines such as aged care, palliative care and psychiatry. The practice of these specialties demands a team approach so shortages of specialised nursing and allied health staff must also be addressed 
There is some evidence to suggest that medical practitioners who have grown up and been educated in country areas will tend to return there as qualified medical practitioners.  

Medical students should be drawn from a diversity of regions and backgrounds and should be exposed to suburban, regional and rural healthcare settings throughout their training.  After graduation, rural and regional rotations provide further exposure to practice in these settings and encourage graduates to consider career options in rural and regional settings.

It is important to ensure that students and trainees have positive experiences during their country rotations.  The provision of appropriate clinical and educational infrastructure, accommodation and recreational facilities in country areas will help to attract and retain young medical practitioners.  Innovative approaches to the provision of access to clinical skills laboratories and other learning technologies should be explored and implemented wherever possible.
Financial incentives may also encourage the movement of medical practitioners into country areas.  Taxation and superannuation benefits, expansion of bonding programs and adjustments to the Medical Benefits Schedule in favour of country practitioners are options that might be considered.

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Sustainability of the Medical Workforce
The retention of medical practitioners in a sector, area, hospital or practice depends on the creation of an environment where the practitioner feels welcome, supported and fulfilled in his or her work.  Support programs for international medical graduates and their families in regional Victoria have been particularly successful in creating such an environment in regional and rural settings.

The education and training of pre-vocational medical practitioners must be complemented by initiatives that will help them to integrate into the communities in which they are practicing. 

There have been significant increases in the numbers of full fee paying overseas students graduating from Victorian medical schools in recent years.  Their impact on the Victorian medical workforce has not been fully assessed.  If full fee paying students remain for only one to two years of prevocational training, it could be argued that the Victorian healthcare system does not benefit from its substantial investment in their training.  Conversely, the return of full fee paying overseas students to their home country with basic medical or specialist qualifications may be seen as an appropriate contribution from Australia towards the development and improvement of the healthcare system in those countries. 

Quality and Safety
Where prevocational and vocational trainees are learning ‘on the job’ in hospital or community settings, the safety and quality of patient care must be assured by having in place a robust system for their training, assessment, education and supervision.  
Training
During their period of prevocational training, medical graduates consolidate their learning from university and apply their knowledge and skills in the clinical workplace.  They develop their communication, clinical decision-making, team management and health advocacy skills while gaining an appreciation of the importance of life-long learning and an understanding of professionalism and ethics in medicine.  Medical boards, state and territory jurisdictions and hospitals around Australia have defined learning frameworks, curricula and guidelines that identify the knowledge, attributes, skills and behaviours that are expected of prevocational trainees.  
A Medical Training Review Panel project is currently addressing the development and implementation of a national core curriculum for pre-vocational training which should embrace and complement state and territory initiatives.  An agreed national curriculum will also provide a sound basis for the categorisation, assessment and accreditation of training positions in hospitals and practices throughout Australia.  
Committee member, Ms Debbie Paltridge, Director of Medical Education, St. Vincent’s Health has recently completed a Churchill Fellowship on curriculum development and the assessment of junior medical staff competencies.  Ms Paltridge’s experiences and findings are of direct relevance to pre-vocational medical training and the Productivity Commission Health Workforce Review. 

PMCV strongly supports the development and implementation of a national curriculum for pre-vocational training.  The curriculum must be flexible, meaningful to those who will use it and its implementation must be supported by access to appropriate educational resources, measurement and assessment tools. 
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Quality and Safety   cont’d.

Assessment
Graduates entering the hospital system will exhibit a range of knowledge and skills depending on the location and nature of their university education, their aptitude, previous clinical placements and, particularly when they have graduated overseas, the time that has elapsed since their graduation.  A set of assessment tools is required so that graduates’ knowledge and skills can be assessed early in their hospital career.  This will identify areas where graduates are capable of independent or supervised practice from the outset.  It will also identify areas where further education, training or experience is required and assist with the development of individual learning plans. 

PMCV has developed a number of tools to assist with the initial assessment of International Medical Graduates (extended multiple choice questions; clinical assessment modules; and behavioural interviewing techniques).  These tools are all equally applicable to the assessment of local graduates and are ready for immediate implementation and use.   

Supervision
Junior staff supervision is usually undertaken my senior clinical staff who may be ill-prepared for this important role.  Supervisors should have a clear understanding of the pre-vocational curriculum and the learning objectives for the rotations that they are supervising.  They may require additional training or support in their role as medical educators.    

PMCV strongly supports recognition of the important role of medical educators and supervisors.  Appropriate financial recognition of their teaching and supervisory role is essential.

Education
Medical Education Officers support the learning and professional development of junior doctors at the hospital level.  They have overseen the development and implementation of learning frameworks and clinical portfolios that guide the prevocational training of junior doctors.
Medical Clinical Educators (MCEs), trained and coordinated by PMCV, provide clinical skills training and assessment for International Medical Graduates and local graduates as required.

The development and growth of the medical workforce depends heavily on the recognition and appropriate resourcing of clinicians and educators involved in teaching, training, skills development, assessment and supervision of prevocational medical practitioners

Appropriate use of new health information technology through programs such as the Victorian Government HealthSmart initiative will help to reduce the administrative burden on junior medical officers and potentially enhance their prevocational learning experience using decision-support and on-line teaching tools. 
Alternatives to traditional ‘apprenticeship’ models of medical training should be explored, supported by innovative use of information technology and knowledge management systems.

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Vital Role of Postgraduate Medical Councils 
There are complex interrelationships between health services, universities, professional colleges, the Department of Human Services and a range of other stakeholders in healthcare and pre-vocational medical training.  Restructuring across hospitals and health services and the development of new training models such as the physician training consortia in Victoria further complicate these relationships.

The Post-graduate Medical Council of Victoria, our sister organisations in other states and territories and the national coordinating body, the Confederation of Postgraduate Medical Education Councils (CPMEC), are ideally placed to oversee the coordination, development and growth of pre-vocational medical training throughout Australia in order to ensure the safety, quality, sustainability and cost-effectiveness of the Australian healthcare system. 

Appendix 1
Senior staff and committee chairs from the Post-graduate Medical Council of Victoria would welcome the opportunity to discuss the contents of this submission in more detail with representatives of the Productivity Commission Health Workforce Review.  Contact details are as follows:

Chairman, PMCV Board: 
Prof. Napier Thomson  (Napier.Thomson@med.monash.edu.au)
Chairman, PMCV Committee & Education Sub-committee: 
A/Prof. Brendan Crotty (b.crotty@unimelb.edu.au)
Executive Officer:
Ms Carol Jordon  (cjordon@pmcv.com.au)
Medical Director & Chairman, Workforce Sub-committee:
Dr Ian Graham  (medicaldirector@pmcv.com.au)
Chairman, Accreditation Sub-Committee:
Dr Rod Fawcett  (rodney@barwonhealth.org.au)
Chairman, International Medical Graduates Sub-committee & CPMEC:
Prof. Barry McGrath  (Barry.McGrath@med.monash.edu.au) 
Chair, HMO Managers Sub-Committee:
Ms Kath Ronan  (kath.ronan@boxhill.org.au)
Churchill Fellow:
Ms Debbie Paltridge  (paltridj@svhm.org.au)

Postgraduate Medical Council of Victoria,
P.O. Box 2900, St. Vincent’s Hospital,
41 Victoria Parade, Fitzroy, Victoria, Australia, 3065.
Telephone:  61 3 9419 1217     Facsimile:  61 3 9419 1261