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114 MJA •Volume 186 Number 3 •5 February 2007
MEDICAL EDUCATION — VIEWPOINT
The Medical Journal of Australia ISSN: 0025-
729X 5 February 2007 186 3 114-116
©The Medical Journal of Australia 2007
www.mja.com.au
Medical Education — Viewpoint
n Australia, doctors must complete a 1-year internship and
generally spend at least 1 additional year rotating through various
terms before entering a specialty training program. These prevoca-
tional years should provide a bounty of opportunity for doctors to
develop essential skills, but currently this process is impeded by
several factors, including the lack of a formalised national prevoca-
tional training program, inadequate funding of education and skills
training, and high service demands. To ensure a high quality medical
workforce, the needs of doctors in training must be identified and
met.
Here we discuss how the Australian Curriculum Framework for
Junior Doctors, which was launched in 2006, could affect prevoca-
tional medical training, as well as important issues regarding imple-
mentation and resource allocation. Our conclusions represent a
consensus of personal opinions of the Chairs of the Junior Medical
Officer Forums of New South Wales, Queensland, South Australia,
Victoria and Western Australia, who all contributed to the ideas
expressed in this article.
The current situation
There is a common misconception that a medical graduate steps
into a hospital and instantly becomes a doctor. In reality, the
process of becoming a doctor is gradual, beginning at the under-
graduate level, where one learns the principles of sound clinical
practice, and continuing through the supervised hands-on experi-
ence of prevocational and vocational training. This process involves
the acquisition of skills, knowledge, reasoning and experience, and
is a vital foundation for later unsupervised practice. Although
clinical experience during training is essential, it must be supple-
mented by on-the-job teaching from senior clinicians and struc-
tured education programs.
There are no published data documenting the amount of teaching
available to prevocational doctors in Australia, so we make generali-
sations based on our experience. On a daily basis, doctors in training
spend minimal time at work involved in dedicated education and
training activities. As a vital cog in the day-to-day operation of the
public health system, much of their time is occupied by repetitive
administrative tasks. In many hospitals, the only structured educa-
tion interns and residents receive is 1 hour of formal teaching a
week. This teaching is of variable quality and relevance and, because
of service demands, junior doctors are frequently too busy to attend
these sessions. When they are able to attend, interruptions to answer
pager calls often make effective learning virtually impossible
(although some hospitals now have pager-free teaching time).
Valuable teaching from consultants and registrars also takes place,
but this is sporadic and impromptu. Teachers are left with the
difficult task of determining what should be taught and how this
should be done.1 The systems that do exist for delivering education
are inefficient, under-resourced, under pressure and unsustainable.2
Ultimately, prevocational doctors have little time for learning, and
little formal teaching is provided.
To illustrate these issues, a recent national survey, commissioned by
the Australian Government Department of Health and Ageing,
showed that 64% of prevocational doctors felt generally prepared for
their job, 31% felt adequately prepared for clinical emergencies and
45% felt prepared for performing procedures.3 Only 20% reported
exposure to clinical skills training and 56% felt that they had adequate
contact with consultants. More than 80% of these trainees wanted
more formal instruction from their registrars and consultants, and
increased exposure to high-fidelity simulation and to professional
college tutorials.
Prevocational medical training and the Australian Curriculum
Framework for Junior Doctors: a junior doctor perspective
Andrew J Gleason, J Oliver Daly and Ruth E Blackham
ABSTRACT
•The current system of prevocational training does not meet
the needs of junior doctors because of a high administrative
workload, insufficient funding for education, and a lack of
centralised guidance for trainees, teachers and hospitals.
•The Australian Curriculum Framework for Junior Doctors
is designed to identify the training objectives for the
prevocational years.
•The Framework has the potential to improve the quality of
training of junior doctors, but this depends on how well it
is implemented and resourced.
•It is imperative that any group responsible for implementing
or assessing the Framework have a representative junior
doctor, among others, on its decision-making committee.
•Stringent accreditation of training institutions is vital to the
effective implementation of the Framework.
•The Framework should be used to promote teaching and
learning, not as a barrier to vocational training or as a check-
MJA 2007; 186: 114–116
list to complete.
For editorial comment, see page 112
I
1 The Australian Curriculum Framework for
Junior Doctors8
•The Framework is an educational template that identifies the core
competencies and capabilities necessary to provide quality health
care. It will enable individual doctors to assess their education and
training needs.
•It outlines the general knowledge, skills and behaviour that
prevocational doctors should acquire, regardless of their
planned specialisation or training location.
•It bridges undergraduate curricula and college training
requirements, and is intended to assist education providers,
clinical teachers and employers to provide a structured and
planned program of education for junior doctors.
•It is built around three learning areas — Clinical Management,
Communication, and Professionalism — which are divided into
11 categories.
•Each category comprises a number of learning topics, each
of which details the associated capabilities expected.
•It is envisaged that learning and assessment resources will
be made available to support each learning topic. ◆
MJA •Volume 186 Number 3 •5 February 2007 115
MEDICAL EDUCATION — VIEWPOINT
Although a high workload makes learning difficult, increasing
numbers of junior doctors will not alleviate this problem unless
adequate resources are provided for training. A survey of medical
students and interns in WA showed that 80% of respondents pre-
dicted a negative effect of the increased medical student numbers on
teaching, and 77% predicted a negative effect on training positions for
junior doctors.4 A very strong emphasis on training is necessary to
cope with increasing numbers of medical graduates. In keeping with
this, the Productivity Commission has identified the inadequacy of
funding for clinical training, and a failure to consider the clinical
training implications of increases in the number of undergraduate
university places.5
The state of prevocational medical education in Australia stands in
stark contrast to that in the United Kingdom, where an overhaul of
training for junior doctors has recently taken place. The resulting
Foundation Programme is well organised and has pledged funding of
£73 million.6,7
The Australian Curriculum Framework for Junior Doctors
With the development of prevocational curricula overseas, there has
been a move towards curriculum development in Australia. This has
led to the production of a draft Australian Curriculum Framework for
Junior Doctors (Box 1), based heavily on existing curricula developed
by the Postgraduate Medical Education Councils of NSW, SA and WA,
the Committee of Deans of Australian Medical Schools, the Australian
Council for Safety and Quality in Health Care, and curricula from the
UK and Canada.7,9-14 The Framework, produced under the auspices
of the Confederation of Postgraduate Medical Education Councils,
will be available for viewing and feedback at http://
www.cpmec.org.au/curriculum.8 The first substantive version of the
Framework was launched at the 11th National Prevocational Medical
Education Forum in Adelaide on 29 October 2006.
The Framework recognises many of the training needs of prevoca-
tional doctors, and has created a unique opportunity to improve the
quality of medical training in Australia. The long-term outcome
depends on how conscientiously and effectively it is implemented and
resourced. Some brief suggestions regarding implementation appear
in the preamble of the current version of the Framework, and it is
expected that implementation will vary with local practice. A steering
committee will be formed to discuss implementation in more detail,
but it is important that we, as junior doctors, express our views
beforehand.
The Framework is designed to support the process of turning
medical graduates into generalist doctors. For this objective to be met,
a number of areas must be addressed (Box 2).
2 Issues to address in adopting the Australian Curriculum Framework for Junior Doctors
General aspects
•The Framework should aid in the development of learning objectives that the junior
doctor can achieve in each rotation, depending on the duration, case mix, and
supervision provided.
•Responsibility for training should be a partnership between employing hospitals,
training governance bodies and doctors, so that a disproportionate amount of work
does not fall on the individual prevocational doctor.
•The curriculum and assessment should not replicate or replace learning that takes
place at unive rsity. It should reinforce and revisit th is learning, taking advantage of th e
benefits of the clinical training environment.
•Effective learning occurs through the integration of general medical knowledge, skills
and attitudes in everyday clinical practice, supported by adequately resourced
educational programs, supervision and time for learning.
The process of implementation
•Any consultation process discuss ing implementation must provide adequate time
and resources to engage relevant parties, especially junior doctors, and allow
comprehensive discussion of the issues.
•A robust and accountable process must be created to ensure any recommendations
for implementation are followed.
•The responsibility for implementation should be well defined and shared among
individual hospitals, postgraduate medical councils, and other relevant bodies.
Practical aspects of implementation
•Hospitals must meet their training responsibilities and should not continue to place
service demands above the training needs of doctors.
•Teaching time n eeds to be a regular, protected, paid part of every junior doctor’s day.
The Australian Medical Association recommendation of 5 hours per week of pager-
free quarantined education time for prevocational doctors is a reasonable goal.15
•Clinicians must be paid to teach, ensuring the provision of expert supervision.16
Teaching responsibilities must be incorporated into job descriptions, and resources
provided to allow time to fulfil this role. It is no longer possible to rely on pro-bono
teaching by senior clinical staff, who are frequently too busy to prioritise teaching.17
•Innovative solutions to balancing service demands and training needs must be
sought, and the efficacy of these solutions should be adequately evaluated.
The assessment process
•Assessment should aim to demonstrate a
high standard of clinical ability, not just serve
a certification role or as a hurdle to career
progression.
•Although assessment is necessary to ensure
that teaching methods are effective, the
process should not be unnecessarily
onerous.
•Assessment should provide effective
feedback for the learning and development
of the doctor. It should not be adapted to a
tick-box form that has little meaning or
relevance.
•Assessment should provide feedback to the
hospital about the resources for and quality
of their training environment.
•Assessment should be used by bodies such
as the Postgraduate Medical Councils to
accredit hospitals on their ability to provide
training and experience. Hospitals that are
unable to provide adequate training should
not be accredited to receive prevocational
doctors.
•Assessment should not be used as a criterion
for obtaining prevocational or vocational
positions or registration.
•Assessment should begin through meetings
with supervisors to discuss agreed goals and
objectives.
•Learning objectives should be reviewed
periodically during the term by the junior
doctor and supervisor, so that areas of
learning that have not been reviewed can
be addressed. ◆
116 MJA •Volume 186 Number 3 •5 February 2007
MEDICAL EDUCATION — VIEWPOINT
The use of the Framework must not become a chore for the junior
doctor to complete in his or her free time. The demands of working as
a junior doctor are too great to have this additional burden. Training of
junior doctors should be seen as a key result area for every Australian
hospital. As such, the hospital and individual departments should
take responsibility for the education and competency of junior
doctors. Hospitals and governing bodies have a duty of care to the
Australian populace that requires they ensure doctors are trained as
well as possible. Not adequately meeting these needs has far-reaching
implications for the general community for years to come.
Conclusion
Australia has the economic and intellectual resources necessary to
train the best doctors in the world, and we believe that this should
become a reality. The education of junior doctors as generalists
before entry into vocational training is integral to the development
of highly skilled medical practitioners. Ensuring that this process is
as effective as possible will require debate and centralised organisa-
tion. Although ostensibly daunting, this is by no means a far-fetched
task — it merely requires a modicum of funding and some creative
changes to our training system and culture. The Australian Curricu-
lum Framework for Junior Doctors has the potential to add to this
process, provided it is well resourced and implemented in an
effective manner with substantial input from junior doctors (Box 3).
At stake is the standard of health care provided to the community.
For this to be protected, an ongoing investment in prevocational
medical education is required.
Acknowledgements
We thank the following for their invaluable opinions and contributions:
Marion Mateos and Anand Rajan (Co-Chairs, Junior Medical Officer
Forum, NSW Institute of Medical Education and Training), Matthew
Peters (Chair, Resident Medical Officer Committee, Postgraduate Medi-
cal Council of Queensland), Anna Lowe (Representative, Resident Medi-
cal Officer Committee, Postgraduate Medical Council of Queensland),
and Michael Edmonds (Chair, Junior Medical Officer Forum, Postgradu-
ate Medical Council of SA).
Competing interests
Andrew Gleason received funding from the NSW Institute of Medical
Education and Technology to attend meetings of the Writing Group of the
Australian Curriculum Framework for Junior Doctors.
Author details
Andrew J Gleason, MBBS(Hons), BSc, Hospital Medical Officer1
J Oliver Daly, MB BS, BSc(Hons), Obstetrics and Gynaecology
Registrar2
Ruth E Blackham, MBBS, Hospital Medical Officer3
1 The Alfred Hospital, Melbourne, VIC.
2 The Royal Women’s Hospital, Melbourne, VIC.
3 Sir Charles Gairdner Hospital, Perth, WA.
Correspondence: ajgleason@gmail.com
References
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prevocational hospital doctors: exposure, perceived quality and desired
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(Received 22 Aug 2006, accepted 31 Oct 2006) ❏
3 Recommendations on implementation and resource
allocation for the Australian Curriculum Framework
for Junior Doctors
Do Do not
•Consult stakeholders, especially
junior doctors.
•Use the Framework to guide
allocation of specific and
adequate funding for teaching
time, facilities and learning
resources, including regular,
protected, paid education
sessions.
•Use the Framework to promote
teaching and learning, and
ensure a high standard of clinical
ability in junior doctors.
•Use the Framework to assess
teaching opportunities provided
by hospitals as part of
accreditation.
•Use the Framework as a
barrier requirement to
vocational training.
•Use the Framework as a
“log book” or check-
list for junior doctors
to chase.
•Expect all aspects of
the Framework to be
learnt through clinical
attachment alone.
•Expect senior clinicians
to have sufficient
“spare time” to teach
junior doctors during
day-to-day work.
◆
