Medical education in Australia

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 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.[6]

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.[7]

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.[7]

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).[7]

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.[7]

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.[8]

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.[9]

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.[10] 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 or she would probably benefit from further rotations in the various critical care specialties (that is, Intensive Care Medicine, Emergency Medicine, or Anaesthetics).[11]

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).[11]

Residents typically have general registration with the Medical Board of Australia; that is, having successfully completed internship in Australia.[7] 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.[12]

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.[13][14]

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. Registrarship or vocational specialty training is akin to an apprenticeship or clerkship in other professions. It is a period of on-the-job training and assessments in order to qualify for fellowship of one of the recognised specialist medical colleges, which 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.[11]

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 [15]

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.[16][17]

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.[11]

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.[11]

In Australia, hospitalists are career hospital doctors; they are experienced generalist medical practitioners whose principal focus is the provision of clinical care to patients in hospitals; they are typically beyond the internship-residency phase of their career, but have decidedly chosen as a conscious career choice not to partake in vocational-specialist training to acquire fellowship specialist qualification. Whilst not specialists, these clinicians are nonetheless senior in their years of medical practice, and depending on their scope of practice and experience, they typically work with a reasonable degree of independence and autonomy under the auspices of their specialist colleagues and supervisors. Hospitalists form a demographically small but important workforce of doctors in hospitals across Australia where on-site specialist (or registrar) coverage is otherwise unavailable.

The commonest pathway in medicine, is to complete medical school, then internship and residency, before finally completing a specialty training program as a registrar thereby becoming a specialist medical practitioner. Hospitalists typically come from clinicians who have completed their successfully completed their internship-residency, and usually some further formal or informal rotations as a registrar, but have decided not to, or have yet not, complete their vocational specialty training. The reasons for why hospitalists choose their career track are varied, some of which include:

• doctors who do not have any intentions of specialising as a conscious career choice and prefer working as a non-specialist hospitalist clinician;
• 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 but have decided to seek (primary or secondary) employment as a non-specialist hospital clinician (such as a fellowship qualified General Practitioner working part-time as a Career Medical Officer in the Emergency Department or as a Surgical Assistant);
• doctors who are concurrently in the process of specialising but are taking temporary leave from their specialty training and/or additionally working as a non-specialist clinician elsewhere usually in the capacity of a temporary locum tenens (such as a Resident or Registrar at a public teaching hospital working part-time or casually as a Career Medical Officer at a private hospital).[19]

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 Career Hospital Doctor [20]

Hospitalists are typically employed in a variety of public and private hospital settings on a contractual or salaried basis. Traditionally, career medical officers or hospitalists are employed as permanent full-time or part-time staff, but more commonly in recent times, due to a significant workforce of clinicians been in-flux with their specialty training and insufficient staffing of middle-grade clinicians at hospitals, there has been an increase supply and demand for hospitalists on a locum tenens or casual basis. Dependent on their place of employment and duties, the responsibilities and remuneration of non-specialist hospitalists are usually comparable to somewhere between registrars and consultants. Despite the common trend for clinicians to specialise nowadays, non-specialist hospitalist clinicians have an important role in fulfilling shortages in the medical workforce, especially when specialist (or registrar) coverage and accessibility is unavailable, where there is an area-of-need, and after-hours or on-site medical care is required. These clinicians and employed across Australia in a variety of clinical environments which include Medical & Surgical Wards, Mental Health Units, 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.

General Practice is formally a speciality of its own with formal vocational specialist training. That is, those wishing to practice as a non-vocationally registered General Practitioner (Non-VR GP) without 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 limited Medicare rebates. The exception to this are those who were 'grandfathered' as already working as GPs for at least 5 years prior to 1996. Non-specialist doctors are issued a restricted Medicare provider number that allows them to initiate referrals and request pathology and radiology investigations, but not access full Medicare billings.[21]

The Australian Medical Association (AMA), 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 specialist colleagues.

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; paying annual fees to both the Medical Board and Specialty College for their specialist registration. 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 being 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 specialist 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 beyond the scope of General Practice. Medicare also makes this delineation for the purposes of appropriately allocating referrals, rebates and billings amongst 'Non-VR' GPs versus 'VR' GPs versus 'Specialist' Consultants. That is, those wishing to practice as a non-vocationally registered General Practitioner (Non-VR GP) without 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 limited Medicare rebates. The exception to this are those who were grandfathered as already working as GPs prior to 1996. Non-specialist doctors are issued a restricted Medicare provider number that allows them to initiate referrals and request pathology and radiology investigations, but not access full Medicare billings. 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.

Fellowship qualified specialists 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) ensures clinicians remain up-to-date and evidence-based in their medical practice as mandated and audited by the Medical Board of Australia:

1. Medical practitioners with Specialist registration (that is, fellowship qualified General Practitioners and Specialist Consultants) must continue to meet the CPD requirements set out and logged by their relevant speciality college.
2. Medical practitioners with General registration only and not enrolled (nor have intentions to enrol) in a specialty-vocational training program (that is, non-fellowship General Practitioners and non-specialist Hospitalists) 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; notwithstanding, these clinicians may elect to enrol into a relevant specialty college CPD program as a non-fellow and have their educational activities logged through that college.
3. Medical practitioners with General registration only and enrolled in specialty-vocational training program (that is, Registrars) must attend relevant educational activities and complete assessment requirements as part of their training obligations as monitored and facilitated by their specialty college and clinical supervisors at their teaching hospital or clinic.
4. Medical practitioners with General registration only and working in a pre-vocational training capacity (that is, Residents) must attend relevant educational activities and complete performance reviews as facilitated by clinical supervisors at their teaching hospital or clinic.
5. Medical practitioners with Provisional or Limited registration (that is, Interns or International Medical Graduates), must complete a term of supervised practice, meet the educational standards set and successfully complete any assessments during that probational period as set by the Medical Board and/or Specialty College and/or teaching hospital or clinic, prior to been eligible for General or Specialist registration.[22]

Education of junior doctors (that is, Interns to Residents to Registrars) is typically arranged on a regular basis by the hospital at which these clinicians work at and are facilitated by the senior staff specialist clinicians, as well as a proportion of self-directed learning in their own time. The forms of education can include but not limited to:

• Formal lectures and teaching sessions
• Case presentations
• 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 fellowship qualified General Practitioners and Specialist Consultants, is typically facilitated by the relevant specialty medical college; with each college having its own CPD program. Similarly, Hospitalists and Registrars financially enrolled in the College as non-fellow or trainee members may also partake in the CPD program and educational activities, some of which are highly recommended or mandatory. 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 or workshop may be worth 3 CPD points, whereas reading a journal article and completing the online quiz may be worth 1 CPD point). 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.

Mandatory education activities typically require the clinician to participate in activities that ensures ongoing up-to-date competency and receive feedback on core skills and clinical knowledge related to their scope of practice. These typically include:

• Ensuring up-to-date first aid and resuscitation skills certification; such as, CPR, ALS, APLS, EMST (ATLS), et cetera
• Ensuring an up-to-date logbook of core skills and procedures; such as, performing at least 3 endotracheal intubations annually
• Participating in a clinical audit of patients seen by the clinician or colleagues within their department
• Participating in a performance review and receiving feedback from a senior colleague

In addition to the above hospital-based education already mentioned, additional forms of self-directed education include such activities as:

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

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