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Australia Medical Education Study
What makes for success in medical education? Synthesis Report
8BCommonwealth of Australia 2008
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190BA Synthesis prepared for the
191BDepartment of Education, Employment and Workplace Relations
What makes for success in medical education?
95BMedical Education Study: A Synthesis
Urbis Pty Ltd
97BContact for Synthesis:
Medical Education Study
Strategic Analysis and Evaluation Group
Department of Education, Employment and Workplace Relations
Key Messages 8
Executive Summary 10
10BPurpose and Methodology 15
29BThe Department of Education, Science and Training Australian Medical Education Study 16
310BThe Australian health care system 22
42BResearch Undertaken for the Australian Medical Education Study 31
515BThe Nature of the AMES Research 32
63BPreparation for Internship 48
76BStrengths, weaknesses and challenges 145
5. The fundamental knowledge, skill and attributes required for medical graduates include basic and clinical medical sciences, procedural clinical skills and professional skills. While there is agreement that medical sciences and procedural skills are critical to medical education, there have been no predetermined standards or definitions which could improve the necessary articulations between medical schools and the clinical environment of practice, although the Australian Curriculum for Junior Doctors and the AMC’s 2006 Standards document provide widely agreed listings of those skills and attributes.
6. Early vertical and horizontal integration of university and postgraduate education, together with improved governance between educational and health providers, would help address the development of skills critical to the clinical experience such as the procedural, communication, professional and specific skills necessary to deal with chronic conditions and population-health issues.
7. Assessment was generally seen as problematic within both university and clinical environments and the lack of appropriate feedback was widely reported. Issues included equity and the need for training in assessment methods. Constructive and supportive assessment with feedback was rated highly. Summative assessment was widely criticised, but also regarded as an important driver of student learning, and the need for valid and reliable assessment instruments was identified. An outcomes-based approach was widely recommended as an appropriate basis for a relevant facilitating assessment framework.
8 Preparation for specialty training. The research did not, in general, identify links between medical school education and preparation for specialist training. Supervisors considered that preparation for specialty training emanated from the intern year and beyond, rather than from the medical school phase of education. There was agreement that postgraduate vocational training needed to define more clearly the basic science knowledge required by each specialty, with:
9. While clinical education in all environments (ie metropolitan, rural, hospital and community) is perceived as a highly valued teaching/learning format and the most effective tool in preparing graduates for internship, there are clear concerns relating especially to ensuring adequate depth and breadth of clinical exposure for undergraduate students in a context of increasing student numbers, reduced access to patients in the public health system, and difficulties in maintaining the apprenticeship relationship between more experienced doctors and doctors in training. Particular issues include:
10. Significant issues of concern were expressed particularly around the resourcing, relationships, articulation and cooperation in the continuum of medical education, such that there are considerable challenges to be faced by stakeholder organisations in ensuring appropriate collaboration.
The Department of Education, Science and Training commissioned the writing of a synthesis document to consolidate and synthesise relevant background information together with the findings from all the research activities related to the Australian Medical Education Study (AMES). This synthesis responds to the overarching question for the study: What makes for success in medical education?
The research methods used comprised a submissions process, literature reviews, and the gathering of new data via fieldwork carried out within Australia during the period under review (2005-2007). Three strands of inquiry were established to focus on aspects of wide-ranging debates occurring within medical education which could add value to currently available knowledge, namely:
Key findings of the study are summarised below in terms of the eight research questions posed by the AMES Steering Committee.
What are the educational outcomes – particularly expected competencies – for graduates who are completing their undergraduate medical degrees and entering internship?
The AMES research showed that those responsible for supervising interns held diverse views about the knowledge, skills and attitudes that interns should acquire at medical school. However they were clear about the key things that interns should be able to do, namely focus on patient management, recognise illness and know their limitations. Interns themselves expected that their medical school should enable them to practise with appropriate support and supervision.
The range of medical science content that educators, students and other stakeholders would like to see dealt with at undergraduate level (eg anatomy, physiology, pathology, biochemistry, and microbiology and immunology among many others) is very wide, and difficult to cover within even a six-year course. Accordingly the effective teaching of the scientific method itself is a key part of undergraduate education. The development of ‘clinical acumen or insight’ is regarded as crucial, and this refers to the capacity to synthesise multiple sources of information, clinical prioritisation and the making of clinical judgments.
The literature suggested some resistance to learning communication skills, but studies reinforced its importance. The AMES data indicated that skilled communication, linked closely with patient-centred care, was a widely-accepted educational outcome of undergraduate medical education. The AMES empirical research identified a number of key professional attributes as central to success as an intern and beyond. These included taking responsibility/independence; motivation; confidence; a positive work ethic; compassion; self insight and emotional resilience.
Findings from the AMES suggested that there was wide approval for the AMC’s set of expected competencies which form the basis for medical school accreditation in Australia.
What are the educational outcomes – particularly expected competencies – for graduates completing their undergraduate medical degrees and entering postgraduate education?
Participants in the AMES empirical research did not generally make strong connections between undergraduate education and the preparation for specialty training. The intern year was seen as playing a key role in this regard. Research participants perceived undergraduate medical education as contributing to later postgraduate specialisation most distinctly via its capacity to provide students with an identity and grounding in the profession’s scientific base, but also by equipping students with:
Stakeholders would like to see greater exposure to, and information regarding, medical specialties and subspecialties during the undergraduate years. There was also high value placed on mentoring and guidance by specialists during the years of undergraduate medical education.
How well does undergraduate medical education prepare students for their role as interns and their transition to postgraduate specialist training?
Those whose opinions and experience were reflected in the AMES expressed diverse opinions on this question. While some stakeholders argued, for example, that medical schools currently provided inadequate grounding in the basic medical sciences, others took an opposing view. There was a greater degree of agreement that people entering internship tended to be lacking in ‘work readiness’ – which meant that this needs to be further developed during the intern year itself. Interns who took part in the research perceived themselves generally well prepared for the intern role and were generally satisfied with the educational grounding they had received as undergraduates and the way they had been taught. Some, however, did not feel emotionally ready for or confident about the transition to practice.
Which areas of study/content and methods of learning/teaching delivery and assessment methods have been most and least successful in preparing students for internship and specialty training, including research? Why?
The AMES research showed that the content areas and skills that were generally considered to be taught and learned most successfully were communication skills, generalist medical skills and general approaches to clinical medicine/general medicine, observance of legal and ethical principles and history taking.
At least some stakeholders believed that the least successful study/content areas included basic medical science, with clinical pharmacology and anatomy being of particular concern. Other concerns included subspecialty training, procedural skills such as wound management; certain professional skills including understanding of and communication within the clinical hierarchy, time management, continuity of care and handover, and teaching skills.
Clinical experience was considered the most successful method of learning; this included various forms of clinical education such as ‘teaching with the patient present’, clinical skills laboratories, supervised patient care and simulation. ‘Humiliation and ridicule of students’ was identified as the least successful teaching method.
In terms of preparation for specialty training, students and junior doctors saw successful methods as including careers information, contact with role models, selective exposure in clinical environments, and first-hand experience of the delivery of specialist services.
Problem-based learning (PBL) and self-directed learning (SDL) attracted both positive and negative comment. Points raised by the AMES research team from Monash University included the suggestion that introduction of PBL was perceived by some to be linked by some to the poor teaching of basic medical sciences. The teaching of basic medical science was seen as an area of considerable concern to many, particularly surgeons.
Effective assessment was considered to require appropriate forms of feedback, a good match between assessment and teaching/learning and a good ability to discriminate between levels of student competency. Assessment was the aspect of medical education with which students were least satisfied; there were perceptions of assessment as lacking in consistency, meaning and validity, and complaints about lack of appropriate feedback. Various stakeholders perceived that there was a failure to identify and deal appropriately with students who were unsuited for clinical practice Constructive and supportive assessment with feedback was rated highly.
How is undergraduate clinical education in Australia currently organised and delivered, and what are the perceived strengths and weaknesses of the current arrangements?
The current organisation of clinical education was described as graded exposure to the acquisition of the skills and attitudes needed for the clinical process in concert with the acquisition of the relevant knowledge base. The perceived strengths of clinical programs were immersive pre-internship programs, active clinical responsibilities during the undergraduate years, rural rotations and access to clinical teachers. Weaknesses of clinical programs related to governance issues, the limited availability of clinical educators, variability of the clinical environment, loss of diversity, and preparation for specialty training.
What types and level of clinical exposure do undergraduate medical students need to prepare them both for internship and for further specialist training and how effective are the different types of clinical exposure in preparing medical students for internship and specialist training? Are medical students perceived to be getting the necessary clinical exposure?
There was a broadly-held acceptance of the fundamental importance of early clinical content and its increasing density as the course progresses. Findings pointed to the need for a planned and organised phasing of a wide range of clinical education setting and content options, and clinical exposure that incorporated direct patient contact, quality supervision and the presence of practising professionals. A higher value was placed on participation compared to observation, and the quality of the clinical attachment was more significant than its length. Rural environments provided excellent clinical opportunities, but had a range of often practical difficulties that need to be overcome in order to ensure their effectiveness. Access to simulation varied substantially across medical schools and it was seen as generally underused. Teaching from nursing staff and allied health professionals was not well rated, although with current workforce issues this view may need to be challenged and addressed. .
Satisfaction with clinical programs was high amongst students and student perceptions of preparedness to practise clinical skills were generally high. However, there are many issues relating to the need for incentives and resources for clinical education in light of inter alia increased student load and uncertain availability of clinical educators/supervisors. Issues surrounding medical schools support for clinical educators and changes in the hospital environment flowing from changes to the health care system were also raised.
What are the perceived strengths and weaknesses of current undergraduate medical education arrangements, and what are the challenges?
Medical education in Australia has responded to national and health service priorities and continues to do so. It is now providing leadership internationally in medical education. Medical schools have responded to the challenges of the rapid expansion of knowledge and disciplines to be addressed in medical education and have developed curricula which, while not neglecting the transmission of factual knowledge and practical skills, aim to stimulate enquiry, develop analytical ability and encourage the development of essential or desirable attitudes in the students. Students are graduating with the capacity to be skilled communicators who display empathy, compassion and patient centred behaviour. This capacity is nurtured and encouraged by teaching/learning methodologies inherent in the ‘new’ curriculum. Students are graduating with a demonstrated capacity for acting in accordance with ethical and legal guidelines. Students are graduating with the ability to demonstrate proficiency in generalist medical skills, including history taking and physical examination.
Assessment in the current undergraduate medical education system was regarded as a major problem. Current approaches to summative assessment were widely criticised, and the lack of appropriate feedback was often noted. Ongoing assessment, including the capacity to identify those ill-suited for clinical practice, emerged as a more important issue than student selection as a means of ensuring quality and competence in the future medical workforce. Students were perceived as graduating with perceived deficiencies in a number of clinical and procedural skills expected of junior doctors, eg ‘wound management’ and ’calculating accurate drug dosages’. However the level of proficiency that graduates should be achieving prior to internship remains unclear. Some of the skills required of junior doctors by clinical educators/employers would best be obtained through extensive clinical experience, which may only be possible at intern or postgraduate level. Some graduates experienced difficulties in making the transition from university to the work environment, including difficulties in managing the hierarchy, problems with ‘documentation’, inadequate interprofessional communication, and difficulties in handing-over and follow-up in a shift work environment. Medical education, which is clearly regarded by all stakeholders as a continuum is, and has been historically considered institutionally and organisationally fragmented in Australia.
There was a widespread view that students were graduating with inadequate knowledge of many of the basic medical science foundations, particularly with regard to clinical pharmacology and anatomy. However, observers were not unanimous in assessing the basic science component as a ‘weakness’. The knowledge base - including basic medical science, physiology, theoretical knowledge, medical conditions and clinical pathways - of the current cohort of junior doctors was rated by clinical educators as an area of excellence. Qualitative research pointed to a complex interplay of factors, including ‘the role of senior colleagues’ and students’ confidence in their own abilities, that affect perceptions of the relative weakness or strength of graduates’ medical science foundations. Thus the debate around the basic medical sciences remains ongoing, with their status in current medical education being seen positively by some and quite negatively by others.
There were also diverse views about professionalism. Whereas ethical behaviour in junior doctors was viewed by clinical educators as a strength, graduates were also criticised for displaying attitudes such as ‘lack of interest, commitment and responsibility’ and ‘Generation Y attitudes to work’. There were again diverse views on graduates’ application of the principles of evidence based medicine. Some data in AMES-7 suggested that junior doctors with a grounding in PBL and SDL were proficient in seeking and applying evidence; other material suggested that there are significant gaps relating to content, particularly knowledge of scientific foundations.
Taking all the AMES data together, it can be said that the key overall challenge for Australian medical education is to continue adapting to the rapid changes in health care needs and priorities, technologies, financial and governance arrangements, whilst remaining true to its scientific, historical and professional foundations. The challenge is to ensure that doctors continue to receive the solid knowledge, skills and attitudinal foundations that will enable them to contribute to the health of citizens and to a national health care delivery system that is amongst the best in the world. The range of data made available by the AMES indicates that stakeholders recognise and are attempting to face this challenge.
In what ways could undergraduate medical education be modified so as better to achieve the desired outcomes?
Specific changes in undergraduate medical education that the AMES has highlighted as important issues for discussion by the medical education community relate to the following:
1 UAssessmentU. As noted in the Key Messages, assessment in both clinical and university environments was seen as problematic. Issues included equity and the need for training in assessment methods. There is an evident need for the development and utilisation of valid and reliable assessment instruments.
2. UBolstering the clinical education workforceU. While this is within the jurisdiction of the universities in particular, it will call for sound collaboration with both the medical profession as a whole and with health authorities, and for a concerted effort to mobilise and provide training for practising doctors to take on educational roles.
3. UImproving continuity in medical educationU. Greater institutional integration across the three broad levels of medical education, (undergraduate, early postgraduate and vocational) would be required in order to improve their alignment within the broadly recognised continuum of medical education This would require policy changes and therefore consultation and cooperation among all stakeholders. In addition, as suggested in numbers of submissions, any changes would need to be based on research-derived evidence, including comparisons with similar systems overseas. As a first step, the transition from undergraduate to specialist or vocational study would require the best available information for students; a handbook or compendium of higher training programs would be a valuable resource in this regard. There is a similar need for a national catalogue of early postgraduate programs. It may also need to be decided early on whether a new coordinating body would be required or whether stakeholders could agree to a current organisation adopting this coordinating role.
39B4. UCooperation and coordination.U There were calls for approaches that better integrate or coordinate elements within the education system, and between medical education and the delivery of medical services. Selection of students, feedback and assessment of students need to be understood as a continuum that serves to ensure that medical graduates are as well equipped as possible for further training and for practice. This selection-feedback-assessment process needs to be seen – along with course content, teaching methods and clinical education – as part of an integrated medical education curriculum. In turn this curriculum needs to be effectively embedded in the context of the wider tertiary education system, the planning and development of the health workforce, and the delivery of health services to the Australian population.
The research underpinning the AMES study was necessarily extensive, diverse and intensive. The scope of the research, the breadth of participation and the depth of examination mean that it was neither possible nor useful to develop a consensual view on many of the issues or questions raised. The issues discussed, however, are of such consequence to the continuing strength of Australian health care that it is extremely important that the views, however diverse, are highlighted as issues to be given serious consideration at every level of decision making which affects Australian medical education – governments - local, state and federal - universities, hospitals, health centres, medical practices and the range of clinical environments in which students and interns participate.
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