Peter Brooks: Simulation for streamlined training

AUSTRALIA has one of the best health systems in the world — but that does not mean it cannot be improved.

Educating medical students has changed significantly over the years, with programs now available through Australian medical schools ranging from school-leaver to graduate entry, with durations from 5 years up to 7 years for a basic degree plus graduate program.

The system must be one of the most flexible in the world, and flexibility is surely as important in medical education as it is in other forms of learning.

Yet, it seems that after medical school some of that flexibility ceases. Post-registration and specialist training is still very much time based and is perhaps, more than ever, due for a critical review.

SimHealth 2011 (the annual scientific meeting of the Australian Society for Simulation in Healthcare) was held in Sydney recently and emphasised some of these issues. Dr Amitai Ziv, director of the Israel Centre for Medical Simulation, was an inspiring speaker and showed how simulation can be used to train doctors in quality and safety issues, about team care and for a variety of procedures.

Training to a set of competencies using simulation for one arm of assessment is not only feasible, but has been used in other industries, such as aviation, for years. So why don’t we at least trial some of these approaches in a formal sense?

A significant number of students in graduate entry programs, for example, know what branch of medicine they want to pursue by the end of year 2. As well, all programs have some core and some optional components, particularly in the clinical years.

So here is a challenge — a medical school could work with a specialist college to define a curriculum that might fulfil some of the criteria for the “first part” examination. The college could then set an exam for students to sit at the same time as their MBBS/MD, similar to the ECFMG (Educational Commission for Foreign Medical Graduates) exam when we did our finals.

If the student passed they would be given recognition of prior learning (RPL) to allow them to enter year 2 of specialist training. Students who have completed other activities, such as surgical assistance in the evenings or at weekends or pathology specimen preparation, could also be given RPL in their chosen fields.

In both these examples students could be paid for their work, somewhat like the New Zealand students are paid in their final years as junior assistant interns.

If this program was used in the immediate post-registration years you might reduce the time for specialist training by a further year or so. Add the benefits of using simulation across the training program and my hypothesis would be that specialist training could be reduced by at least 3 years.

Interestingly, both the Royal Australasian College of Surgeons and Royal College of Pathologists of Australia held discussions on this some 5 years ago but they did not get any support.

There are some arguments against this approach, such as reducing the generalist base (even though our whole health system is focused on specialism) which might lead to less career flexibility. But it is a hypothesis worth discussing and testing —it might even benefit patients — as it could offer a return on education investment and more task-ready practitioners.

Simulated learning environments might provide a further opportunity for medical schools to engage with the colleges to test some of these ideas and see if we could come up with something that improves on what we have been doing for the last few centuries!

The key to this will be the willingness of the medical profession to look at new learning technologies and to develop a more flexible approach to training. What we have is pretty good — but it is very lengthy. This could be an opportunity to develop programs which are more focussed on contemporary practice, and perhaps even focused on future practice.

Professor Peter Brooks, of the University of Melbourne, is director of the Australian Health Workforce Institute.

Posted 4 October 2011