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IN Australia, postgraduate year (PGY) 1 doctors, known as interns, have access to formal education programs in addition to work-based teaching and learning. However, the formal education of PGY2 doctors — also referred to as prevocational doctors or, more commonly, as residents — remains variable between jurisdictions and often between individual health services.
This is symptomatic of the “prevocational vacuum”, a phenomenon first described in the United Kingdom in the 1990s. The vacuum occurs prior to commencement of vocational training, and in Australia generally encompasses the PGY2 year without inclusion of the PGY1 internship. Prevocational positions have also been described as having “poor job structure, poorly planned training, heavy workloads, inadequate supervision, minimal assessment and a lack of career advice”.
Following the Review of Medical Intern Training, the Commonwealth of Australian Governments Health Council has accepted a recommendation to move from a one-year internship model to an integrated 2-year transition to practice model. While the PGY1 year will continue as a prerequisite for general registration, the effect that implementation will have on the PGY2 year remains to be seen, and, in some jurisdictions, it may result in changes to the way that prevocational education is viewed or required.
Given the potential for impact on prevocational doctors, the Junior Medical Officer (JMO) Forum of Victoria has sought to explore the current status of PGY2 education in our state, to inform development of future education programs. Through surveys and feedback discussions, we have identified common issues relating to the provision of PGY2 education and commentary pertaining to potential solutions.
Importantly, it is increasingly understood that prevocational doctors in rural and regional centres may encounter differing clinical and educational challenges relating to the geography of their work. It is therefore critical that opportunities for tailoring of rural and regional education programs are considered in the development of new transition to practice models to best meet and support workforce needs.
The challenges
Prevocational doctors are a varied and disparate cohort with assorted specialty and career ambitions. However, despite their inherent heterogeneity, these doctors ultimately report a similar and consistent feeling of being lost within the vast hospital or health network system. To better understand this experience, it is important to first reflect on the roles that PGY2 doctors ordinarily assume due to current workforce arrangements.
Having completed the PGY1 internship, prevocational doctors obtain their general registration and have an increased capacity to work independently. Subsequently, they are utilised to complete service, external or nights rotations, and to give relief for the sick leave and annual leave of their peers. They may also cover inpatient ward jobs while their juniors and seniors are attending intern and registrar teaching sessions or assessments relating to their respective intern and registrar formal education programs.
In this way, prevocational doctors act as stop-gaps to prevent potential or actual discontinuity in clinical care, making it difficult to participate as hospital trainees in their own right. Indeed, even where PGY2 education programs are readily available, feedback provided to the JMO Forum of Victoria suggests that junior staff are frequently unaware of these opportunities, likely due to a disconnect between the doctor and the wider service.
The solutions
Prevocational education must become a protected and expected component of continuing professional development, supported from the top down. To address the complexities inherent in the provision of PGY2 education, solutions should be multifaceted and consider the needs for service provision, the logistics of attendance and participation, content-based concerns, and overarching hospital culture around work-based teaching and learning.
Suggested formats for education by junior doctors in Victoria have included the delivery of longer sessions, with drop-in/drop-out encouraged to allow for unexpected or urgent clinical tasks, and the need for a centrally accessible room to minimise physical time off the ward. The use of videoconferencing to external sites is felt to be underutilised, with preference for uploading of video recordings to an education portal or creation of online resources for self-directed learning and encouragement of night-based education models.
PGY2 education programs also should focus on new learning needs, and not simply be a repetition of intern education. Prevocational doctors are often preparing to assume more clinical responsibilities, including roles as registrars, and would find benefit from education relating to management of a clinical team, including delegation and delivery of feedback to junior staff, as well as other aspects of career progression.
Finally, pager and other announcement reminders relating to PGY2 education should be sent not only to prevocational doctors, but to senior nursing staff, senior clinicians and managers as relevant. This creates a culture of value around PGY2 education, and may improve integration of prevocational doctors within the service and support the development of formal structure within their roles.
The opportunities
Prevocational education represents an opportunity to close the gap between structured internship programs and specialty training programs as administered by the Colleges, with potential for reducing the experience of the “prevocational vacuum” and improving overall job satisfaction. All health services could benefit from increasing integration of PGY2 doctors into the continuing professional development pathway, with likely effects on recruitment and retention.
The specific impact that the “prevocational vacuum” is having on the already maldistributed rural health workforce is not clearly defined but may contribute to the persistent misconception that junior doctors have a reduced capacity to progress their clinical careers in rural and regional settings. This is particularly relevant in locations where small PGY2 cohort sizes resulting in low numbers at teaching can limit the feasibility of providing class-based educational opportunities.
To this end, it is our view that implementation of recommendations by the Review of Medical Intern Training must involve consultation with regional specialty training hubs in rural and regional settings. This will not only ensure that prevocational education is tailored to the region of service delivery and includes information pertaining to the progression of rural health careers but will also allow for integration of rural education models and improved coordination of training pathways from graduation to fellowship.
Conclusion
Junior doctor feedback is critical to identifying and understanding opportunities to enhance training in the prevocational space and is necessary for development of new transition to practice models. We believe that PGY2 education which is supported, accessible, structured and relevant has the potential to improve the “prevocational vacuum” experience, with flow on effects to recruitment and retention efforts, particularly in rural and regional settings.
We would like to thank members of the JMO Forum of Victoria for their role in collecting and providing feedback around the provision of PGY2 education in our state, and for stimulating this discussion. It is our hope that further, formal exploration of the prevocational experience will be undertaken within our state and nationally.
Dr Skye Kinder (PGY3) is passionate about rural and regional health, with particular interests in policy, workforce planning and service and process enhancement. She is currently an elected member on the Board for the Postgraduate Medical Council of Victoria. In 2017, she was named Victoria’s Junior Doctor of the Year. She can be found on Twitter @skyekinder.
Dr Danielle Taylor (PGY2) recently completed her internship in regional Victoria. In 2018, she represented Bendigo Health within the JMO Forum of Victoria, leading a project that explored PGY2 education needs. Her interests include surgery, medical education and rural health. She can be found on Twitter @DaniTaylor678.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.
And perhaps more forgotten those in uncredited / SRMO positions from PGY3 onwards. This group some times get some local m registrar teaching but often really slip though the gap
I thank the authors for their contribution to the discussion on the training crisis. But reforming the PGY2 year is the definition of kicking the can down the road. Nothing that the authors have proposed will rectify any of the issues posed by the training crisis, the most important of which might be the grossly protracted training times.
So whilst most of the suggestions in this article are good ones, they are flying under a false flag. Worse still, suggestions like these give the cartels – sorry – the colleges, the opportunity to claim that they are promoting reform, knowing full well that it will make no difference to the real issue: artificially restricted training places to prop up exorbitant (by world standards) private incomes in capital cities.
Militant (yes militant) action is needed. It is hard to see how anything other than an Australian wide walkout by all uncredited staff will result in any substantive improvement in this direst of situations. The UK strike has shown that such regrettable action can take place responsibly and without compromising patient care. It would, of course, mean that consultants would have to actually be in theatre or on the wards rather than in their private practice. If that were to happen I suspect previously ‘insurmountable challenges’ would be overcome very quickly. I mean, you’ve got to keep up with the Porsche payments after all…
Take a look at jdocs.surgeons.org – much of which is open access as a framework for PGY 2 and 2+
Need to consider years 1-2 as progression then the following 1 or more depending on when specialty programs start. Relevant to all medical fields.
Interesting article- there really needs to be more structure. Another major issue affecting junior doctors is a lack of physical facilities- the AMA recommends a bed per overnight worker, adequate meal (including some food provided) and recreation space- who has this? Residents quarters are almost universally and too small, sometimes even non- existent.
Thanks for an insightful article.
The challenge presented is to support learning in a context where there are so many challenges to a structured learning plan. A migratory workforce with a high variance in clinical exposure, endless 24/7/365 rosters, short staffing, opportunistic teaching requirements and ever-changing supervisors results in disconnected, incomplete training.
A range of platforms are already in existence to support learning in this environment – eg https://osler.force.com/juniordoctors – which require both top-down and bottom up support.
These platforms should not be viewed as digitisation of existing processes – rather, the should seek to provide educational support in new, more effective and more efficient ways. For example, an over-reliance on face-to-face learning for topics and concepts that can be provided in a more consistent and widespread manner (for example, online forums, modules etc) is intrinsically inefficient and supervisor-centric. To make a difference to this problem, both learners and teachers will need to become more comfortable with alternatives to traditional teaching methods