Rural general practice placements: alignment with the Australian Curriculum Framework for Junior Doctors

As part of the strategy to meet growing workforce demands in the Australian medical system, medical student numbers have been increased. In 2014, 3108 students are expected to graduate — up from 1335 in 2006.1 This growth is associated with challenges for education and training systems, including shortfalls in clinical placements and in adequate supervision for students and junior doctors. The growth also presents an opportunity to redress the current workforce maldistribution, but it is unrealistic to rely solely on a “trickle-out effect” that assumes increased numbers will lead to more medical graduates practising in traditionally underserved areas.

Consideration of alternative training settings provides an opportunity to explore socially accountable approaches in learning objectives and curricula,2,3 provision of high-quality clinical experiences in underserved populations4–6 and expansion of training options in rural areas. To ensure that students and junior doctors currently training are appropriately equipped to practise in a range of underserved areas, a strategic approach among educators and training institutions is required, including expanding training options in areas that are outside the traditional vocational training rotations.7–10

Offering general practice placements for interns is an important strategy for avoiding the expected shortfall of clinical placements and supervisors in the hospital system. While medical schools and vocational training are already providing training experiences in underserved areas such as rural sites, it is timely to investigate the option of a rural general practice placement during the intern year. Such placements must ensure that experiential learning is aligned with outcomes expected from the Australian Curriculum Framework for Junior Doctors (ACFJD). The ACFJD was designed by an experienced group of clinicians who outlined the knowledge, skills and behaviours required of junior doctors in postgraduate years 1, 2 and above. Areas covered by the framework include clinical management, professionalism, communication, skills and procedures, and clinical symptoms, problems and conditions. All clinical placements for prevocational doctors in Australia must meet the standards outlined in this framework. We have reviewed the available literature regarding skills and competencies gained by junior doctors in rural general practice placements, with particular reference to the ACFJD competencies.

Recommendations from a recent Senate report11 identified the need for a review of current literature to identify and develop a strategy to address gaps in research and knowledge affecting rural health service delivery (Recommendation 2). Although not a systematic review, our work provides a narrative review conducted in a systematic way. A recent publication12 stated that mixed methods reviews are an emerging field of research. The authors suggested that reviews in medicine using both quantitative and qualitative data should be considered within the scope of systematic reviews. Our literature review provides a starting point for documenting evidence related to rural training settings for junior doctors and the clinical skills they learn during a rural placement.

Methods

The review was undertaken in May 2011 using three different strategies. All strategies followed a similar systematic approach using the search criteria outlined in Box 1. Initially, articles published in English that reported rural placements for junior doctors were identified from the OvidSP and Scopus databases. The search terms for rural included definitions that incorporated regional centres as well as more rural and remote locations. Articles were identified by keywords, subject heading, title or abstract using criteria outlined in Box 1. Reviewers systematically worked through all the articles and then collated the relevant content under one or more core competencies outlined in the ACFJD.

A poor initial return rate meant the search was re-evaluated. Using the same criteria, we conducted a hand search of contents pages of relevant journals such as Medical Education, Academic Medicine, the Medical Journal of Australia and Australian Family Physician. Data were also sourced from reports, conference abstracts and grey literature available from government and other organisations (Box 2).

Articles reporting undergraduate and junior doctor outcomes in the same article were included, while articles reporting medical student outcomes were only included if they provided evidence of outcomes that would be transferable to junior doctors undertaking rural clinical placements. Articles were discarded if they focused on: topics outside the scope of this review; education and training needs of qualified general practitioners; general practice workforce or registrar issues, such as recruitment, retention, gender roles and training posts in rural hospitals; or undergraduate curricula or placements exclusively.

Results

The initial search strategy identified 389 articles from OvidSP, of which only two could be classified using the framework competencies, and 216 articles from Scopus, none of which were relevant to the framework. Eighty-nine papers were identified from the journals and 29 of these could be classified according to the framework competencies. Overall, 195 items were identified as potentially relevant. Of these, 36 articles and reports were included.

Publications ranged from 1997 to 2011. The highest number in any year was six in 2005. The countries most often included were Australia (17 articles or reports) and the United Kingdom (13). The most common research design used in the literature was qualitative (14 publications). This was followed by survey (9), retrospective cohort (7) and opinion piece (6). Box 3 outlines these results, and a summary of the relevant literature is shown in Appendix 1.

From these publications, we report learning outcomes for junior doctors training with rural GPs, including only documented skills and procedures. As we used data that were already in the public domain, ethics approval was not required.

Most of the literature initially identified as potentially relevant provided evidence about skills gained by medical students or vocational trainees in rural general practice placements, or the distribution of GPs in Australia, patient characteristics and reasons for encounters across a range of geographical locations. There was little published research covering the range of skills or competencies gained by junior doctors on rural clinical placements, especially non-traditional placements such as rural private general practices. The 36 articles and reports we identified as relevant focused on the advantages of junior doctor rural general practice placements for gaining advanced skills in communication and professionalism, as well as for developing autonomy in clinical management and decision making. Benefits for academic performance were also noted. Less evidence was available regarding exposure to particular clinical conditions, awareness of the impact of continuity of care, the development of specific clinical skills and the impact on later academic performance.

Advantages of rural placements

Academic performance

Academic performance covered formal assessments and supervisor reviews during clinical placements. Two reviews investigated differences in academic performance between undergraduate and postgraduate medical students undertaking rural and remote placements in the UK or United States.13,14 Neither found any difference between the academic performance of those on rural or remote placements compared with their urban colleagues. The UK review14 stated it was a myth that a general practice placement could affect career or academic performance,15 while the US review13 found two studies showing students on rural placements performed no worse than those on urban placements. Their key finding was that students on rural placements did as well as, if not better than, their urban counterparts.

In individual retrospective cohort studies from the US,16,17 Canada18,19 and Australia,20,21 findings were similar. There was no significant difference in performance between students and junior doctors training in urban settings compared with those in rural and remote settings.

Skills and procedures

A survey of ambulatory patients in an outpatient department and general practice in a remote Queensland town found that the types of patients seen in the outpatient department and private general practices were similar.22 It concluded that in remote Queensland, private general practices and outpatient departments could provide complementary placements for junior doctors.

Several studies demonstrated benefits of rural general practice placements for junior doctors. These included the opportunity to follow patients from general practice to hospital and back to general practice to experience the impact of continuity of care; development of a greater degree of autonomy, responsibility and confidence; more opportunities for procedural skills training; development of more discrimination in prescribing and requesting tests; and less tiredness due to the nature of the working day compared with hospital placements.23–25 Results from the Prevocational General Practice Placements Program (PGPPP), in which junior doctors participate in a general practice placement for 10–12 weeks (including the option of general practice clinics in rural and remote locations and with Indigenous communities), were similar. Outcomes from this program have shown that junior doctors’ procedural skills, communication skills and experience of continuity of care increase.26–28

Disadvantages of rural placements

A number of potential problems with general practice placements were identified. These included a greater sense of isolation from peers; extra costs associated with rural and remote placements, such as travel and cost of living; more on-call weekends than their urban counterparts; limits on the professional and physical capacity of a general practice to provide consulting rooms and supervision;24 ensuring appropriate indemnity cover; provision of suitable housing; and establishment of suitable education and support infrastructure. From an organisational perspective, issues raised included indemnity cover for junior doctors, training doctors and feeder hospitals; provision of housing to include families; and establishing education infrastructure to support junior doctors equivalent to that available for urban junior doctors.23,25

Alignment with the ACFJD competencies

We mapped the clinical skills and procedures that junior doctors are able to practise during a rural general practice placement, identified in the literature, against the five domains within the ACFJD. Results are shown in Appendix 2 and search references in Appendix 1. A number of additional skills were also identified. The findings are summarised below.

Professionalism

Professionalism competencies had the highest number of learning topics and individual items described in the literature.15,29–33 All individual learning topics were covered except “Practitioner in difficulty”, and nearly 50% of ACFJD professionalism competency items were mentioned.

Communication

Communication was the next most commonly mentioned domain. A rural placement is often the first opportunity for junior doctors to deal with patients as distinct individuals rather than just focusing on their illnesses.15,29–33 It has been shown that junior doctors participating in a rural placement program developed improved communication, self-assertiveness, the ability to practise preventive care and continuity of care with their patients and an increased understanding of Indigenous patients.26–28

Clinical management

Compared with urban practice, the range of problems encountered in rural general practice is likely to be broader, and clinical management more comprehensive. The learning topics we identified included systems knowledge; continuity of care and enhanced understanding of the interface between primary and subsequent care; history and examination; public health, problem formulation, investigations, referral and consultation; and discharge planning.22,33

Skills and procedures

Two articles identifying skills and procedures could be mapped to the ACFJD. These covered intramuscular injections,31 endocervical swab or Pap smear, assisting in the operating theatre, surgical knots and simple wound suturing, local anaesthesia, simple skin lesion excision, mental health and ophthalmic procedures.32 A number of articles reported exposure to procedural skills generally but did not provide specific examples that could be mapped directly to the ACFJD.15,26,29,30,33

Clinical problems and conditions

Clinical problems and conditions were usually described only in general terms. Examples included seizure disorders, joint disorders, chest pain and cough,15 sexually transmitted infections,31,32 dermatological conditions, contraception, nutrition and metabolic conditions, depression, infectious diseases, domestic violence32 and addiction.32,33

A number of areas were not specifically covered by the ACFJD but were mentioned in the literature as likely learning topics covered by junior doctors in rural general practice placements. These included assisting with childbirth; providing vaccinations; primary health care in Indigenous communities; deeper understanding of health and illness; otitis media and otitis externa; the lymphatic system and enlarged nodes; men’s health; medication and recognition of side effects and interactions; treating patients in context — both rural and Indigenous; and capacity for personal and professional growth.

Discussion

The available literature highlights the benefits of general practice placements for junior doctors in terms of developing professionalism, building rapport and communication skills with patients, and gaining an understanding of patients in context. The opportunity to develop clinical responsibility and professional identity was reported, and resulted in a strong sense of satisfaction. Some articles reflected opportunities to practise clinical or procedural skills in rural general practice settings and highlighted the importance of these placements in understanding the interface between primary care and secondary or tertiary care systems.

While our review has identified rural general practice placements for junior doctors as excellent training opportunities aligned with many of the ACFJD competencies, there is a lack of credible research evidence identifying and documenting specific clinical skills and procedures. Much of this review relies on professional experience in reports and other non-peer-reviewed documents. It is likely that there is some underreporting of clinical rural general practice experiences, and the results reported may not be generalisable to all rural general practice placements. However, this strengthens the argument for more robust research into the educational value of internship posts in these settings at this point of the medical education continuum, and the barriers to creating them.

While relatively little research has been published confirming the value of non-urban general practice settings for intern and junior doctor learning, particularly against the competencies identified in the ACFJD, there is evidence of high-quality learning experiences and outcomes for placements in community and non-urban locations at the undergraduate medical student level and at vocational training level.21,22 There is also evidence of a wide range of clinical conditions managed, patient demographics and investigations occurring in rural general practices when compared with urban practices.34,35

Rural general practice placements have the potential to be as beneficial for junior doctors as hospital placements, and provide complementary learning experiences.10 As increasing numbers of medical graduates enter the health system, alternative placements to tertiary hospitals are required to provide high-quality clinical training while developing the aptitude, interest and skills of junior doctors for subsequent practice in areas of high unmet need.9

Many of the competencies identified in the ACFJD should be achievable in rural general practice placements, contingent on adequate supervision and mentoring. However, the placement must be of similar quality to more traditional placements, with facilities available for junior doctors to consult, learn, study and seek advice. Building the capacity of a small number of distributed teaching sites as teaching centres of excellence, resourced with adequate preceptor training and support, may be one way of furthering this agenda.35 Implementation of a rural general practice placement during the intern year is an important strategy for ameliorating expected training pressures in the health system while broadening the range of experiences available to junior doctors.

1 Search criteria

Criteria

Search terms

Training level

Junior doctor, intern, post graduate year (PGY) 1,2

Specialty of general practice

General practitioner, family physician, rural doctor/specialist

Location

Australian Standard Geographical Classification-Remoteness Areas 2–5 (inner regional, outer regional, remote, very remote)

Rural, Remote Metropolitan Areas 3–7 (rural classifications, Rural 1–3; remote classifications, Remote 1–2)

United States, United Kingdom, Canada, New Zealand, South Africa

Time period

1997–2011

2 Data sources for search

Source

Organisations

Australian Government

Health Workforce Australia, Australian Institute of Health and Welfare, National Health Workforce Taskforce

State and territory governments

General practice training providers

Peak bodies

Australian College of Rural and Remote Medicine, Royal Australian College of General Practitioners, Rural Doctors Association of Australia, Confederation of Postgraduate Medical Education Councils, Australian General Practice Training program

Non-Australian organisations

United Kingdom General Medical Council, Royal College of Physicians and Surgeons of Canada, World Organisation of Family Doctors (WONCA)

Reference lists

Material discovered when reading articles, reports and other literature

3 Literature summary

	Number
Year

1997	1
1999	2
2000	2
2001	3
2002	3
2003	4
2004	3
2005	6
2006	3
2007	2
2008	2
2009	2
2010	1
2011	2
Total	36
Country
Australia	17
Canada	4
Denmark	1
Ireland	2
United Kingdom	13
United States	3
Total	40
Research design
Randomised crossover	1
Retrospective cohort	7
Survey	9
Qualitative	14
Review	3
Descriptive	1
Opinion	6
Total	41*

* Five articles that fitted into two categories (four qualitative/surveys and one opinion/survey) are counted twice.

Murra Mullangari — Pathways Alive and Well

A clinically qualified and culturally competent Aboriginal and Torres Strait Islander health workforce is vital if Australia is to make a difference to Indigenous health

The Murra Mullangari — Pathways Alive and Well program is an initiative of the Australian Indigenous Doctors’ Association (AIDA) in partnership with other peak Indigenous organisations. Using culture and identity as a strength, the program was developed with the aims of building the aspirations and capacity of Aboriginal and Torres Strait Islander senior high school students to remain in the academic pipeline and pursue careers in health.

In the language of the Ngambri people, upon whose lands the inaugural program was held, Murra is the path and Mullangari is health and wellbeing coming from the ceremonies, including the Bogong Moth Ceremony.

The program was informed by the Patty Iron Cloud National Native American Youth Initiative, run in Washington DC each year by AIDA’s peer organisation — the Association of American Indian Physicians. After attending the program in 2010, three senior members of AIDA returned committed to establishing a similar program across all health careers, rather than just medicine and biomedical research. After almost 2 years of seeking financial support for an Australian program, commitment was given by the Australian Government to establish a pilot program in June 2012.

In April 2013, the inaugural Murra Mullangari — Pathways Alive and Well program commenced, with 30 Indigenous senior secondary students (from almost 200 applicants) travelling to Canberra to participate in a 5-day residential component, which included a traditional welcome to country by Aunty Matilda House at the Aboriginal Tent Embassy, a smoking ceremony and the warm words of former Governor-General and AIDA Patron, Sir William Deane, who highlighted the importance of education and the pursuit of dreams.

The students visited local and national institutions such as the Winnunga Nimmityjah Aboriginal Health Service, the Australian Institute of Aboriginal and Torres Strait Islander Studies and the Australian Institute of Sport. Participants took part in interactive workshops at the Australian National University Medical School and University of Canberra Faculty of Health, as well as learning about university entry pathways and support at the Tjabal and Ngunnawal Indigenous Higher Education Centres. The program also featured workshops led by current health professionals in the disciplines of medicine, exercise science, nutrition, Aboriginal health work, psychology and nursing.

Murra Mullangari Facilitator Gregory Phillips encouraged participants to express themselves and their aspirations through painting. This artwork is a combination of the reflections of all 30 participants along with the program staff, facilitator and group leaders, on culture, the Murra Mullangari experience and their continuing personal goals.

Murra Mullangari partners continue to seek funding support to run further programs and would welcome contact from any MJA readers.

Murra Mullangari — Pathways Alive and Well. By 2013 participants, facilitator, group leaders and program staff.

Students as teachers

Medical students have been teaching their colleagues for generations

In 2013, Silbert and colleagues have taken a “modern” look at students teaching their colleagues.1

Eighty-nine years ago, my father failed anatomy. During his repeat year, the students at his dissection table asked him, their more “experienced” colleague, for help. That year, he passed anatomy with a distinction.

After gaining his Fellowship of the Royal College of Surgeons (FRCS) (Edinburgh), he served as a surgeon in the North African and Italian campaigns. Returning to South Africa in 1946, he asked the Foundation Professor of the Department of Anatomy at the University of the Witwatersrand in Johannesburg — the well known Australian, Raymond Arthur Dart — if he could teach anatomy. Dart said that he had no money to pay him, but that he could teach part-time if he wished.

After a year of unpaid teaching, Dart explained that he had been testing him, and that he could have an appointment as a lecturer (later senior lecturer and then reader) at a full-time salary for part-time work. Dart wanted him to keep up his surgery so that he could teach practical and surgical anatomy.

In 1960, my father left South Africa in protest at the government’s apartheid policy.

Many generations of students in South Africa,2 Australia, the United States3 and Israel learnt their anatomy from him. Here he taught anatomy to students at the University of Queensland, the University of Sydney4 and the University of New South Wales.

Doubtless many readers of this little piece would have been taught by him. There was nothing like being asked by him to have pen and paper ready and to write down the answer to his anatomical question — then to watch him study the class roll, call out your name — ask who was sitting next to you, and then tell you to look at what he or she had written and to tell it to the class!

He claimed that his best teacher was a London surgeon who arrived to lecture to primary FRCS candidates. “Today, gentlemen [there were no ladies doing surgery in the 1930s], we will discuss the surgical anatomy of the stomach. Are there any questions?”

“No? In that case, tomorrow we will discuss the surgical anatomy of the breast. Good day!” and he walked out.

My father learnt, the next day, through an avalanche of questions to the lecturer, more about the surgical anatomy of the breast than he had ever been taught. And so it continued throughout that course, influencing his later teaching methods.

“Students as teachers” — it’s been going on, to my personal knowledge, for almost a century.

In memoriam, Maurice (Toby) Arnold.

Maurice (Toby) Arnold (1907–1994)

Veterans told: Govt does not pay gym memberships

The Government is cracking down on war veterans attempting to claim benefits for gym membership and participation in general exercise programs.

The Department of Veterans Affairs and Exercise and Sports Science Australia have jointly launched an education campaign to warn veterans and exercise physiologists that gym and exercise program memberships are not covered by the Commonwealth, and attempts to claim benefits are in breach of guidelines.

In a letter announcing the crackdown, senior DVA official Letitia Hope said the Department had “identified that, in some instances, exercise physiology services were being provided inconsistent with policy requirements.

Ms Hope said the Department funded exercise physiology as a specific form of treatment, and its duration was to be determined by clinical necessity.

“The aim…is for the exercise physiologist to devise an exercise regimen for the patient’s condition, and to provide the patient with th skills to manage the exercise component of their treatment on their own,” she wrote.

“DVA does not fund ongoing, regular participation in exercise programs or ongoing group exercise supervision by exercise physiologists.

“If veterans wish to continue with an exercise program following their treatment, it becomes a private arrangement between the veteran and the gym or exercise physiologist.”

Ms Hope said it was long-standing Department policy not to pay for gym memberships or general exercise programs.

Adrian Rollins

Abbott Govt starts to wield the scalpel

Department of Health secretary Jane Halton has admitted that “hundreds” of jobs will go amid signs the Abbott Government is eyeing off major spending cuts in health, including the Pharmaceutical Benefits Scheme.
Appearing before a Senate Estimates hearing on 20 November, Ms Halton dismissed media speculation that her department was set to shed 350 jobs, instead intimating that the final number of positions cut could well be more.
“It will undoubtedly be in the hundreds,” she said. “There is no doubt about that. It is not in the thousands, and it is not below 100.
“Will it be precisely 350, as The Canberra Times and various other people have claimed? I think the answer to that is no.
“Will it be that order of magnitude? I think it is very difficult to say, other than within a range.”
Earlier, a senior Health official admitted the Department was in “some state of structural flux”, and was still determining where to allocate staff and identify redundant positions.
But the official denied there would be any forced redundancies.
A number of agencies have come under close scrutiny from the new Government, which has launched reviews of Medicare Locals and the Australian Institute of Health and Welfare, and is believed to be looking closely at the operations of Health Workforce Australia and the National Health Performance Authority.
Apprehension of severe cuts in the health sector has been heightened by the Government’s shock decision last week to immediately axe all funding to the Alcohol and Other Drugs Council of Australia – just seven months after it had been given a written assurance its funding was secure until July 2015.
The Commission of Audit, appointed by the Government to identify savings, has raised the prospect of cuts to the Pharmaceutical Benefits Scheme, according to The Australian, warning that subsidies for some medicines may become unaffordable in the longer term.
In a pointer to where it is looking for saving, the Commission has in recent held discussions about health funding, the PBS, the National Disability Insurance Scheme and school funding, The Australian said.
Health Minister Peter Dutton has repeatedly assured the health sector that the overall health budget will not be cut, though funds were likely to be reallocated in line with the Government’s policy priorities.
But confidence in these assurances has been tested after the Government appeared to walk away from its pre-election commitment to implement the Gonski reforms to school education.
Adrian Rollins

Reports indicate that changes are needed to close the gap for Indigenous health

Major changes in health services are needed to redress health disparities

Two recently released reports from the Australian Institute of Health and Welfare (AIHW) make it clear that there must be major changes in the way health services for Indigenous Australians are delivered and funded if we are to improve Indigenous health and health care and ensure real returns on the substantial investments that are being made.1,2

These reports show Australia’s level of financial commitment to Indigenous health. In the 2010–11 financial year total spending on Indigenous health was $4.552 billion,1 almost double that spent in 2004–05. This was $7995 for every Indigenous Australian, compared with $5437 for every non-Indigenous Australian;1 over 90% of this funding came from governments. The surest sign that this money was not well invested in prevention, early intervention and community services is that most of it (on average $3266 per person but $4779 per person in remote areas) was spent on services for patients admitted to hospitals, while spending on Medicare services and medicines subsidised by the Pharmaceutical Benefits Scheme (PBS) on a per-person basis was less than that for non-Indigenous Australians by $198 and $137, respectively.2

The series of AIHW reports since the 1995–96 financial year highlights both where progress has been made and where programs have failed. There have been considerable increases in funding for primary care, acute care and community and public health. The 2010–11 data do not reflect the full implementation of the Indigenous Chronic Disease Health Package, but do suggest that the measure to subsidise PBS copayments for patients with chronic disease is having an effect, specifically in more remote areas where PBS spending is higher than in regional areas.

On the other hand, it is obvious that access to primary care services in remote areas remains limited, and access to referred services such as specialists and diagnostics is poor for Indigenous people everywhere, even in major cities. Per-person spending on non-hospital secondary services is about 57% of that for non-Indigenous people.2 Indigenous Australians receive nearly all their secondary care in hospitals.

The hospital data hammer the story home. In 2010–11, the overall age-standardised separation rate of 911 per 1000 for Indigenous people was 2.5 times that for non-Indigenous people; for people living in the Northern Territory the rate was 7.9 times that for non-Indigenous people.3

About 80% of the difference between these rates was accounted for by separations for Indigenous people admitted for renal dialysis, but further examination highlights how a lack of primary care and prevention services drives increased hospital costs. In 2010–11, total expenditure on potentially preventable hospitalisations for Indigenous Australians was $219 million or $385 per person, compared with $174 per non-Indigenous Australian.3 For all Australians most of this spending is for chronic conditions like complications from diabetes, but, too often, Indigenous Australians are hospitalised for vaccine-preventable conditions like influenza and pneumonia, acute conditions like cellulitis, and injury.

Avoidable hospitalisations are an important indicator of effective and timely access to primary care, and provide a summary measure of health gains from primary care interventions. The inescapable reality is that current primary care interventions are not working.

We know what the problems are. Around two-thirds of the gap in health outcomes between Indigenous Australians and other Australians comes from chronic diseases such as cardiovascular disease, diabetes, respiratory diseases and kidney disease.4 Suicide and transport accidents and other injuries are also leading causes of death.5 Half of the gap in health between Indigenous and non-Indigenous Australians is linked to risk factors such as smoking, obesity and physical inactivity.6 A number of studies have found that between a third and half of the health gap is associated with differences in socioeconomic status such as education, employment and income.7

The 2006 Census (the latest available data) found that 39% of Indigenous people were living in “low resource” households (as defined by the Australian Bureau of Statistics8), almost five times the non-Indigenous rate.9 Such disparities in income limit Indigenous people’s capacity to pay for health care and provide some context for why they are more likely to use public hospitals than privately provided services that require copayments.

There are commitments from all the major stakeholders, political parties and policymakers to close the gap. There is a new National Aboriginal and Torres Strait Islander Health Plan 2013–2023. And, arguably, there are enough funds if these are spent wisely. What is needed is a new approach to how health care is developed for and delivered to Indigenous Australians.

The approach needs to be grounded in three broad principles:

Adhering to the principle of “nothing about me without me”.10 Shared decision making must become the norm, with patients and their needs at the centre of a system they drive.
Addressing the social determinants of health, in particular, the impact of poverty.
Addressing cultural barriers in the way that Indigenous people want.

These are not new ideas and all the right words are in the new national health plan, as they were in the previous strategy document — cross-portfolio efforts, partnership, sustainability, culturally competent services, community, a rights-based approach to providing equal opportunities for health. What we must do is move beyond these fine words to meaningful action.

We have the exemplar of how to do this with Aboriginal Community Controlled Health Organisations (ACCHOs), and we need to (i) provide increased opportunities for engagement, collaboration and service delivery with ACCHOs and (ii) expand this way of working into mainstream services. This will require a different approach to policy development and implementation.11

The key barriers to health care for urban and remote populations alike relate to availability, affordability and acceptability12 and the dominance of biomedical models of health.13 ACCHOs are a practical expression of self-determination in Indigenous health and health service delivery,14 and have been very successful at reducing many of the barriers that inhibit Indigenous access to mainstream primary care.15 Importantly, ACCHOs provide both cultural safety, which allows the patient to feel safe in health care interactions and be involved in changes to health services, and cultural competence, which reflects the capacity of the system to integrate culture into the delivery of health services.16

However, the success of the design and work practices of ACCHOs have had little influence on the mainstream health system17 which remains, necessarily, the source of health care for many Indigenous people. And it can be argued that the current funding and regulatory practices of Australian governments are a heavy burden and consume too much of the scarce resources of ACCHOs in acquiring, managing, reporting and acquitting funding contracts.18

Governments and all stakeholders, including Indigenous people themselves, need to be bold enough to redesign current mainstream health policies, programs and systems to better fit Indigenous health concepts, community needs and culture. This approach should not be seen as radical — it is where we are currently headed with Medicare Locals. We should not ignore the fact that ACCHOs have led the way in developing a model of primary health care services that is able to take account of the social issues and the underlying determinants of health alongside quality care.19 Tackling these reforms will therefore benefit all Australians, but especially those Indigenous people who currently feel disenfranchised. Without real and meaningful change, we are all condemned to more government reports bearing sad, bad news and a continual yawning gap of Indigenous disadvantage.

Doctors ahead in slow early going

Doctors and other professionals have emerged as one of the early winners from the 2013 Federal election campaign after Labor decided to defer its highly unpopular cap on tax deductions for self-education expenses.

While the AMA and more than 60 other professional organisations, business groups and education providers remain committed to having the measure scrapped, the Federal Government hopes to have drawn much of the short-term electoral sting out of the issue by holding the introduction of the cap over until mid-2015.

But, aside from this move – made on the eve of the campaign proper – the Australian Greens have made most of the early running.

Even before the election was called, they had flagged they would reinstate indexation of Medicare rebates.

Barely a week later, the Greens again grabbed the initiative by promising to establish – as per AMA policy – an independent panel of medical experts to monitor and report on health care for asylum seekers being held in detention.

They followed this up with a commitment to “stop the bombardment” of junk food advertisements on television directed at children.

The announcements overshadowed a commitment by Labor to provide $20 million to prevent, research and manage foetal alcohol spectrum disorder, which has blighted the lives of many children, particularly from disadvantaged communities.

Even less visible has been the Coalition, which has so far largely kept its own counsel on health policy.

Adrian Rollins

Promises, promises….

Who has promised what on health policy so far…

Announcement	Date	Cost	Comment/reaction
Labor
$2000 cap on tax deductions for self-education expenses deferred 12 months to mid-2015	2 August	$250 million over four years	AMA and Scrap the Cap Alliance vow to continue fighting measure; Coalition yet to comment
Medicare rebate indexation frozen to mid-2014	14 May	$664 million	Greens promise to reinstate indexation
Foetal alcohol spectrum disorder strategy	6 August	$20 million
Coalition
Medicare Locals to be reviewed	24 May	n.a.
Medibank Private to be sold off		tbc	Greens don’t rule out supporting sell off
Private health insurance means test to be scrapped	24 May	tbc
Government policy to cap indexation of private health insurance rebate backed	27 May	$700 million saving
National Health and Medical Research Council funding guaranteed	24 June	$3.7 billion
Greens
Medicare rebate indexation reinstated	27 July	$600 million
Independent Health Advisory Panel to oversee asylum seeker health care	6 August	$2 million
Universal dental care	27 July	tbc
Ban on junk food ads to children	8 August	n.a.

n.a. – not applicable

tbc – to be confirmed

Students as teachers

Students who learn to teach effectively may facilitate other students’ learning and their own

Few would challenge the assertion that senior doctors play a vital role in teaching and supervising peers, junior colleagues and students. Junior doctor teaching of medical students is also significant, and students estimate that up to one-third of their knowledge can be attributed to junior doctors.1 Effective teaching is a learned skill; teaching workshops develop and refine teaching skills, improve attitudes towards teaching and may introduce new teaching tools.2 Such “faculty” development, although more available these days, still remains optional for many, and particularly for junior doctors, learning such skills may compete with patient care responsibilities and specialty training.1

We believe Australian medical schools should strongly consider implementing a comprehensive, vertically integrated student teaching program employing peer-assisted learning (PAL). PAL refers to “people from similar social groupings who are not professional teachers helping each other to learn and learning themselves by teaching”.3 Through PAL, students learn how to teach and give feedback, and under supervision are given the chance to practise and consolidate these skills. It has been used successfully to teach theoretical information, as well as procedural and clinical examination skills to medical students in small group settings.4,5 Although most evidence is based on predominantly extracurricular programs in American and European medical schools, an extracurricular program at the University of Western Australia (UWA) has recently been described with similar findings.6

Recent publications offer detailed discussions of many issues related to the implementation of PAL.4,7 A number of practicalities deserve special consideration in the Australian context, and in this paper we offer recommendations on how these issues might be approached.

Should learning to teach be compulsory for all students?

We are strongly in favour of compulsory teaching skills training. The ability to teach effectively from day one is an essential skill for junior doctors, both to improve the doctor–patient interaction (explaining medical information to patients) and because of their involvement in student teaching. In addition, the structure of a hospital medical or surgical team is in fact an example of PAL, where the difference in experience between teacher and student may be as small as 1 year.8 Completion of a comprehensive training course will not only equip students with the skills required to teach, but will also improve their personal learning effectiveness and communication skills.4,5 The latter is especially important, as evidence suggests that communication is a learned skill that requires specific training, rather than a skill developed purely through experience.9 Increasing awareness of the importance of communication skills training has seen it become a core component of medical curricula in recent years, and we consider teaching skills training to be an important but necessary extension to this.

Should all students be required to teach?

Challenges associated with involving all students in teaching activities include capacity, and difficulties with engaging unenthusiastic students or those who are poor teachers or struggling students themselves. Commitment to teaching is an important characteristic of effective teachers, and students who are forced to participate in PAL are unlikely to demonstrate this.10 Ultimately, the ability to practise and develop effective teaching methods will confer the greatest gains to tutors and thus tutees. In addition, the experience of teaching increases students’ confidence, reduces anxiety and may increase the likelihood that they will participate in teaching as a junior doctor.4,5

At what stage of the curriculum should PAL be introduced?

The specific stage at which it is appropriate for PAL to be introduced will differ depending on a number of factors, including the type of course (undergraduate or graduate entry), course duration, and the tutorial content (eg, theory or clinical skills). It seems logical that PAL should be introduced early in the medical curriculum in order to allow skills to develop and maximise benefits. PAL has successfully been implemented using tutors and tutees from all stages of the medical course,5 including first-year students for whom the ability of peer teachers to alleviate anxiety may be particularly valuable.8 PAL is a versatile teaching tool and has been applied to the teaching of theory, procedural skills, peer physical examination and the examination of hospital patients.4–6

How will tutors be trained?

Adequate tutor training is an important element of any teaching program, and a number of papers offer recommendations about the content of training courses.4,7 Adult learning theory and the principles of effective teaching should be discussed with particular emphasis on the settings in which PAL tutorials will be conducted (eg, small group discussions, bedside tutorials, procedural skills training). Training on how to give constructive feedback and how to evaluate one’s own teaching is important, and an interactive workshop that provides students with the opportunity to practise teaching and receive feedback from their peers is highly desirable. PAL tutor training courses described in the literature are often delivered in short, focused sessions just before the first scheduled tutorial.7 Ongoing periodic training throughout the medical course and continuing into postgraduate training is likely to consolidate and further develop skills.4 Ideally training would be delivered by PAL supervisors who have obtained higher degrees in education and have extensive teaching experience.

Medical schools in and are fortunate to have a comprehensive “how to teach” course readily available for training student tutors. Teaching on the Run (TOTR) is an internationally recognised training course that was developed in Perth, WA, specifically designed to improve the teaching skills of clinicians in a busy clinical setting. At UWA a modified TOTR course, co-facilitated by a senior clinician and a senior student, is delivered to student tutors. It focuses on the skills required to teach in a PAL context, including how to teach with patients, and has been shown to be well received.6

How should student tutors be assessed?

The most appropriate methods of evaluation will differ between individual PAL programs depending on a number of factors, for example the content of tutorials and the availability of resources.7 Appraisal of tutor performance is likely to be most reliable if obtained from a combination of experienced faculty teachers, fellow student tutors and tutees. In addition, both qualitative and quantitative methods of feedback are important. The most valuable feedback for tutors may be informal (preferably anonymous) feedback from tutees after each tutorial, as they are the ones who can best comment on teaching effectiveness and have the most to gain from improving tutor performance. Feedback from fellow tutors and faculty teachers is an important supplement to that from tutees as it can be used to evaluate the tutor’s use of teaching principles and techniques. We suggest that tutorials should be observed periodically for this purpose, and that tutors should also be able to request formative evaluation and feedback from experienced teachers. Formal testing of tutee knowledge using quizzes before and after tutorials may also be useful as an objective measure of tutorial outcomes and will facilitate quality control.

It is important to consider whether the teaching ability of students should be formally assessed if student tutors are to have a formal role within the medical curriculum. Although it is imperative to ensure that both their level of knowledge and standard of teaching are adequate, introducing formal assessment may risk adversely affecting student willingness to participate or attitudes towards teaching. For this reason, if formal assessment is to be performed we suggest that a pass or fail rating be used rather than a numerical score. One method by which teaching skills could be formally assessed (if required) is through the inclusion of a “teaching station” in end-of-year examinations. For example, instead of instructing candidates to suture a wound they could be asked to teach a “student” how to do it.

Further potential challenges

Challenges commonly faced when introducing PAL programs include finding adequate time (for tutor training and PAL tutorials) and inadequate resources (both human and financial, for the development, monitoring and evaluation of PAL).7 This issue will be best addressed by educators if considered during the planning stage of implementation, ideally in the context of curriculum restructuring.

Conclusion: why now?

Increasing awareness of the benefits associated with PAL and developing students’ teaching skills has seen a surge in the number of overseas medical schools providing tutor training programs linked to PAL opportunities. Despite this, Australian medical students are missing out: few of our medical schools provide teaching skills training for students (own unpublished data). A number of Australian medical schools have recently completed or are currently undergoing course restructuring, offering an excellent opportunity to formally implement a vertically integrated PAL and teaching skills program into medical curricula. Students will gain experience and confidence in teaching, improve their communication skills, and benefit from the ongoing process of revision and reinforcement of core medical knowledge. These skills may facilitate a more therapeutic doctor–patient relationship, and increase the student’s enthusiasm for future teaching in a postgraduate setting.

Global health training and postgraduate medical education in Australia: the case for greater integration

To the Editor: We read with interest the viewpoint offered by Mitchell and colleagues, highlighting the need for improved integration of global health training in postgraduate medical education in Australia.1 This subject has garnered interest in Australia and overseas with reference to ophthalmology. In the United Kingdom, the case for structured global health training has been advocated in ophthalmology postgraduate education, where financial and bureaucratic disincentives inhibit motivated trainees from broadening their clinical experience overseas.2 The Royal Australian and New Zealand College of Ophthalmologists (RANZCO) received a grant from The Fred Hollows Foundation to develop the International Ophthalmology Development Register (IODR), which is available to RANZCO Fellows and final-year trainees. The IODR seeks to match the knowledge, skills and experience of those interested in global health ophthalmology with the needs and opportunities of training hospitals, non-government organisations and educational institutions within the Asia–Pacific region.3 Additionally, the IODR also includes a database that lists opportunities for international medical graduates from the Asia–Pacific region to undertake fellowships or observerships in Australasian teaching hospitals.3 Since going live in June 2012, the IODR has received over 100 registrations from these organisations and international medical graduates, and has had visits from individuals from over 60 countries.3 RANZCO has formed a set of good-practice guidelines for international development, aimed at trainees and Fellows planning to work in developing countries.4 Principles inherent in these guidelines include ensuring ethically appropriate, high-quality clinical practice, promoting sustainability of eye care programs and teaching eye care appropriate to communities’ needs.