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

To the Editor: Mitchell and colleagues have done medical education a service by outlining all the potential benefits and harms associated with global health training.1 They are right to state that sustainability is key — however, all too often in the past, it has been sustainability that has been lacking. According to Yikona, writing in 2003: “Case by case analysis of medical schools in sub-Saharan Africa would show an excellent first 10 years followed by a general downward spiral”.2 How are we to stop global health training going into a similar downward spiral?

There is unlikely to be a single answer, and potential answers are more likely to be found by looking forward rather than backward. The current technological revolution may, for example, have a profound impact on how we view global health training. In the past, doctors have had to travel to new locations to deliver education but today that is no longer necessary. Medical education may be delivered by means of synchronous video-conferencing over the internet. Surgeons can demonstrate new procedures by this means; physicians can diagnose patients with physical signs using teleconsultation; lecturers can simply lecture. Medical schools can put all their educational resources online and make them freely available to any learner in any country — to access them at a time and place that suits them.3 Curricula can be exchanged, improved and localised as they are transferred from one country to the next. Medical education may thus be delivered by fully qualified experts, rather than by doctors in postgraduate training.

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

In reply: We thank Walsh for highlighting that sustainability is a critical challenge in global health training (GHT) programs and that technology is creating new options for international engagement. He has also articulated a vision of qualified specialists taking a greater role in the delivery of clinical education in resource-poor settings. We share this aspiration.

One of the end points of GHT is a lifelong commitment to international education and collaboration. We envisage a future where significant numbers of Australian doctors participate in institutional relationships with health services and education providers in resource-poor settings. Technology might be exploited to deliver remote education and enhance supervision, with the overall effect of building local capacity. These partnerships should be mutually beneficial.

Several Australian hospitals and colleges have successfully developed longitudinal relationships with health services abroad. Senior trainees should contribute to these collaborations, in part because learning how to foster international partnerships is a key component of GHT. Although there are barriers to registrar involvement, we believe it is an important factor in ensuring sustainability.

Partnership and leadership: key to improving health outcomes for Aboriginal and Torres Strait Islander Australians

The Australian Indigenous Doctors’ Association urges all medical professionals to support and participate in the values it hopes will be embedded in future health policy

This year, we will see the development of a new National Aboriginal and Torres Strait Islander Health Plan to guide governments in improving the health of Aboriginal and Torres Strait Islander Australians.1 Development of the Health Plan will be led by the Minister for Indigenous Health, with the support of a stakeholder advisory group to bring together the government and organisations with expertise in Indigenous health.2

The aim of this Health Plan is to shape the tone, direction and content of Indigenous health policy into the future. Apart from becoming familiar with the evidence and government priorities on areas of Indigenous health that relate to our work, medical professionals should note the particular values and themes that the Australian Indigenous Doctors’ Association (AIDA) wants to see embedded throughout the document; these include culture, partnership, Indigenous leadership and workforce. These principles are inextricably linked and are important not only to federal policy development and implementation but also to individual medical professionals in a range of areas, including in our day-to-day interactions with patients, care planning and staff recruitment and development.

Workforce will need to be an important feature of the Health Plan because building an adequate health workforce is crucial to delivering high-quality, sustainable health services for Indigenous people. The Indigenous medical workforce in Australia is growing, but Indigenous people are still underrepresented in this area. In 2011, the intake of first-year Indigenous medical students in Australian universities reached parity at 2.5% — for the first time matching the proportion of Australia’s population made up of Indigenous people.3 To ensure that the Indigenous medical workforce continues to grow, academic, professional and cultural support is essential. In particular, Indigenous medical students and doctors are more likely to stay and thrive in learning and working environments that consistently demonstrate cultural safety.3

The solution to both a stronger workforce and further improvements in Indigenous health is partnership: our people working alongside non-Indigenous people in order to achieve an agreed goal. Such partnerships are seen in collaboration agreements which spread across the medical education continuum. Agreements currently exist between AIDA and Medical Deans Australia and New Zealand, and AIDA and the Confederation of Postgraduate Medical Education Councils; an agreement will soon be launched between AIDA and the Committee of Presidents of Medical Colleges. This collaboration did not happen overnight; it was a lengthy process, with trust being built over time and through each organisation demonstrating its commitment to improving Indigenous health. These best-practice models are available on the AIDA website (http://www.aida.org.au/partnerships.aspx) and should be recognised by all medical professionals as a best-practice framework for improving Aboriginal and Torres Strait Islander Health.

For Aboriginal and Torres Strait Islander peoples, health is not just about an individual’s physical wellbeing; it is a holistic concept that encompasses the social, emotional and cultural wellbeing of the entire community. AIDA asserts that the Health Plan needs to embed Aboriginal and Torres Strait Islander cultures at its centre in recognition of the importance of culture to the health and wellbeing of Indigenous people. As medical professionals, we must also embed culture in the provision of health services to Aboriginal and Torres Strait Islander people, as evidence shows correlations between increased cultural attachment and better health and wellbeing.1 In achieving this, it is important that the Health Plan

be developed and conducted through genuine partnerships between governments, Indigenous organisations and communities, not only because such an approach is consistent with what is contained in the United Nations Declaration on the Rights of Indigenous Peoples, but because it makes good sense.4

AIDA recommends creating strong partnerships with Indigenous organisations and communities to guarantee Indigenous participation in decision making and showcase strong Indigenous leadership in communities.3

Aboriginal and Torres Strait Islander leadership, particularly through the peak national health bodies, is paramount in providing government with professional advice from Indigenous health practitioners in developing the Health Plan.3 AIDA recognises that Aboriginal and Torres Strait Islander community-controlled health organisations play a central role in the health of Indigenous people; however, it is also important that members of the non-Indigenous mainstream health workforce play their role in delivering equitable services for Aboriginal and Torres Strait Islander people. It is expected that the National Aboriginal and Torres Strait Islander Health Plan will be released later this year. I encourage you, upon reading it, to ask yourself what your role is in delivering quality and culturally appropriate health care to Aboriginal and Torres Strait Islander people, and to consider how this role could be strengthened. As members of the health workforce, we need to locate ourselves within the Health Plan and implement strategies in partnership with Indigenous communities and organisations. AIDA argues that this combination of strategic action and partnership is critical to achieving equitable health and life outcomes for Aboriginal and Torres Strait Islander people.

Refining the concept of cultural competence: building on decades of progress

The impact of culture in the clinical encounter is recognised as a contributing factor to patterns of health service utilisation and is a key focus of cultural competence training.1,2 While some studies have identified beneficial effects of cultural competence on health professionals’ knowledge, attitudes and skills, and on levels of patient satisfaction, few have explored its effects on health outcomes. This is unsurprising given that the factors affecting health outcomes are numerous and complex. The Commission on Social Determinants of Health has noted that health inequalities are largely related to the circumstances of people’s lives and to the services available to treat illness.3 In turn, people’s circumstances and the health care system are shaped by social, political and economic realities. Cultural knowledge is embedded in these circumstances and realities, and helps frame patients’ explanatory models of illness and clinicians’ decision making.2 It has been argued, however, that these two world views can collide in the clinical encounter.4 Cultural competence training aims to improve the quality of health care and reduce health disparities by focusing on communication and trust between patients and health care providers and enhancing provider knowledge about sociocultural factors linked to health beliefs, practices and utilisation of services.5

The idea of educating health professionals to be culturally competent began in earnest in the United States in the 1990s. The term “cultural competence” first emerged in the late 1980s and was defined as “a set of congruent behaviors, attitudes, and policies that come together in a system, agency or amongst professionals and enables that system, agency, or those professionals to work effectively in cross-cultural situations”.6 Cultural competence in health care was described as an emerging field in the US in 2002; however, over the past decade it has become firmly embedded in professional accreditation standards.7 In Australia, health professional competencies consistently make reference to cultural competence,8,9 and the concept has received legitimacy with its incorporation into significant health policy documents.10–13

While strategies associated with cultural competence aim to make services more accessible for patients from diverse cultural backgrounds, more recently they have focused on specific groups, particularly Indigenous Australians, where the failure of services to address large disparities in health outcomes is stark and confronting. Connecting Indigenous patients with the health system and communicating effectively can be challenging and has often not been done well (Box 1 and Box 2). Indigenous cultural competence has been identified as a desirable attribute of Australian health professionals.13–18 Perhaps as a result of the plethora of alternative concepts such as cultural safety, cultural awareness and sensitivity, cultural security and humility, and more recently cultural literacy, the use of an overarching term was inevitable, despite most concepts having different frames of reference.17,19 Cultural competence strategies usually target the health workforce with the aim of improving the interactions between the patient, the provider and the health care system, as the intermediate step to improving health care utilisation, service delivery and health outcomes. Many aspects of this concept remain the subject of debate.

Social science perspectives

Limitations of cultural competence highlighted by social scientists working in clinical and academic settings largely fall into three categories: lack of clarity around the concept of culture, inadequate recognition of the “culture of medicine” and the scarcity of outcomes-based research that provides evidence of efficacy in improving health.

Unpacking culture

While it is recognised that a patient’s cultural background may be significant in clinical encounters, lack of clarity about the concept of culture can distort its impact.2,4,20–22 Anthropology, the discipline from which the term “culture” originated, offers many definitions but most make reference to a system of shared meanings or guidelines that are inherited and provide a lens through which to view the world. Contemporary anthropologists stress variations that exist across cultures with respect to beliefs, practices, norms, behaviours and expectations. Helman, for example, notes that culture is “an increasingly fluid concept, which in most societies is undergoing a constant process of change and adaptation”.20 Social scientists stress that cultures are complex, heterogeneous and dynamic, and intricately connected to the social context of people’s lives.2,4,21,22

So how does this understanding of culture differ from its usage in medical settings? Critiques from social scientists suggest that culture is often conflated with race and ethnicity, resulting in reification of existing racial categories.4 Central to this criticism is the failure to recognise diversity within cultures and the concomitant reductionism whereby culture is identified as a variable associated with essential differences between groups. Culture is viewed as a “risk factor” and cultural attributes as potential sources of the problem. Kirmayer noted that culture has been framed in terms of “ethnoracial blocs” which “conflate language, geographic origin, ethnicity and race” and “do not capture the diversity of society and the rapidly growing numbers of people who define themselves in hybrid ways that cut across these categories or escape them entirely”.21 Cultural competence literature tends to associate culture with group membership and shared beliefs and values that influence behaviour in health care settings.21 Not only does this approach underestimate cultural diversity within groups, but the process of “essentialising” culture removes individuals from their complex social worlds in which the structural and material determinants of inequality may be as powerful as cultural influences on health inequity. In an attempt to provide more conceptual clarity around cultural competence, Lo and Stacey coined the term “hybrid habitus” which interprets patients’ cultures as “the broad, less than fully conscious cultural orientations that shape a patient’s sense-making in clinical settings . . . [and] in turn, are shaped by surrounding, intersecting structural forces”.22 These forces may include socioeconomic status, gender, language and experiences of racism, all of which can interact with cultural orientations and influence the clinical encounter. This deeper understanding of culture in all its complexity has practical implications in health care settings. A patient’s culture is not reduced to stereotypical attributes, but rather understood as comprising layers of meaning that extend beyond values, beliefs and practices and are shaped by and in turn shape social structures.

However, any examination of the meaning and use of “culture” needs to consider the culture of medicine itself to assess its role in reproducing or addressing health inequities.

Culture of medicine

In the US, Good and colleagues questioned why disparities in health care continue to exist despite the introduction of cultural competence training in health professional programs.23 They suggested the need for a critical analysis of the culture of medicine where the “social processes within our complex medical institutions” are explored, including the presence of institutional racism, power imbalances and the role of professional socialisation. Taylor reinforces this, noting that cultural competence strategies have an overemphasis on the patient’s culture with scant attention paid to the culture of biomedicine.24 Institutional and professional medical culture is characterised by expert language and efficiency in clinical decision making based on legitimate medical knowledge. Taylor suggests that “it is confidence in the truth of medical knowledge that underwrites physicians’ special power to alleviate suffering”. Medical knowledge is thus not seen as a cultural product but as “real” knowledge which leads her to describe medicine as “perceiving itself to be a ‘culture of no culture’ ”.24 While some may disagree with this, it has consequences for the development of cultural competence curricula that “go beyond focusing on ‘other’ cultural groups, and attend to cultural dimensions of medicine itself”. Central to this discussion is the potential mismatch between professional medical socialisation, institutional practices and cultural competence strategies. Indeed, clinicians sometimes can be at odds with institutional directives and feel constrained by administrative practices that may compromise patient care.

Despite cultural competence training becoming commonplace in medical programs in Australia and elsewhere, few studies have focused on the culture of medicine itself. As Good et al note “rarely do students have the time or the formal sanction to critically analyze the profession and institutions of care to examine how treatment choices, quality of care and research practices are shaped; or how medical culture may produce processes that evolve into institutional racism . . . in clinical practice”.23 Kleinman and Benson go further, suggesting that the culture of biomedicine is “key to the transmission of stigma, the incorporation and maintenance of racial bias in institutions, and the development of health disparities across minority groups”.2 Implementing a more expansive notion of cultural competence that incorporates greater critical analysis of biomedicine has potential for less discordance between institutional culture and strategies aimed to improve culturally informed care.

Problems of measurement and limited outcomes-based research

Finally, critiques of cultural competence by social scientists and others have drawn attention to inadequate measures of the concept and the scarcity of outcomes-based research that links cultural competence strategies to better health.25–30 A study of quantitative measures of cultural competence found many hidden assumptions in survey questions designed to assess the impact of educational interventions, including the notion that frequent contact or immersion experiences necessarily enhance competence.29 Much depends on the kinds of interactions and the quality of the experiences, with contact alone not necessarily fostering insight. Recent studies also have found a lack of rigorous evaluation of cultural competence measurement tools, with few instruments having been validated. Chun noted that cultural competence training is often viewed as “unscientific” due to inadequate measurement techniques that can undermine implementation efforts.27 This is reinforced by findings of a review of the methodological rigour of studies evaluating cultural competence, which found a consistent lack of rigour, the consequence of which “limits the evidence for the impact of cultural competence training on minority health care quality”.26 In addition to rigorous instrument evaluation, qualitative methods, including observations, interviews and reflective journals should supplement traditional survey techniques when determining the effectiveness of cultural competence training.29

The first systematic review of studies assessing whether educational interventions to improve cultural competence were linked to improvements in health outcomes concluded that where an association was established, it tended to be in a positive direction.28 However, the authors identified many methodological limitations of existing studies and drew attention to the overall paucity of high-quality research, concluding that the evidence was not robust. Looking ahead, they noted that “subjective constructs such as patient trust and the quality of the patient experience using validated measures have emerged as outcomes of intrinsic value that should also be considered in the cause-effect dynamic”.28 Inherent in cultural competence measurement issues is the question of who decides whether a health professional has achieved cultural competence; arguably, the patient as the recipient of services is best positioned to make this judgement. The authors noted that because educational interventions are often removed from clinical outcomes, other measures such as enhanced trust between patient and practitioner and a high degree of satisfaction with a clinical encounter are worthy outcomes in health care settings and may also contribute to improved levels of utilisation.28

Conclusion

Social science critiques of cultural competence highlight the lack of conceptual clarity around the use of the term “culture” in clinical encounters, inadequate recognition of the “culture of medicine” and a scarcity of outcomes-based research that provides evidence of efficacy in improving health.

The value of training in cultural competence as an educational intervention will ultimately be validated by enhancing access to and achieving equity of health services and better health outcomes for culturally diverse groups. Given strong evidence that inequities in health arise from inequities in society, cultural competence strategies should not be divorced from addressing the material circumstances of people’s lives, an issue pertinent to the oldest and newest inhabitants of Australia. Perhaps there are unrealistic expectations about what culturally informed health care delivery can achieve in the absence of systematic attention to the structural and financial impediments to implementing the professional advice provided in health encounters. A nuanced and sophisticated understanding of “culture” in clinical settings would be a useful start to discerning the role that cultural competence plays in reducing health disparities in minority groups.

1 No wonder people don’t come back*

One of the Aboriginal doctors was doing a paeds [paediatrics] trip and a patient had been driven overnight from Wiluna. And the doctors barely had time to see them [the family] and then they did not make them welcome, so this Aboriginal doctor was horrified. No wonder people don’t come back. It is the same with ordinary appointments. The reason why people miss appointments is because they can’t see the value of them. And I’ll ask them what happened at their outpatient appointment and they’ll say “They did what you do”. “What did they say?” “They said they will write you a letter”. “Did they examine you?” “Not really”. So there is a sense that these appointments are futile, especially the follow-up ones.

The young doctors that see the patients are afraid to discharge them from the clinic and so when they see them and everything is the same, they rebook them for another appointment for no good reason except they are too nervous to say “you don’t need to come back”.

It is a hassle to get a babysitter for your six kids, find transport, wait 4 hours . . . for nothing.

* Transcript notes from an interview with an experienced general practitioner who works at an Aboriginal Medical Service. The GP describes the lost time and opportunity costs for patients travelling
great distances for appointments that may be very brief and perhaps
not even necessary.

2 The heart of the matter*

Another thing is patients are not told enough; it’s a bit of a paternalistic attitude that doctors have anyway, and even more so with Aboriginal patients, they are not given enough information. One story is of a patient who told me he loved this private cardiologist and I was amazed. I couldn’t understand why, because this guy was as rough as guts and the doctor was a posh three-piece suit sort of guy . . . When I asked him he said because the doctor had a fabulous model of a heart and he shows me everything, you know. He just thought that guy was the bee’s knees . . . he took the time to show him pictures of his arteries . . .
so taking the time to show people with models and trying to explain what you’re doing is just fundamental . . .

Of course it’s hard in hospitals because doctors have so little time; but if they don’t explain things properly and patients don’t take their tablets because things aren’t clearly explained then they are wasting their time anyway.

* Transcript notes from an interview with an experienced general practitioner who works at an Aboriginal Medical Service. This excerpt highlights good communication and its importance in breaking down barriers between patient and clinician.

History of the LIME Network and the development of Indigenous health in medical education

The Leaders in Indigenous Medical Education (LIME) Network has developed over time as an avenue for sharing, developing and improving upon the emerging discipline of Indigenous health in medical education

The Leaders in Indigenous Medical Education (LIME) Network (a program of Medical Deans Australia and New Zealand, funded by the Australian Government Department of Health and Ageing [DoHA]) has an 800-strong membership of Indigenous and non-Indigenous medical educators, health educators, university leaders, health practitioners, policymakers and community members concerned with improving health outcomes for Indigenous people. The Network encourages and supports collaboration within and between medical schools in Australia and Aotearoa/New Zealand to enhance the quality and effectiveness of Indigenous health curricula in medical education and to enable best practice in the recruitment and retention of Indigenous medical students. Over time, it has developed a portfolio of work that provides quality review, professional development, capacity-building, research and advocacy functions for Network members, and has developed links with specialist medical colleges and educators from other health disciplines. The Network is founded on Indigenous leadership and celebrates the many successes that are occurring in the field of Indigenous health and medical education.

Background

Historically, the relationship between Indigenous peoples and the medical fraternity has had its challenges. In Australia, doctors were involved in implementing segregation policies and played a role in the removal of Aboriginal children from their families.1 Over time, and in recognition of the role of Aboriginal and Torres Strait Islanders in informing government policies and initiatives, researchers and medical practitioners began to acknowledge the special place of Aboriginal and Torres Strait Islander people in the health system.1–6

The status of Indigenous peoples’ health in Australia and Aotearoa/New Zealand remains well below that of their non-Indigenous counterparts.7–9 While there is a range of historical, social and economic factors that influence these figures, the quality of care provided to Indigenous peoples is also an important factor requiring attention.10 The institutions that educate future medical professionals, therefore, have an important responsibility in developing a workforce that is responsive to the needs of Indigenous people.11–13

Joining forces: an informal network for Indigenous health

While formally recognised in 2005, the collaborative effort that underpins the LIME Network has a longer history. In the 1980s, the need for specific training in Indigenous health in medical education was formally submitted for the first time in Australia as part of the Inquiry into Medical Education and Medical Workforce (Ian Anderson, Professor and Foundation Chair of Indigenous Higher Education, University of Melbourne, personal communication).14 Publications on the importance of acknowledging the place of Aboriginal people in the Australian health care system were increasing15,16 and the first Aboriginal and Torres Strait Islander medical student recruitment programs were being implemented at sites across Australia (Shannon C, Leon D, Report on the LIME Workshop, 8–10 June 2005, Freemantle).17,18 Recommendations from health conferences increasingly emphasised the need to build an appropriate health workforce and include Indigenous health in education and training.1,19,20

Importantly, in March 1997, the Inaugural Indigenous Graduate and Undergraduate Medical Conference was held at Salamander Bay, New South Wales, followed closely by the Second Indigenous Medical Conference in July that same year (Garvey G, Smith S, Proceedings of the Inaugural Indigenous Graduate and Undergraduate Medical Conference, 31 March – 3 April 1997, Salamander Shores; Garvey G, Smith S, Proceedings of the Second Indigenous Medical Conference, 14–16 July 1997, Salamander Shores).

Convened by the University of Newcastle, and funded by the Australian Government’s Office for Aboriginal and Torres Strait Islander Health (OATSIH), these conferences led to the establishment of the Australian Indigenous Doctors’ Association (AIDA), which was formalised in 1998. Further goals and recommendations of these conferences that are pertinent to the LIME Network objectives today included that:

the deans of medical schools make a commitment to increasing content on and awareness of Indigenous issues in medical curricula;
teaching of Indigenous health be embedded throughout medical curricula;
consultation with and participation of Indigenous academics and people in the teaching process is essential; and
the number of Indigenous students entering medicine should increase (University of Newcastle, Recommendations to the Medical Deans meeting arising from the Second Indigenous Medical Conference, 29 August 1997, Perth).

These and other recommendations were presented by Aboriginal and Torres Strait Islander doctors, academics and medical students to a Committee of Deans of Australian Medical Schools (CDAMS, now Medical Deans Australia and New Zealand) meeting in Perth in August 1997, and were subsequently endorsed. The need for significant and effective Indigenous consultation and leadership as a fundamental element of any successful policy or program in Indigenous health was also acknowledged.21

A national curriculum and formalisation of the LIME Network

Following the CDAMS endorsement of the recommendations described above, two national reviews of Indigenous health in medical education were conducted — one by the Australian National Audit Office on behalf of the Department of Health and Aged Care,22 and one by Gail Garvey and Ngiare Brown from the University of Newcastle.21 Both reviews identified a lack of consistency and a scattered approach to the inclusion of Indigenous health in the core medical curriculum and the methods used to recruit Indigenous Australians to study medicine.

As a response to the review findings, in November 1999, representatives from CDAMS and OATSIH and Indigenous medical educators from a number of universities came together to develop a strategy for Indigenous medical education with a twofold focus: workforce (recruitment and retention of Aboriginal people) and curriculum (Ian Anderson, personal communication). A series of meetings was initiated to develop core Indigenous health curricula and a collaborative process for ongoing national oversight to ensure that Indigenous health became a meaningful and sustainable component of medical education.23,24

In 2003, the Indigenous Health Curriculum Project was formalised through a partnership between CDAMS and OATSIH. The Project was hosted by the University of Melbourne’s VicHealth Koori Health Research and Community Development Unit (which was later renamed the Onemda VicHealth Koori Health Unit) under the leadership of Ian Anderson, and Gregory Phillips was employed the National Program Manager. The National Curricula Workshop, held in August 2003 in Victor Harbor, South Australia, brought together leaders engaged in Indigenous health and medical education from around the country to engage in the Project’s objectives:

[The] meeting . . . in Victor Harbor . . . helped the leadership in medical schools, giving them a sense that “this is a safe place”.

— Ian Anderson

James Angus OA (Professor and Dean, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne), who attended the meeting on behalf of CDAMS, reflected:

I knew there was a possibility of this taking off, because there was leadership, there was interest, there was passion.

An audit of all existing Indigenous health curricula in Australian medical schools followed25 and, in the process,
the formal cooperation and collaboration between medical schools, CDAMS and the Project team began:

The audit was the first thing. That’s how we engaged the people. Basically, people needed to be heard. They were struggling all by themselves in these institutions, often one Aboriginal worker or part-time worker expected to do everything themselves, and they were struggling. So the first thing was just being there and talking to them all and giving voice to their concerns.

— Gregory Phillips

The audit findings led to and informed the development of The CDAMS Indigenous Health Curriculum Framework.26 The Framework was officially launched in August 2004, with the endorsement of CDAMS representing deans from every medical school in Australia:

We had this wonderful ceremony where we launched the curriculum . . . Sir William [Deane] made the point that he found it truly amazing that all the deans could agree on this core piece of curriculum that would be taught in every medical school in the country because, in his experience, academic professional groups can never agree on what is core.

— James Angus

The Framework provided medical schools with guidelines for developing and delivering Indigenous health content in core medical curricula. Following a determined effort by those involved in the Project, the Framework was included in the Australian Medical Council’s guidelines for medical school accreditation in 2006.27 Gregory Phillips wrote:

This curriculum framework [is] an investment in the future of not only the health and well-being of Aboriginal and Torres Strait Islander peoples and communities, but the training of a more competent medical workforce, and an improvement in the health status of all Australians.26

The Project also sought to establish a “sustainable, functional and effective network” of Indigenous and non-Indigenous medical educators who could collaborate and support each other in the delivery of Indigenous health curricula.28 To support this objective, a meeting was convened at Clear Mountain, Queensland, toward the end of 2004, which led to the establishment of the LIME Network and plans for the first LIME Connection conference.

The LIME Network program

The first official meeting of the LIME Network was at the inaugural LIME Connection conference in Fremantle, Western Australia, in June 2005, with 74 delegates in attendance. Gregory Phillips presented the LIME Network discussion paper, including the Network’s draft objectives and the LIMElight Awards concept (Shannon C, Leon D, Report on the LIME Workshop, 8–10 June 2005, Freemantle).28 The objectives were endorsed by CDAMS in October that year and, with funding from DoHA, the LIME Network was established as a program in its own right. Gregory Phillips wrote:

The LIME Network should ultimately be about empowering its members and participants to achieve the highest quality possible in implementing Indigenous health in medical education and curricula.28

The Network has operated as a bi-national program since 2008, and the quality of its processes and program outputs has been acknowledged by several higher education awards (Melbourne School of Population Health Knowledge Exchange Award, University of Melbourne, 2010).29,30

The overarching objectives of the Network are:

internal quality review;
professional development, capacity building and support;
promoting best practice and building an evidence base through research and evaluation;
professionalising the discipline;
multidisciplinary and multisectoral networking;
advocacy and reform; and
hosting the LIME Connection conferences.

At the heart of the Network is the LIME Reference Group of medical educators, comprising Indigenous and non-Indigenous representatives from every medical school in Australia and Aotearoa/New Zealand. The LIME Steering Committee — made up of medical school deans and representatives from AIDA, Te ORA (Maori Medical Practitioners Association), the National Aboriginal Community Controlled Health Organisation, Indigenous Allied Health Australia, the Committee of Presidents of Medical Colleges and DoHA — ensures input, communication and partnerships with key representative bodies.

The LIME Network has been pivotal, over a sustained period, in strengthening the connections within and between universities and individuals dedicated to ensuring the quality and effectiveness of teaching and learning of Indigenous health in medical education and best practice in the recruitment and retention of Indigenous medical students:

LIME gives us a language in which to speak with one another. It is about us and what we do collectively to grow. It provides a beautiful, strong and congruent environment that supports communication and brings a focus to the bigger picture.

— Lisa Jackson Pulver AM, Professor and Director of the Muru Marri Indigenous Health Unit, University of New South Wales, and LIME Network Reference Group Member

The materials and resources developed as part of the Network’s program of work contribute to the quality and rigour of Indigenous health teaching and learning and provide a forum for peer mentoring and participant support.

[W]e are learning from other people’s lessons and talking to others who totally understand the hard decisions that we have to make. Also more and more now, we are collaborating on research in areas of teaching and learning, Indigenous health and growing the workforce — it has become part of improving each other’s academic practice.

— Papaarangi Reid, Associate Professor, Tumuaki/Deputy Dean and Head of the Department of Maori Health, Faculty of Medical and Health Sciences, University of Auckland, and LIME Network Steering Committee Member

The LIME Connection conferences have become a flagship of the Network’s activities and have been held biennially since 2005. Attracting educators, students and professionals, primarily from the field of medicine, they provide opportunities to share innovations, make connections and gather evidence on best-practice approaches from around the world. Importantly, outstanding work by medical educators is celebrated through the LIMElight Awards.

Coming to the first LIME conference helped me understand that there were other Indigenous/non-Indigenous colleagues facing the same challenges as me. It was like an awakening to go from feeling so isolated to understanding you had a place in a community. LIME Connection gives us the opportunity to learn and further develop our work in a supportive environment.

— Suzanne Pitama, Associate Dean of the Maori/Indigenous Health Institute, University of Otago, Christchurch, and LIME Network Reference Group Member

Conclusion

The LIME Network has developed over time to be a significant avenue through which information about Indigenous health and medical education can be shared, developed and improved upon.

It is not just one or two schools. It’s old, new, rural and urban schools. There is a non-competitive nature to the sharing. We are working hard to support each other’s work. The buy in from so many schools across both countries over a long period of time is exceptional.

— Shaun Ewen

The CDAMS Indigenous Health Curriculum Framework is being widely utilised (not only in medicine, but in other health disciplines) and the quality review tools and evidence-based materials developed as part of the LIME Network program31,32 are ensuring that Indigenous health is developing as a discipline in its own right.

[The] Network is a wonderful enabler. It allows not only the connection, but it’s a two way street, so that we’ve got a repository of the resources . . . [and] the outreach . . . the knowledge gets shared and continues to advance. It’s done in a very exciting, personally empowering, respectful and safe environment.

— James Angus

The leadership and support of Medical Deans Australia and New Zealand, AIDA and Te ORA, and the commitment and collegiality of medical educators involved, has been integral to the ongoing development of the LIME Network. We now see record numbers of Indigenous students enrolled in medicine33 and increased consistency and quality of Indigenous health teaching and learning in medicine.34

As an emerging field, Indigenous health is forging new approaches to education and training that will affect the way health care is understood and delivered. This will have implications not only for Indigenous patients, but for the community more broadly.

The goal of the network, the overall goal should be to empower people to make change, and to give voice to their concerns and to help them get the change they need. So to give voice but also to professionalise Aboriginal health as a discipline, that’s what it’s really about, and to give broader support so that it’s not just Aboriginal people doing Aboriginal health.

— Gregory Phillips

Launch of the CDAMS Indigenous Health Curriculum Framework, Melbourne, 2004 — (left to right) Professor S Bruce Dowton, Professor James Angus, Sir Willam Deane, Dr Lowitja O’Donoghue,
Mr Gregory Phillips, Aunty Joy Murphy Wandin and Professor Ian Anderson).

Associate Professor Kelvin Kong, Dr Tom Calma, Associate Professor Papaarangi Reid, Dr Mark Wenitong, at LIME Connection II, Sydney, 2007.

LIME Reference Group meeting, Gold Coast, 2012.

Remote supervision in postgraduate training: a personal view

Using telehealth infrastructure for remote supervision could create medical training places where they are needed

Remote supervision is used increasingly in postgraduate general practice training in outback Australia and northern Canada.1,2 In this model, general practice supervisors and registrars working in different locations communicate via information and communication technology. However, the concept of remote supervision compared with the traditional apprenticeship of general practice training raises questions about how registrars can learn without observing their general practice supervisors at work. And how do general practitioners supervise registrars without overseeing them?

Remote supervision began as a trial to give registrars experience of solo general practice during training. General practice supervisors supplemented phone communication with onsite teaching visits.3 This pilot project met the training standards without any reports of adverse patient outcomes.3 It led to the formation of the Pilot Remote Vocational Training Stream and then the Remote Vocational Training Scheme (RVTS).1

After relocating to Central Australia, I became a remote supervisor and then medical educator with the RVTS. Many registrars thrived and developed in ways that challenged my traditional definitions of quality clinical education. In 2007, 21 doctors out of 24 had completed training; 17 of these registrars did all their general practice training in very remote locations. Most still worked in rural areas and 20 had College Fellowships.4 By 2012, 70 general practice registrars were training via remote supervision with RVTS,5 as were a small number of doctors in the Australian College of Rural and Remote Medicine Independent Pathway. Real-time interactions between registrars, their patients and remote supervisors are now possible; in Canada, supervisors manage emergencies via videoconference6 and can remotely control a robot to read registrars’ notes and assess patients by remote ultrasound scan.

Despite the expected difficulties of identifying registrars’ blind spots at a distance, remote supervisors were also enthusiastic about this model of training. They felt liberated from the managerial and assessment roles of onsite supervisors and could support registrars in tailored educational relationships.7

The expansion in the number of medical graduates, from 1915 in 2009 to 3254 in 2016,8 is increasing demands on training positions and the clinicians who oversee supervision and training.9 More generalists are required, as is training in regional, rural and remote locations,10 which should equip and encourage doctors to practise there once qualified.11 Different models of clinical teaching that can deliver extra training capacity without diluting quality are needed.12

The federal government is funding telehealth to improve access to medical services for Australians who cannot get to a specialist, or who live in rural and remote areas.13 This has resulted in investment in information and communication technology infrastructure and familiarity in using it for meaningful and important interactions. This shift in clinical practice creates opportunities for a parallel educational shift to provide extra training posts by extending remote supervision. Indeed, the Royal Australian College of General Practitioners standards scheduled for introduction in 2014 allow remote supervision,14 so this training model could be introduced in other rural locations15 or underserved areas of primary care such as clinics for refugees. To make this happen, reliable and fast internet access is needed nationwide, with 24-hour access to equipment and technical support.

Accredited training places for specialties other than general practice could also be provided at remotely supervised training posts. Registrars who have almost completed training could undertake regional, rural or remote fellowships. Gaps in the ability of local staff to provide clinical supervision would be supplemented by supervision from tertiary centres, using the facilities now in place for telehealth, to create a supervision team with local contextual and subspecialty expertise.

Remote supervision poses broader structural challenges. There are inevitable tensions for registrars in work-based learning — from feeling used and exploited by too many clinical demands to having limited access to clinical experiences and authentic learning opportunities. Getting an optimal balance is harder to achieve remotely. Also, supervisors usually provide dedicated teaching time and review patients in response to registrars’ questions. In contrast, safe remote supervision requires changes to supervisors’ workflow, to allow significant time and commitment to proactively contact registrars and monitor their work. It should not be an untimetabled or unbudgeted extra. Registrars, their families and supervisors should be carefully selected, supported and their wellbeing monitored by educational organisations.16

The assumption that quality medical training only occurs in major centres risks perpetuating Australia’s maldistribution of medical workforce and health care expenditure by location rather than clinical need. Remote supervision — within a package of educational and family support, and changes to supervising specialists’ funding and routines — is one option to redress the balance.

Attitudes of a private hospital community to medical student teaching

To the Editor: A shortage of training opportunities for medical students in public hospitals has led to greater need for collaboration with the private sector.1–3 In 2011, Sydney Medical School established the first private hospital clinical school in New South Wales at the Sydney Adventist Hospital (SAH). Essential to its success is the support of the hospital’s patient and medical community.

We conducted two cross-sectional surveys, adapted from previous research, to assess attitudes toward participation in medical student teaching among SAH patients and staff.4 Between August and October 2011, hospital volunteers recruited patients and staff from all departments on various days, but did not record refusals. We included visitors if they were previous or potential future patients. Doctors had limited time for completing the survey while seeing patients, so we sent them the survey by email. The SAH Human Ethics Research Committee approved the study.

A total of 283 surveys were completed by inpatients (52%), outpatients (30%) and visitors (18%). Sixty-seven per cent of survey participants were women. Patients were categorised as surgical (75%), medical (49%) or gynaecological (19%). More than half the patients had a tertiary education (53%). Among staff, 143 surveys were completed by doctors (49%), nurses (46%) and allied health professionals (5%). Their time at SAH ranged from 1 year to > 10 years. Fifty-two per cent of the staff were women.

Most patients and staff (≥ 88%) agreed that they would allow students to observe during consultations or procedures (Box). Patients also desired the doctor’s constant presence, and time alone with the doctor. Over 56% of patients and 78% of staff indicated that they would accept more active student involvement in simple procedures or examinations. Patients were less accepting of students’ presence during intimate examinations or of students assisting in surgery.

These results support student teaching in a private hospital, with levels of cooperation exceeding those observed in a similar survey of private and public patients.5 Our findings may reassure those concerned that privately insured patients would not consent to participate in teaching. In fact, about half of SAH patients and staff agreed that they would like to have a student present.

Most of the patients and staff felt that the appearance or manner of students would affect their participation. These factors, along with presence of and time alone with the doctor, can be directly addressed to enhance the experiences of patients and doctors involved in student teaching. A hospital dress code for medical students exists, as does training in professionalism.

Lack of time for teaching is clearly an issue for SAH staff, as for public hospital staff. Assisting practitioners to incorporate efficient teaching into the private clinical arena is an area for future investigation.

The privilege of having private health insurance does not reduce the responsibility to contribute to the training of future doctors. Despite the limitations of this study, we have shown that patients and staff of a private hospital largely accept this responsibility. Reassessing actual levels of cooperation after exposure to medical students will be important.

Patient and staff agreement with survey statements about participation in medical student teaching at a private hospital (rank ordered)

Patient and staff survey statements	No. (%) of participants agreeing with statement*

Patient surveys (n = 283)
Would allow student to be present during consultation with doctor	256 (90%)
Want doctor to always be present during the consultation	253 (89%)
Would allow student to observe my surgery	250 (88%)
Important to have some time alone with the doctor	215 (76%)
Would allow student to see my medical records	208 (73%)
Would allow student to perform simple medical procedure on me (eg, blood culture or placing a drip)	180 (64%)
Would allow student to examine me	161 (57%)
Would allow student to perform intimate examination under supervision of specialist while I am anaesthetised	127 (45%)
Would allow student to assist specialist at my surgery	122 (43%)
Would allow student to perform intimate examination under supervision of specialist	102 (36%)
Will learn more about my condition if student is present	93 (33%)
Will have better care if a student is present	51 (18%)
Feel uncomfortable with student of opposite sex	41 (14%)
Care would be better if did not consent to student being present	13 (5%)
Would like to have a medical student present†	130 (46%)
General appearance or manner of student affects my participation†	183 (65%)
Staff surveys (n = 143)
Would allow student to watch my patient care	134 (94%)
Prepared to teach medical student	115 (80%)
Comfortable sharing patient’s personal history with student	114 (80%)
Would allow student to perform simple procedure on my patients (eg, blood pressure)	111 (78%)
Have time to teach medical students	55 (38%)
Better able to care for patients if student is not present	15 (10%)
Will give better care if a medical student is present	11 (8%)
Feel uncomfortable with student of opposite sex	8 (6%)
Would find a medical student intimidating	3 (2%)
Would like to have a medical student present†	72 (50%)
General appearance or manner of student affects my participation†	98 (69%)

* Five-point Likert scale used; “agree” combines response categories “strongly agree” and “agree”. † Identical questions asked of both patients and staff.

It’s time to examine the status of our undergraduate mental health curricula

To the Editor: Review of undergraduate mental health education is timely, given the growing disease burden of mental disorders and the need to better equip doctors for their central role in treatment. Curricula should prepare all doctors with competencies in recognising and treating mental health problems,1 because these occur frequently in patients across all branches of medicine, leading to poorer outcomes.2 Curricula should also prepare a minority of doctors for specialist psychiatry training.1

Review of practices is particularly pressing in Australia, where current medical school expansion provides critical opportunities to influence many training doctors’ competencies. Despite this expansion, published reviews and curriculum models are notably lacking. Australian medical schools, unlike those of other countries, have yet to agree on a core curriculum in undergraduate psychiatry, and delivery, content and assessment vary widely.3 These factors increase the probability of isolated curriculum development and inefficiency in preparing doctors with core skills. The Royal Australian and New Zealand College of Psychiatrists has called for greater collaboration across medical educators to develop core psychiatry curricula.1

A strategic curriculum requires learning outcomes that move beyond traditional psychiatry competencies in mental status examination, to include preventive health care as well as key attitudes, knowledge and skills needed to equip future doctors to treat mental illness. Chronic challenges also require consideration — these include difficulty in recruiting psychiatrists, lack of clinicians for teaching, and stigma towards psychiatry as a specialty and towards those with mental disorders. High-quality, multidisciplinary, multi-setting teaching may boost teaching resources, expose students to first-line psychological interventions and sensitise them to early-stage presentations. Additionally, with current concerns over the mental health of doctors, medical education provides opportunities to better equip doctors to take care of their own wellbeing.

There are calls to allocate a third of medical school curriculum time to teaching about brain and mental disorders, proportional to their disease burden.4,5 We estimate that the current proportion in Australia is far lower. In 1999, an Australian study found inconsistency among medical schools, and an overall average of 416 hours psychiatry teaching.6 We have been unable to locate published figures on the percentage of total teaching hours allocated to psychiatry in Australian medical schools. More recent, and proportional, figures are needed.

Current challenges are to achieve consensus on core mental health curricula across Australian medical schools, and to ensure adequate curriculum time to enable updated learning outcomes. Publishing and critiquing our approaches to curriculum delivery will facilitate reform.

Where is the next generation of medical educators?

To the Editor: The thought-provoking editorial by Hu and colleagues laments the “erratic supply of medical educators”.1 Curriculum design and review, course accreditation, and student teaching and assessment at all levels require specialist expertise in education. The 17th National Prevocational Medical Education Forum, held in Perth in November 2012, revealed pressures throughout the medical education and training pipeline.

With an unprecedented increase in student numbers in response to population growth and increasing demand for doctors, particularly in general medicine and rural practice, the requirement for more medical educators is critical. Hu et al’s editorial is timely in identifying this need and in recognising medical education as an evolving specialist discipline within the medical profession. However, much of the clinical teaching in our medical schools still depends on a motivated minority of senior specialists in clinical practice who are drawn from a much larger pool of potential educators.

In Western Australia, we face significant population growth and a current shortage of up to 1000 general practitioners2 as we prepare for the establishment of the state’s third medical school at Curtin University. One hundred new domestic medical students are anticipated to be in their clinical placement years by 2019. We applaud Hu and colleagues for drawing attention to the persistent shortage of specialist medical educators, and acknowledge our ongoing debt to members of the profession who find satisfaction in the Hippocratic tradition.

Where is the next generation of medical educators?

To the Editor: The arguments put forward by Hu and colleagues for recognition of medical education as a specialty are persuasive, especially considering current national requirements for accreditation to ensure delivery of high-quality programs.1

In recent decades, medical educationalists have flooded journals and other publications with articles (Box). Many have resulted from, and led to, innovative educational programs. Unlike other areas of scientific research, however, the true impact of these educational programs may only be appreciated after 10 years.2 Such research needs to be done to demonstrate the effectiveness of educational interventions.

Medical educators need to prove to the community that they have clearly improved the quality of both teaching and learning, and their graduate doctors. Very few education providers assess the quality of the clinical care their graduates provide, instead using evaluation of the course as a surrogate marker, which can be modified by successful statistical manipulation of data.3 This evaluation needs to be done by external organisations such as colleges of postgraduate training, and by clinical supervisors in prevocational and vocational training. It is relevant to note that of the four Australian-based authors of the editorial,1 two come from medical schools whose graduates rate the overall teaching quality as worse than average.4

After 25 years, I know which medical school graduates I will happily employ, because they are clinically competent, reliable, keen to learn and show compassion to patients and colleagues. Focused discussions with these graduates consistently show that it is skilled clinicians and excellent mentors, not specialist medical educators, who have honed their abilities.

Number of publications on medical education over time*

* The figures were derived in February 2013 from a search of OneSearch (http://libguides.library.uwa.edu.au/onesearch), a research repository of journal articles, book chapters, newspaper articles, conference papers and broad cross-disciplinary databases.