Change — in health care, its systems and community need — is one of the few certainties in medicine. A past Dean of Harvard Medical School, Sydney Burwell, put it this way in the 1950s: “My students are dismayed when I say to them, ‘Half of what you are taught as medical students will in 10 years have been shown to be wrong. And the trouble is, none of your teachers know which half.’” (BMJ 1956; 2: 113-116). A broader question is: do we ride out change or ride with it?

Many contributions in this issue of the MJA highlight not only change but also the associated challenges, constructive debates needed and hard decisions to be made as medicine and health care evolve.

An obvious, pressing development is the steady increase in medical graduate numbers, which are now double what they were in 2006. This surge means that a 400-place shortfall in first postgraduate-year training positions is forecast within 4 years. These “waves” of future graduates face questions about when, where, how and even if they will complete their junior medical officer year to become fully registered practitioners. Kevat and Lander (doi: 10.5694/mja12.10967) are concerned that the states’ “priority system” for selecting interns discriminates against interstate applicants, including those trying to return to their home state. Highlighting the Australian Capital Territory graduates now considered interstate applicants by the New South Wales system, they argue that this system contravenes the Australian Constitution. It is an issue that may be resolved not by the health system but in a court of law.

More medical students and graduates mean more competition for clinical experience as well as training positions. The new national registration standard will allow greater flexibility in obtaining the requisite clinical experience during internship. For example, Gosbell and colleagues ((doi: 10.5694/mja13.10176) say that the new standard will allow emergency medicine rotations to be done outside of emergency departments, including in some general practice settings. Although access to placements may improve, they say the accompanying national accreditation framework must prevent any dilution of clinical experience.

The quality and extent of students’ clinical experiences may affect their later careers. As de Costa and Rane (doi: 10.5694/mja13.10109) discuss, greater student numbers and the demands of other newer disciplines in medical courses mean that not all medical schools require their students to perform normal deliveries in obstetric rotations. What would the Australian community think if it was generally known that some of our doctors may be graduating without the experience of at least assisting in uncomplicated labour? And what of interns’ confidence levels if they are required to manage labour in regional and rural rotations?

One might wonder whether core clinical experience is being overridden by the introduction of new subjects to medical education. But at least one of these curricular developments may be truly needed, owing in part to the increasingly international orientation of medical schools and their students. As Law and colleagues (doi: 10.5694/mja12.11463) report, around one in four medical students undertake overseas electives in developing countries, with attendant personal risks and educational benefits; accordingly, briefings before and debriefings after such terms need to be scaled up. Mitchell and colleagues (doi: 10.5694/mja12.11611) advocate formal postgraduate global health training, in line with North American courses, focusing on international health equity and fieldwork.

Change in any aspect of the medical profession and health care inevitably raises the perennial question: what is the purpose of medical education? Today, as it was 50 years ago, there is no clear, single answer. But continuing renewal and adaptation to medicine’s evolving circumstances would seem necessary. The question today is how we can continue to adapt successfully to the changing tides.

Global health (GH) is now firmly entrenched as an academic discipline in its own right. Defined as an area for study, research and practice that places a priority on improving health and achieving health equity for all people worldwide, it emphasises transnational health issues, determinants and solutions; involves many disciplines between and beyond the health sciences; and synthesises population-based prevention with individual-level care.1

This article, written from the trainee perspective, considers the relevance of global heath experiences to postgraduate medical education systems in Australia. It examines the risks and benefits of vocational trainee exposure to international rotations in resource-poor settings and makes recommendations for enhanced integration of GH with specialty education programs.

Recognition that doctors engaged in GH practice require a skill set beyond that traditionally incorporated into medical curricula has given rise to the concept of GH training.2,3 The groundswell of activity in this area has occurred in North America, where education in GH is increasingly integrated with medical school and postgraduate training programs. Although there is significant variation in the way GH training is delivered, curricula tend to focus heavily on health equity concepts and generally encourage international fieldwork.2–5 In some institutions, fellowship programs have been developed to allow senior trainees to acquire more advanced skills.6,7

In response to this growth, a comprehensive guidebook for the incorporation of GH training into residency programs has been published.4 Ethical guidelines for overseas rotations have also been produced, including statements by the Working Group on Ethics Guidelines for Global Health Training and trainee associations.5,8 These recognise the ethical complexities involved in international placements.9,10

This evolution is in keeping with a broader movement towards greater social accountability in medical education.11 Consistent with this, a 2010 Lancet commission called for additional emphasis on transformative and interdependent learning in order to produce health professionals who are equipped to face the global challenges of the 21st century.12

To a large extent, the expansion in GH training has been driven by a well documented demand from trainees. For example, a 2007 study of 724 surgical residents in the United States found that 92% were interested in undertaking an international clinical elective and 82% would prioritise this over other opportunities.13 In Canada, a recent survey of 1735 junior doctors identified that 43% had undertaken or planned to undertake GH activities.14

The extent to which Australian graduates are attracted to GH training has not been quantified but there is surrogate evidence of interest. Trainees are increasingly accessing GH learning and networking activities, including Global Health Gateway (an online resource: http://www.globalhealthgateway.org.au), the Global Ideas Forum (a conference for early career health professionals: http://www.globalideasforum.org) and Global Health Drinks (an informal experience-sharing forum in Sydney: http://www.globalhealthdrinks.org). The development of A guide to working abroad for Australian medical students and junior doctors, published as an eSupplement to this Journal, is also indicative of the interest in the area.15

At the undergraduate level, one study has suggested that over 90% of students believe that GH should be a component of medical school programs, and the number of attendees at the annual Australian Medical Students’ Association Global Health Conference continues to rise.16 Membership of university GH groups is also increasing.17

Despite the level of interest, GH training is poorly integrated with postgraduate medical education systems in Australia. Only recently has one college faculty drafted a specific curriculum to prepare fellows for GH practice.18 Key themes include reflective practice, cultural competency, health systems strengthening, community development, aid effectiveness and GH advocacy. While pathways to international work in other disciplines are relatively informal, the requisite skill sets are increasingly being described.19

Among colleges, mechanisms for determining if overseas rotations can be accredited towards fellowship are variable.15 Some have relatively well defined pathways — the Australasian College for Emergency Medicine, for instance, has created a specific option for trainees to undertake accredited training in a resource-poor environment with arrangements for remote supervision.20 Certain other colleges, including the Royal Australasian College of Physicians, have prospective approval processes for senior registrars wishing to undertake overseas placements.15

Although there are now several university-affiliated GH institutes, these are not well integrated with clinical training programs. As a marker of this, growing numbers of medical graduates are enrolling in relevant postgraduate courses, such as Masters of Public Health. These increasingly include a focus on health systems in developing countries.21

In the absence of formal arrangements, access to GH experiences is limited by a number of factors, including a lack of recognition from educational providers, suboptimal supervision arrangements, limited access to cultural competency training, competing training commitments, family responsibilities, loss of income and safety concerns.2,14,15 As a result, vocational trainees interested in working abroad tend to do so outside formal training programs and often through non-governmental organisations or volunteer placement agencies. One example is Médecins Sans Frontières Australia, which in 2012 dispatched 44 doctors (and many other health professionals) to international field settings; a majority of these were non-specialists (Sophie McNamara, Communications Officer, Médecins Sans Frontières Australia, personal communication, February 2013).

Reports of Australian trainees undertaking accredited training in overseas settings suggest that GH experiences can feasibly be undertaken as part of specialty education programs.15,22,23 While some aspects of GH education can be undertaken locally, many trainees will eventually seek international clinical experiences. The benefits of rotations in resource-poor settings are summarised in Box 1. Similar advantages have been described internationally.2,5,24

Several published examples illustrate how GH rotations can work in practice.15,22,23 Characteristically, these include service delivery and education components based on mutually agreed learning and development objectives. For instance, a recently described placement for Australasian College for Emergency Medicine trainees in Papua New Guinea includes both a clinical role in a regional emergency department and a teaching appointment at a local university.22,23

GH training based on sound principles has the potential to provide rewarding training experiences for Australian trainees, broker relationships between Australian and overseas health services and education providers, and build health care capacity in host communities. The establishment of international academic partnerships would also lend itself to enhanced regional research capabilities. Together, these developments would allow Australia to increase its practical contribution towards emerging GH challenges (such as chronic disease in the Asia–Pacific region) and help answer the call for greater leadership in the discipline.25

International clinical experiences also carry the potential for harm to the trainee, the training institution and the host community (Box 2).2,5,9,10,24 These risks are similar to those associated with short-term medical missions undertaken outside of mature and sustainable partnerships.26 The negative effects of “voluntourism” have been well described.26,27

Host communities are vulnerable; however, implementation of risk management strategies and observance of ethical guidelines should greatly ameliorate the potential for harm.5,9,24 Any arrangement where one party is exploited for the benefit of another would be unacceptable.

Notwithstanding the risks, the demand from trainees and educators for GH experiences means that the establishment of formal GH training pathways in Australia warrants greater consideration. This would align postgraduate training with the broader movement towards social accountability in medical education as well as Australia’s broader aid and foreign policy objectives. Similar calls have recently been made in the United Kingdom.28

Necessary steps as part of this evolution include:

• attainment of better-quality data on models currently in operation and the extent of interest among trainees;

• development of guidelines for Australian vocational trainees undertaking placements abroad, which could be supplemented by specialty- and placement-specific advice;

• integration and mainstreaming of GH education into postgraduate training curricula;

• incorporation of GH training into medical education conferences, to highlight best practice and encourage the development of evidence-based programs;

• design, support and evaluation of opportunities for vocational trainees to undertake rotations abroad that are safe, effective and ethically defensible, in part because they are incorporated into mature bilateral relationships and accredited by the relevant training body; and

• development of mutually beneficial and enduring partnerships between Australian and overseas health services, training institutions and GH agencies, underpinned by a commitment to academic collaboration and the exchange of knowledge and experience.

Although no central body has the capacity or authority to manage this process, incremental change should be achievable with collaboration between trainees, health services and education providers.

Experience from overseas suggests that development of effective GH training systems is likely to occur in an iterative fashion, with qualified institutions that have mature international partnerships leading by example. Medical colleges have a key role to play, drawing on the experience of international affiliates, academic institutes and volunteer deployment agencies.

Fortunately, there is no shortage of guidance to inform the process.3–5,9,15,24,29 Particularly relevant are previously defined competencies for Australian health professionals working in international health, including in technical, cultural and interpersonal domains.29 Ethical principles for Australian junior doctors practising in overseas settings have also been published and provide a platform for more substantive guidelines.18

More formal systems of GH training in Australia have the potential to create a cohort of doctors with the skills and knowledge necessary to engage in regional health challenges in a global context. Despite the complexity of developing safe and effective programs based on strong and durable international partnerships, the case for change is compelling.