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Episode 9 - Specialist Training in Australia with AMA Council of Doctors in Training Chair Dr Sanjay Hettige
109 Plays1 month ago
In this episode of The Waiting Room AMA Council of Doctors in Training Chair Dr Sanjay Hettige joins Dr Omar Khorshid and Dr Chris Moy to discuss Specialist Training pathways in Australia.
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Transcript
Are specialist medical colleges maintaining standards or protecting incomes?
00:00:00
Speaker
Specialist medical training continues to change and there are lots of different views between governments and ah within the medical profession amongst the community about whether our specialist medical colleges are high, set of really high standards or whether in fact they're a closed shop that just protects doctors' incomes.
Introduction to The Waiting Room podcast
00:00:21
Speaker
Today we are talking about specialist medical training and unpacking all the issues. Welcome to The Waiting Room. My name's Omar Korshid. I'm joined by my slightly hiccuping colleague today, ah good friend, GP, Dr Chris Moy. Apologies, yes, if I do hiccups with this. it's It's one of those GP problems that doesn't have a solution.
00:00:44
Speaker
You're listening to The Waiting Room, a podcast by the Australian Medical Association with your hosts, Dr Omar Korshid and Dr Chris Moy.
Dr. Sanjay Hettidge on vocational training programs
00:01:01
Speaker
We are really pleased to have our special guest today, Dr Sanjay Hettidge, who is the chair of the AMA's Council of Doctors in Training and a strong advocate, as all the chairs of Council Doctors in Training I've ever met, are for his colleagues, but particularly focusing on issues such as vocational training programs, safe hours, flexible training and mental health support.
00:01:27
Speaker
He's here to talk to us about colleges, about transparency of governance, about ah the place of colleges in our community and within our profession. Welcome, Sanjay. Thanks, Oma, and thanks, Chris. Thanks for having me.
00:01:38
Speaker
Sanjay, you know, it's such an important and incredibly intense job ah being chair of AMA, Council of Doctors and Training. and It's so important for the future of of the profession.
Path to becoming a consultant in Australia
00:01:50
Speaker
Can you start off with that talking us through the current specialist training pathways in Australia? What does it look like from internship to fellowship? Yeah, will do. Thanks, Chris. um So in Australia, it's a long and complex one to go from medical school to becoming a consultant.
00:02:04
Speaker
And I think it's something that people outside medicine don't realise. I think they get the idea of medical training from America. And in here, it's slightly different. So once you graduate, you start your internship, so your PGY one year. So that's the um core year where you rotate through terms like medicine, surgery, emergency.
00:02:21
Speaker
And then you move on to your pre-vocational years, so that we call them PGY two to three. And that's quite unique in Australia. I think and in a lot of countries, doctors go straight from internship to their specialty training.
00:02:33
Speaker
But in Australia, we've got this extended period um in pre-vocational years where you build your CV, gain experience and try to secure your place on a specialist medical training program. And look, that can be a pretty fun few years developing clinical maturity, trying out different things, but there's a lot of stress and uncertainty in those years as well.
00:02:52
Speaker
There's no structured curriculum and it can be quite competitive to get into vocational training places, especially amongst the popular specialties and in major metropolitan centres. Look, once you've done that that hard work, then you're accepted into a specialist college training program. And there are about 64 different specialties and subspecialties in Australia.
00:03:12
Speaker
um And that's called formal vocational training. And that can take between anywhere three to seven years, depending on which training program
Challenges of metro-centric training opportunities
00:03:18
Speaker
you are. And that's, you know, you've got your research requirements, your workplace-based assessments, your exams, and your supervised practice you have to do as part of that.
00:03:26
Speaker
And once you've done all that, you become a fellow of the college and that but allows you to be a consultant in the community. So, yeah, look, it's ah it's a long and hard road for a lot of trainees. um But, so yeah, obviously it's a very worthwhile and valuable um service for the community and I guess it it can be very interesting as well.
00:03:45
Speaker
But, yeah, it's... it's Training opportunities can be limited in some respects, especially in rural and regional settings. So um you know training can be quite metro centric. So I think in a country as geographically as diverse as Australia, um that can be an issue in terms of actually providing those services to the community. Sanjay, I think everyone in the community is aware of the the shortage of doctors, particularly our GP specialists, but of course ah in many other specialty
Balancing high standards with international integration
00:04:13
Speaker
areas as well. It's just hard to to find a specialist even in the private sector.
00:04:19
Speaker
and Now, state governments often point the finger out at colleges saying, well, these guys are restricting doctors. entry and therefore this is why we don't have enough doctors, we should sort of open the floodgates and bring in people from all over the world. But of course the the flip side of that is is maintaining standards of practice.
00:04:36
Speaker
but Where do Doctors in Training sit um in terms of your your thoughts on the very high bars that our colleges set both for their own trainees and international medical graduates are wanting to join our system?
00:04:49
Speaker
Yeah, thanks, Omar. Look, I think this question has definitely changed as I've gone through training. I think when I started training, you're kind of almost railing against the colleges because you spend all these years in pre-vocational land, you know, you're trying to get onto these college training programs. You're like, you know, why is it so hard? Why is it taking so long? I've done all these things.
00:05:05
Speaker
And you wonder about their entry requirements, so on and so forth. But once you get in and you actually experience the Australian training program and how rigorous it is, you understand why those high standards are there and you realise the generalist and broad level of training that you're getting and how that applies to the Australian community and how that's going to make the healthcare care that you deliver to them so much better.
00:05:25
Speaker
So I think now i really appreciate the high training standards that the Australian colleges provide. um I think, um yeah, it really, as I come to the near the end of my training, I feel very confident being to provide a broad range of services in my specialty of radiology to the community.
00:05:41
Speaker
And look, I think this whole idea about um expedited training pathways is really concerned a lot of trainees. I think a lot of doctors and trainees share my sentiments. they're really proud of the Australian training system, and you we see it as one of the best in the world.
00:05:55
Speaker
And you know we're not concerned about international international doctors themselves. We recognize that Australia needs overseas trained specialists. you know We want to build a sustainable um medical workforce in Australia, but we still need people trained overseas to um help help that workforce and make sure we can provide the services we need to the Australian population.
00:06:13
Speaker
But having an expedited pathway, it looks like it's creating a two-tier system. So you've got one group of people that have been through this rigorous training and others that have not been actually um ah adjudicated by the colleges to see where they meet um the same standards as Australian trainees and where they may need to do further training to make sure they're up to up to the standard that we all want.
Impact of expedited pathways on workforce and safety
00:06:33
Speaker
And you know this kind of inconsistency, you know it it can affect workforce morale amongst Australian trainees, but can also have yeah real implications on patient safety and quality of care. um Because you know I think it requires some time to actually understand what the Australian health system is like and the nuances of rural and indigenous health and making sure you've got the right cultural competency as well.
00:06:54
Speaker
So look, what we want is, I think as trainees, is we want an integrated workforce where there are international doctors working here, but they're trained to the same standards as us. And I think that means, you know, the only way that works is through the college being involved to provide that credentialing and supervision and not a parallel system.
00:07:12
Speaker
Yes, certainly, you know, as a medical profession, I think one of our strengths historically has been that we set our own standards and I think the whole ah transformation that's occurred in medicine over the last century is because of the high standards that are set.
00:07:26
Speaker
ah So when governments challenge that, of course, it's it's a real it's a real problem for us and it's ah it's a problem for the community. Now, Sanjay, just quickly to follow up on on this expedited pathway for international medical graduates issue.
00:07:41
Speaker
ah A lot of doctors are very worried about it here in this country, about you know a potential ah competition, about there not being jobs for our local trainees when they finish their training because they've been taken up by someone who who moves into into Australia and hasn't trained here.
00:07:57
Speaker
um Are you actually aware of the numbers? are Are we seeing a lot of people on these new pathways yet or is is this still a relatively limited issue to some specialties? At the moment, it is a limited issue to some specialties, but I think we know what the, we've seen what the government wants to do in terms of moving into different specialties in a tiered way.
00:08:18
Speaker
So I think that means that even that there's, you know, a few specialties that have um already started, such as GPU and aesthetics. And I think people in those specialties, the trainees, when I talk to the training committees in those specialties, um they do have a few concerns, but I think people have seen that and then ah extrapolating onto what's going to happen to their own specialties as um the government moves through ah this tiered system of assessing the specialties and seeing where um they could get, um but where they could assess ah doctors from in international settings as, um as I guess, at competent to the same level as Australian trainees. So I guess that's where the concern is. So yes, it is small numbers at the moment, but I think that
00:09:04
Speaker
Doctors in training are extrapolating and seeing what's happened in the few colleges that this has happened in um and saying, well, if it's happening there, then yes, the things we're going concerned about are, are we going to have a job at the end of the day?
00:09:16
Speaker
And are we going to be able to provide the same level of um safety and um ah I guess quality of care that the Australian public does deserve?
Flexibility in training for workforce retention
00:09:26
Speaker
Sanjay, I think it's really great to hear that you've been on this journey. you You kind of may be a bit knacky towards the colleges earlier on, but I think you realise how you now appreciate that the standards to which training of doctors occurs to.
00:09:40
Speaker
um I mean, but one of the things was going to ask you about that, yeah and you know just on that point, it's it's it's interesting because you know I've had a few consultations with people asking me for advice about you know pharmacy prescribing, pharmacists prescribing and other professions prescribing. and been shocked about how we'll just do a little core topic and we can start prescribing these medications.
00:10:02
Speaker
So I don't think people realise that actually need to know a lot and it's sometimes what you don't know that's actually the more important things and in training and and that obviously gets fulfilled by Australian levels of of of specialty training.
00:10:16
Speaker
But look, um on the flip side is is that there there are thoughts about making a bit more flexible, the training bit more flexible, um you know, and introducing some flexibility. i mean, what one bugbear for me has always been the fact that I think there should always be more...
00:10:28
Speaker
um credit for younger trainees to go out doing rural terms and maybe doing some general practice terms, which would help both with, you know, rural experience and maybe people actually end up in rural areas and in general practice so that they actually work better with with a key specialty in the in the workforce.
00:10:47
Speaker
um But I mean, is that something that really there is some focus on at the moment? Yeah, look, well, I think there is a focus on it because there needs to be. I think the whole thing is that the way that people work, it's not just doctors, I think it's young professionals across, you know different professions across the world is changing and flexibility is becoming more highly valued.
00:11:06
Speaker
And I think the crux is, is that if we want to keep people in medical in the medical system after spending all this money training them, we need to, you know, really embrace flexibility. um So, you know, people are valuing balance, they want variety and they want, you know, the purpose of what of of why they come to work each day and the fact that careers evolve.
00:11:25
Speaker
And, you know, they want careers where they can, you know, step in and out of training, they you can maybe explore different specialties, you know, balance clinical work with research, advocacy or family life. And I think, you know, that's the whole thing that people want. They want, to you know, more of a modular career, I think, these days where you know i guess the nine to five or you know I guess in medicine case, you know nine to seven, nine to nine kind of work life, five to six or seven days a week, that's not for them. you know They wanna provide high quality medicine and medical care to their patients, but they also want to be able to have um kind of a portfolio career as well and explore other options.
00:12:03
Speaker
um So I think if you don't embrace that um when you're planning a medical workforce, if you're in a medical administrator, i think you're just going to lose people from the system. And then your question is, well, how long is it going to get more people into the system? Or I guess the next question, which you know I guess you you don't really want to ask because this provides poorer quality care to patients is, well, how do we substitute that,
Financial strain on colleges and trust with trainees
00:12:24
Speaker
right? So I think at the end of the day is that I think more flexibility actually means we're investing in the doctors that are already there, making sure they stay in the system and keeping up those high standards that we want um so that Australian public gets the care they deserve.
00:12:37
Speaker
Now, Sanjay, I can imagine that colleges are feeling under a lot of pressure at the moment. They've they've had their monopoly on CPD for doctors are taken away from them and now doctors really have a choice as to whether to be a member of a college or not.
00:12:52
Speaker
um And, of course, the governments are also intervening when it comes to accreditation standards in hospitals. which were the college's only real way of um of supporting their trainees in their workplace and making sure that standards were were satisfactory and that trainees were being treated properly. A lot of them under a financial strain despite you know very high fees for both members and trainees, with my own college ah perhaps being out in the extreme in terms of fees but also financial strain.
00:13:24
Speaker
um where Where do you think this is going and and how do we how should we be acting as an AMA and as a profession to protect this profession-based model that served us so well for so long?
00:13:37
Speaker
Yeah, good question. I think this is where, you know, I think as much as I said that I value you know what the colleges are doing, I think the colleges also need a lot of introspection at this moment to see um where they can improve to make sure they're sustainable and viable going forward. Because if we want to keep this unique system of God in Australia, that's what's needed. And some, they need some harsh,
00:13:57
Speaker
hard words towards themselves. And I think the AMA needs to be part of that process as in collaborating with them to um see where AMA can help, um make sure that the colleges can protect themselves and advocating effectively for what's best for trainees, but also their members, but then also how can they change for the better?
00:14:19
Speaker
And I think you know a lot of trainees are feeling that directly. I mean, you know you talked about financial. I think that's a big thing that trainees feeling at the moment. Their fees are going up um in large increments, and they're wondering why.
00:14:30
Speaker
um And I get that we're in an environment where regulation is increasing, the amount that colleges need to do, and the cost of that is increasing. But when there's no transparency about that, it really erodes trust.
00:14:42
Speaker
um And I think that trust is really important because colleges are volunteer organizations, right? Like, I mean, we're all, I mean, you know and you know, Chris, Omar, I'm sure you've done a lot you know in your own colleges and that's all been volunteer time. You haven't been paid for that. And that's, this is a system where that has to be given back once you become a fellow of the college. But I feel
Need for a national health workforce strategy
00:15:03
Speaker
a lot of trainees are are feeling the thing of there hasn't been any transparency about what's the fees that have been increased or changes in the program all of a sudden, um you know exams being added, assessments being added or taken away at a moment's notice. And then I guess if that trust isn't there, you don't really feel like giving back to your college at the end of the day.
00:15:19
Speaker
And I guess having CPD homes means that there's now an outlet for people to go to where they're like, well, do I even need to be part of the college system anymore, which is you know dangerous. But I think it also means that colleges should embrace that in terms of look if that's there then we should really make our trainees and make our fellows feel well what's the value of being part of our college and how are we treating you with respect and i think that's pretty simple just being quite transparent with what you're doing where the money's going if changes are coming why they're needed making sure you're consulting broadly um so we make sure that we've got a volunteer labor workforce going forward um that can continue the system and making sure that we're maintaining those high standards going forward and that colleges remain independent
00:16:02
Speaker
Sanjay, just to shift you into a different area, um and I'll take you back to before your time. um My potted history about health workforce planning in Australia is one of disaster.
00:16:13
Speaker
mean, back in the, as I recall, back in the the Rudd years in the national health reform, he's had the Health Workforce Australia, which was the really one coherent effort to try and work out what our needs for health right across health were in the community, particularly in rural areas.
00:16:28
Speaker
and then worked backwards from there to work out how many people we needed to train in area every area of health, and particularly in medicine. um And that got disbanded by the coalition to go for the free market at that point, which hasn't really served us well.
00:16:41
Speaker
And we've been in the the wilderness for so long now. And what people don't realise is that health workforce planning is something that affects, you know, the next decade. So anything we do now is in the next decade. I mean, where are we now? And do you think it would make a difference to have a much more concerted effort in this area?
00:16:58
Speaker
The short answer would be yes, but I'll expand that a bit further. um So i think I think you're right, Chris. I mean, you know, Health Workforce Australia was around. Sure, it wasn't um the perfect ah um ah ah system, you know, like, you know, there were issues, but it was something that actually um gave us hope that we could have a nationally coordinated, independent um advisory, you know, is advisory um system to actually implement a national work medical workforce strategy. Because what exists now is, I think, it's quite a politicised system.
00:17:31
Speaker
I think um the government um uses certain forums to say that their um you know, collaborating with key stakeholders in the system. But the feeling I get is more of a tick and flex exercise um that's going on and really things are just sort of moving at a level where health ministers are sort of setting an agenda.
00:17:51
Speaker
And I always feel worried that that agenda doesn't align to what's best for the Australian population's health needs um and maybe more short term than we want.
00:18:03
Speaker
So I think if we had to coordinate national medical workforce strategy that aligned with you know training and community community needs, that would be amazing. um you know At the moment, we've got a very siloed system. Everyone's trying to do their own thing.
00:18:17
Speaker
And I think um government's kind of taken slight advantage of that. um And yeah, it'd be great to have a system that's ah more in line with long-term goals about you know the unique challenges we face in Australia, which is ah um large geographical region to serve with different health, who have different health needs, and how do we encourage doctors to work across that wide variety um of of the health landscape that Australia has in a coordinated fashion um that make sure that doctors in training and um I guess the health workforce in general and and um
00:18:54
Speaker
are staying in that system and are having fulfilling careers within that system as well. So I think, you know AMA has got it completely right here. We need to get back to an independent workforce planning agency um and I think that will serve
Colleges' collaboration for modern efficiency
00:19:08
Speaker
our community. You mentioned the word siloed there in describing some of the actions of our colleges and and certainly in my experience dealing with the colleges During the pandemic and and as AMA president, it became clear that they're all trying to do the same thing in different ways and and sometimes failing.
00:19:29
Speaker
um So, for instance, the the classic example was that the technology failures that occurred with the examinations across various colleges at various times, which caused huge disruption to the lives of trainees and even to the the the medical workforce supply into our health system.
00:19:46
Speaker
um And it it seemed obvious at that time that maybe they should work together and and develop the technology together to be able to deliver simple things like exams you know across the country and ah in ah in a way that was um a little bit more reliable than what's happened in the past.
00:20:02
Speaker
And if you look around the world, there are different models. You know, Canada has one enormous ah college which, you know, obviously looks after everybody and seems to be leading the world in a lot of their educational principles and and standards.
00:20:16
Speaker
And then, of course, you can go the other way where um where universities ah have taken over the whole thing and, of course, you know Most of us are pretty pretty skeptical about what that would look like in Australia if universities ran ran specialist training.
Future of specialist training in Australia
00:20:28
Speaker
But do do you have a sense of ah where the future is for our colleges? wait If you look forwards 10 years, what what's likely to happen on and what should happen? Yeah, it's interesting you um noted the Canada system and then also the idea of um universities running training programs. And look, these are internal debates that the Council of Doctors and Training have had. you know what What would be better? you know Especially when we're really railing against the colleges, say, when a increases happened and you're sort of thinking, well, yeah know is there way we could do something better? But then I think what we always come to it's, um it's a devil, you know, and also the the unknown risks of having training delivered by all other organizations. And I think, you know, universities are are a clear example because, um you know, say training was run by a university, you know, you'd be really worried about how people are going to get that on the on the job training experience if a university is running things and also
00:21:16
Speaker
i ah you know I might not be fan of the fees that colleges sometimes charge, but then you look at the courses that universities run and the astronomical fees they charge, and I think there's you always see that things ah could get worse.
00:21:30
Speaker
um But going back to your question about what's um how you know what's the future of colleges, I think You hit the nail on the head, Omar. I think working together is going to be a major thing that colleges will have to do to actually create efficiencies.
00:21:43
Speaker
And I'm really glad the Council of ah Presidents of Medical Colleges has actually reformed the way they work to hopefully deliver that and actually create a model where colleges are working closer together, they're aligned in their strategic needs and then and knowing that they're in a you know in a ways in an existential crisis currently where government um is not their biggest fan but knowing that they've got a common purpose to make sure they defend the way that training occurs in australia and hopefully that means that they'll work together to create efficiencies and to the ring exams you know a lot of efficiencies and back end um things that must be common across colleges um and hopefully that means that one fees will go down trainees will be happier i think fellows will be happier and it's a
00:22:26
Speaker
a much more efficient way of running, which means that their their long-term survival is ins ensured.
Improving rural training pathways
00:22:32
Speaker
Sanjay, we'll finish up with a question, perennially problematic question, which is about rural.
00:22:38
Speaker
and our country colleagues. mean, I think the AMA has led some incredible sort of progress in this area and and tried to lead the government in the correct direction with things like entitlements for general practice training.
00:22:53
Speaker
But, I mean, what what do you think continues, the priorities continues to change for rural and regional training pathways to succeed from here? Yeah, I think like, you know, now we know the research has been done. What do you need to actually get people to be working in rural environments? And a lot of that is early exposure to rural environments.
00:23:12
Speaker
So I think that means ah supporting rural medical schools or medical schools which have large rural clinical schools attached to them, making sure that people are in there for, you know, long not long but certain periods of time that ensure they've actually got a sense of what the community is like what working there is like and how they could integrate i think providing training opportunities earlier on so i think this is where the colleges really have to come to the table and i'm glad they have so cpmc recently um released guidelines on selection into rural training and so it's glad i'm glad to see colleges actually taking the initiative and doing that work
00:23:46
Speaker
I know a lot of colleges already do great work in this area. I mean, RACS is a perfect example where certain subspecialty training programs have really um tried to create rural training pathways that mean people can actually do a bulk of their training um in a rural environment. And we know that means that people will then um yeah the rest of their lives get aligned to a rural setting. So their families, um their friends, ah their hobbies, it means that they feel comfortable staying there for um yeah a long period of time and hopefully serving those communities.
00:24:15
Speaker
I think things that need to be done further is looking into, well, how can we expand that? So I think you know these sort of things are in active discussion in circles I've been at. So this includes remote supervision,
00:24:26
Speaker
I think supervision is very hard in rural settings because you know you've just got less supervisors around. So how can you have innovative models of supervision considering we've got you know telecommunication technology that can allow this to happen?
00:24:38
Speaker
So how do we um you know sort of use that to its full advantage? The other one is multi-disciplinary supervision. so I get that as a surgeon, you want to be supervised by and and another surgeger surgical trainee. So you don't you don't want to be supervised by um you know a GP, say. But in that setting, there could be certain things that you require in terms of your work-based competencies that could be supervised by other people.
00:25:01
Speaker
So you know obviously, you're the the role that you're doing and in in the operating theater, yes, it has to be supervised by a surgeon, but maybe when you're seeing patients in an emergency setting, could that be supervised by someone else? So, you know, relying on those kind of um innovative models of supervision ah could be a way to open up more of those rural training places as well.
00:25:20
Speaker
um So I think we just have to be a bit creative about it, and I'm glad that people are finally coming to the table on that.
Evolution of colleges and junior doctor support
00:25:25
Speaker
You know, colleges are conservative structures, but I think they've seen that, you know, to provide that medical care that the Australian community deserves,
00:25:33
Speaker
we have to be innovative and we have to take these things on board. It's ah pleasing to hear, Sanjo, that there's at least a future for our colleges, that they are changing, because i think that the conservative word is probably one that resonates with many of us, but for those who have had a fair bit to do with colleges, including me, though they are changing. They're very, very different now to what they were 20 years ago, and I'm sure they'll be different again, and responding to community needs in 10 20 time.
00:26:00
Speaker
time And certainly the idea of a future without them is one that that fills me with with horror, basically, because, you know, if you had the health ministers ah totally in charge, they've already got too much power when it comes to standards and in medical care. To give them even more and to take away the profession's ability to define its own standards would just be a huge step backwards. So I'm really pleased that junior doctors are supportive of our colleges, but also the call for change and the call for colleges to continue to to innovate.
00:26:30
Speaker
um For listeners who are keen to share feedback on your experiences, get in touch with the Council of Doctors in Training. They are ah very open to to feedback and to ideas and there's plenty of AMA resources including a specialist training pathway guide on the AMA's website.
Listener engagement and discussion participation
00:26:47
Speaker
We're going to continue these conversations, including issues like CPD Home and workforce planning in future episodes of the podcast. ah But thank you so much for joining us, Sanjay, for your time today. And we look forward to to this conversation continuing.
00:27:02
Speaker
For listeners, thanks for listening. You can like so subscribe and subscribe to our podcast. And, of course, please share the link to this podcast with your colleagues. Join the conversation on how we can forge together a better future for specialist training and, of course, to improve the medical care for all of our patients. And I've just noticed my hiccups have stopped, so it may be that doing podcasts actually is a treatment for hiccups.
00:27:26
Speaker
Innovation as well on the um on the Waiting Room podcast. Cheers, everyone. Thanks for listening to The Waiting Room.
00:27:35
Speaker
Learn more about the AMA, including how to become a member, ama.com.au.