Policy Document
Early Streaming Policy
Background
The Australian Medical Students’ Association (AMSA) is the peak representative body for medical students in Australia. AMSA believes that all communities have the right to the best attainable health. As such, AMSA has a key role in advocating for medical curricula that equips future generations of health practitioners with the necessary knowledge and skills to deliver the highest quality of care to patients and the community.
Australia is renowned for producing high quality medical graduates. This quality is largely due to a long-standing tradition of generalist training in the undergraduate and early postgraduate years. The pressure to produce more medical specialists, in response to an Australia-wide doctor shortage, has led to efforts to fast-track trainees into specialty training. Junior doctors are able to access specialty training programs as early as PGY 1 [1]. As an extension of this, streaming into specific disciplines may now start as early as medical school. Streaming may be contextual, where students undertake the entirety of their medical training in a specific setting, usually rural, or discipline specific. This early streaming may constitute a threat to a generalist medical education, and may produce doctors that are pigeon-holed into their area of specific streaming.
Streaming In PGY Years
In 1997 Medical Training Review Panel (MTRP) was created to research and collate post-graduate training options for junior doctors. Recommendations endorsed by the panel upon inception include:
full medical registration should be granted after completion of one year of supervised internship;
emphasis in the first two postgraduate years should normally be placed on achieving a well-rounded generalist orientation in preparation for vocational training;
while there should be no formal streaming into the training program of a particular college prior to PGY 3; the second postgraduate year should include sufficient options to allow vocational emphasis (some of which could be recognised by colleges), if desired by a HMO [2]
The importance of this training is further highlighted by the trend of admissions into specialty colleges. Although colleges can accept candidates into training programs after their PGY1 year is complete, the majority prefer candidates who have at least 2-3 years of experience as a HMO [1]. These years allow for trainees to develop a high standard of medical professionalism, under the mentorship of clinicians from
a broad range of disciplines. Trainees acquire varied streams of knowledge, and integrate these as a whole. This standard is increasingly important as the focus of healthcare in Australia shifts to a team-based, interdisciplinary approach.
Streaming In Medical School
The Australian Medical Council (AMC) accredits all medical school curricula, with the Council approving programs that produce doctors that are proficient in a wide range of domains [3]. These standards allow for individual course diversity, while ensuring medical courses produce competent doctors, who will be functional as junior medical officers upon graduation.
Medical school also involves education and exposure to experiences and knowledge previously foreign to many students. Along the way, students can discover fields that they are passionate about, and also realise their preconceptions about certain areas of medicine were quite inaccurate. In addition to the exposure to various medical careers that clinical years can bring, they also allow for interaction with doctors at different stages in their careers. Students can find out more about the training process, and lifestyle that accompanies the options discussed, to see if it is right for them. They may discover that characteristics of certain specialties are not in line with their future goals, or that their personal traits may not suit certain career choices [4].
Therefore, the possibility of medical schools themselves streaming their students into various specialty fields, or practicing environments, is concerning. Whilst some believe it could allow for a more focused education, it would be forcing students to choose a medical school/stream based on their premature knowledge and opinions. There is evidence to suggest that an early decision could later be regretted, with one study noting nearly 80% rejected specialties they chose at the beginning of medical school [5].
There have been attempts within Australia’s medical schools to introduce a level of exposure to specialties and practising environments in shortage. For example, in 2007 The University of New South Wales (UNSW) initiated a new electives program in their medical course. This was done with support from The Royal College of Pathologists of Australasia (RCPA), and the Institute of Medical Training (IMET) of NSW Health. The program aims to expose students to fields where there is a workforce shortage; with the electives (combined with appropriate PGY training), allowing a student to potentially seek advanced standing within the relevant specialty training program in the future. Although currently limited to pathology, the eventual goal is to expand the program into more specialties, with the The Royal Australian and New Zealand College of Radiologists (RANZCR) expressing in principle support of the scheme [6, 7].
These schemes are voluntary, and their implementation currently does not infringe on the generalist core of the medical courses involved. Furthermore, a student’s future career choices are not
restricted by undertaking these programs. They represent a step in the right direction in terms of increasing exposure, and expediting training, in areas of workforce shortage.
However, programs such as these should be welcomed with a level of caution. There is the potential for arrangements like these to evolve beyond electives and become inherent to future medical courses, to the detriment of foundation generalist education.
As noted above, during training both students and junior doctors practicing preferences may evolve and change multiple-times as more experience is gained [4, 5]. Even at graduation a doctor’s choice may not be made up entirely, with a study showing approximately one fourth of medical students were undecided about a specialty at graduation [5]. By streaming medical students and/or junior doctors early, they are potentially into locked career decisions that are uninformed. Early streaming also possibly denies them the ability to practice in an area of undiscovered talent and/or passion.
The detrimental effects of this on a future doctor’s career mean additional time or finances to make major career changes [8], or working with a significant level of dissatisfaction.
Doctors and medical students who have level diversity within their training, will be able to define their career path based on experience, and gain exposure to the less popular or notable specialties. This will produce well rounded doctors who are adaptable, and functional in the dynamic healthcare situations they may be placed in. Moreover, it has been shown that medical students currently are less-likely to specialise in the less-known or less-notable specialties, which tend to be the ones facing shortages [9].
While streaming programs may be seen as a way of ensuring that there are doctors in areas or specialities of need, there is no guarantee that students will in fact be attracted to these areas without the exposure and experience gained through rotations through a variety of specialty areas. Moreover, current workforce shortages tend to be worst in the generalist-based specialties [10]. Given that doctors with generalist skillsets are crucial for the sustainability of Australia’s health workforce, a generalist training foundation should be even-more desirable, and prioritised within all levels of medical education and training.
Position Statement
AMSA believes that:1. Medical school curricula, and prevocational medical training should consist of a broad-based generalist education;
2. The current medical schooling and prevocational training system provides doctors with the basic knowledge and skills that underpin the entirety of their medical careers;
3. Any attempt to compromise this generalist training will produce doctors that are heavily specialised, and should be avoided;
4. Medical students should not be expected to decide upon, and train in a specific specialty during their degree; and
5. Junior doctors should have a well-rounded base in generalist medicine, before undertaking specialty training.
Policy
AMSA calls upon:
1. Australian Medical Schools to:
a. Avoid implementing a specialty-specific curriculum or program that detracts from a generalist medical education;
b. Expose students to a variety of practice settings during their training, to ensure they receive an appropriate generalist training;
c. Ensure that any streaming of a cohort into contextual settings should: i. Be entered to by a student voluntarily;
ii. Provide students with learning experiences sufficiently broad so that they are qualified to practice in any setting;
iii. Provide learning experiences that are not notably deficient compared to those received in the other student streams;
d. Not brand or market a medical degree or school as specialty-specific;
e. Provide opportunities for students to attain accredited education and training in specialty areas of workforce need, supplementary to the core of the medical course; 2. Australian Specialist Training Colleges to:
a. Not acknowledge discipline-specific training that is offered as a compulsory part of a medical course;
b. Recognise appropriate discipline-specific training taken prior to entry into a specialty training program;
c. Appropriately reduce vocational training time on account of existing experience, taking into account the amount and content of the training;
3. Commonwealth and State Governments to:
a. Resist attempts to fast-track medical students and junior doctors through their generalist training in response to workforce shortages;
b. Ensure that any alternate prevocational training streams offered: i. Are entered into voluntarily by a junior doctor;
ii. Provide a junior doctor with a learning experience that is sufficiently broad-based so that they are able to practice in any setting;
iii. Provide training that is equivalent to that provided in traditional prevocational training settings, so as to not disadvantage and restrict doctors from undertaking specialty training of their choosing;
4. The Australian Medical Council to:
a. Ensure training standards set by the Council continue to emphasise the importance of generalist foundation training in medical school, and prevocational generalist training.
References
1. Medical Training Review Panel. Sixteenth Report [internet]. Canberra (AU); 2013 [cited 2014 Jun 06]. Available from:
http://www.health.gov.au/internet/main/publishing.nsf/Content/38D69486D82F4A59CA257 BF0001ACD8E/$File/Medical%20Training%20Review%20Panel%2016th%20Report.pdf 2. Medical Training Review Panel. First Report. Canberra (AU): Department of Health and
Family Services. 1997. 77p.
3. Australian Medical Council. Standards for Assessment and Accreditation of Primary Medical Programs by the Australian Medical Council 2012 [internet]. Kingston (AU); 2012 [cited 2014 Jun 06]. Available from: http://www.amc.org.au/images/Accreditation/FINAL-Standards-and-Graduate-Outcome-Statements-20-December-2012.pdf
4. Coutts-van Dijk LC, Bray JH, Moore S, Rogers J. Prospective study of how students'
humanism and psychosocial beliefs relate to specialty matching. Acad Med.1997;72:1106-1108.
5. Kassebaum DG, Szenas PL. Medical students' career indecision and specialty rejection: roads not taken. Acad Med.1995;70(10):937-43.
6. University of New South Wales. UNSW Tackles Shortage of pathologists, radiologists [internet]. Sydney (AU); 2007 Sept 24 [cited 2014 Jun 06]. Accessible from:
https://newsroom.unsw.edu.au/news/unsw-tackles-shortage-pathologists-radiologists 7. University of New South Wales. Advanced standing for specialist training from the UNSW
Medicine program [internet]. Sydney (AU); 2010 May [cited 2014 Jun 16]. Accessible from: http://www.med.unsw.edu.au/medweb.nsf/resources/csu5/$file/Advanced_standing4.pdf 8. Jarecky RK, Schwartz RW, Haley JV, Donnelly MB. Stability of medical specialty selection at
the University of Kentucky. Acad Med.1991;66(5):756-761.
9. Bienstock JL, Laube DW. The Recruitment Phoenix: Strategies for Attracting Medical Students Into Obstetrics and Gynecology. Obstet Gynecol.2005;105(5):1125-7. 10. Health Workforce Australia. Health Workforce 2025: Medical Specialties, Volume 3
November 2012 [Internet]. Adelaide (AU); 2012 Nov [cited 2014 Jun 06]. Available from: https://www.hwa.gov.au/sites/uploads/HW2025_V3_FinalReport20121109.pdf
Appendix: Abbreviations
PGY – Postgraduate Year
RMO – Resident Medical Officer (junior medical officer in PGY 2+) HMO – Hospital Medical Officer, same as a JMO
Policy Details
Name: Early Streaming Policy
Category: D - Graduations, Internships and Careers History: Adopted, 2008
Amended following review, Second Council 2014
