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From: Rescuing Medical Education Conference
Stamford Sydney Airport
O'Riordan St (cnr Robey St), Mascot
18 February 2005
Dror Maor
President, Australian Medical Student Association
Thank you, Bill, and thank you, Lindsay and Bruce, for their invitation to come and speak at this very important conference. As students, I have to say that we truly appreciate the fact that an organisation such as the ADF has really taken this issue on board and is really concerned about what is happening with the future of medical education in our country and our future doctors, and that being the students.
I have to say I've been given an honorary title of a doctor on the programme but I am in my final year of medical school, so I think it's about another 8 ½ months before I deserve that title.
Also, one thing that is very important to mention before I start is, I want to thank the students who have attended this. Whilst the ADF has put this conference on it's very important that we as students support the people who are supporting us and the people who are giving us the guidance as future doctors. As you can see in the room there's about, I think - Stephen will be able to correct me - but I think there's 42 students out of this whole crowd who are here from Perth, from Adelaide and New South Wales. I'm not sure if there's anyone from Melbourne or Tasmania, but that's just bad luck on their behalf.
I also think that - one thing that was great, and I would like to thank the Minister in his absence - was to hear - and you don't hear this every day, but they are happy to fund the research into medical education, and how to make the future doctors better doctors and how to create the best doctors for the patients and the community. And that really is what this whole conference should be and is all about.
I'd like you to imagine this - a group of medical students made a decision not long ago to walk from the University of Sydney to the University of Western Australia. The aim of this walk was to compare how students were taught in a clinical setting at one university campus to the other. As they walked through the countryside they had to go through this forest. After about ten minutes in this forest they heard a voice. Now the voice said, "pick up the rocks, pick up the rocks". Some of the students thought they heard a voice, whilst others just decided to ignore it and thought it was no different to the professor who teaches them pathology on a regular day to day basis. Now they all kept on walking and once again a voice said, "pick up the rocks, pick up the rocks". Within this group some of the students decided to pick up as many rocks as possible and filled up their bags, whilst others decided to pick up just one or two rocks, as it would be too difficult to carry these rocks all the way from the Eastern States to Perth. They kept on walking and for some the walk became extremely difficult whilst for others it was a nice walk. Once the students had arrived in Western Australia they stopped and emptied their bags. To their amazement their rocks had turned to gold and diamonds. So those that had filled up their bags and did the hard yards all the way to Perth were extremely happy, and those that only took a couple of rocks were wondering why they had not gone to the effort of carrying more, the effort of picking up more rocks.
Ladies and gentlemen, these rocks are much like the medical education that has been given in our teaching hospitals over the years. For those students who have wanted to, the rocks have been available, and the teaching has been there so that we can be the best possible doctors for our patients. But these rocks are slowly disappearing, and with them the opportunity for a comprehensive education and the opportunity to truly be the best doctor in your field.
The continuing erosion of quality teaching as a result of escalating service pressure and financial challenges for university departments, hospitals and doctors, has seen both a short and a long term destabilising force for our present and future doctors. What is an even bigger concern is that whilst the availability of tutorial and clinical teaching is decreasing today, the number of medical students around Australia is widely increasing. In our public hospital system, consultant sessions are being reduced, RMO and resident numbers have been cut despite the increasing amount of work that is required from them. Therefore it is evident there are less doctors to teach our students and even the ones who are willing to teach have less time to do so.
Now these concerns are echoed in both Australian and US literature where reports link improvements in medical care to those in medical education. The US Surgeon General, in a speech he gave not long ago to the graduates at the Harvard Medical School, stated that "among the missions of the American health system, none is more important to the future of the American health care system then the education of our future doctors".
Now what we can see is that in the lead up to the 2004 federal election, several new medical schools were announced by the Commonwealth. Depending on the outcome of the Australian Medical Council's accreditation process, which we have spoken about before, it is likely that by 2007 the number of medical schools and students Australia wide would have increased by 50%. So from a medical school point of view that's from 12 last year to 18 by 2007.
I have no doubt that Australians will welcome more doctors in the hospitals and in the communities. But students need mentors, so where are the additional specialists in our hospital system? Surgeon, teach thyself, I hear you say. If only that was the case. We have analysed medical school places and so has the AMA and institutions such as CDAMS(?). These figures show that by 2008 the potential intake will be between 2,300 and 2,400 students each year. Now this represents a 40% increase on last year's intake which had already been boosted by 12%. And these figures further show that by 2011 there will be an 85% increase in medical school graduates, that is an 85% increase in the number of interns that we are putting into the health system.
Now this is --- don't get me wrong, this is great news as far as medical students are concerned but without the added infrastructure and support, this could spell absolute disaster for our medical industry. AMSA has consistently acknowledged the need to increase medical workforce numbers and so has the AMA, and from the figures that we have seen, and I have just mentioned, it is obvious that the Minister for Health and the Minister for Education are very serious about increasing these numbers. That's good news. But this is only part of the equation. The Government has a responsibility to provide the resources for quality undergraduate, prevocational and vocational training. However, we are all aware that they are already experiencing a drop in the teaching, as we've all discussed, and coupled with the increase in student numbers, you don't have to be Einstein to do the sums and see the disaster story all over the front page of the morning paper in a few years time.
Ladies and Gentlemen, it's not too late to account for these extra students but the planning must start now, it must start today. There's been a limited increase in the number of supervised places but there is no promise from the Government or from other institutions to further increase these numbers. AMSA is also concerned at the lack of supervised medical student places in teaching hospital as well as the increasing number of interns and residents who walk around the wards completely unsupervised, without guidance from their more senior colleagues. Now this is a real issue that will decline the level of teaching and subsequent level of professionalism in the medical workforce and thus a real decline in the training we give our future doctors.
Now all you need to do is look at some of our hospitals. Let's look at Tasmania for example. Students last year did teaching ward rounds in groups ranging from five to fifteen. Now, most of the people in this room would have been on ward rounds, and obviously the more people you have, the more medical students you have, and the more people you have striving for that knowledge, the harder it is to teach. But I think the numbers we saw in Tasmania last year take this issue on a whole different level.
Now my topic today - Andrew obviously addressed the undergraduate issue and it's not my place to do it, but I think one very important example once again while we're talking about Tasmania is an example of pathology. The number of teaching hours last year, or the last two years, has died from fifteen hours of pathology to just one. And that is one hour of pathology.
But make no mistakes about it, these examples are occurring in many of our teaching hospitals. A major teaching hospital in Perth where I am studying has had the number of consultants in their general medical department cut down by 50% over the last few months. Now this has meant that for the general medical rotation in fifth year - which fortunately I have just completed - instead of having eight groups of four member students, we now have four groups of eight members standing on these ward rounds. Now whilst this may not sound like huge numbers, for the patients and for the three doctors and nurse and the eight medical students surrounding them on every morning ward round, this is a terrifying experience. Furthermore this makes it extremely difficult for any doctor to teach his students and to give them the true hands-on approach and teaching that they need.
Now even the Government realised this when in 2001 a senate report on the public hospital system and public health system included a recommendation by the Commonwealth that the Commonwealth, in conjunction with State and Territories, find ways and means to maintain and sustain and further increase the research and teaching capacity of our public hospitals.
So, ladies and gentlemen, if we do not make the appropriate changes in our system we will be doing the wrong things by, not only our future doctors and the current ones, but most importantly by our patients and the wider community. In the last decade there have been significant changes in health care delivery and all of these have really had a major impact on how future doctors are learning and are being taught.
Let's take, for example, one thousand people, for instance, in the Sydney community area. Now in any given month 800 of these people experience symptoms, 327 consider seeking medical advice, and 217 of these people actually attend a primary care physician. Out of the original 1000, 21 visit an out patient clinic in a hospital, 13 visit an emergency room and 8 are hospitalised in a community hospital. But the most important figure above all this is that less than one person in every thousand is hospitalised in a so-called teaching or tertiary hospital. Now these changes have an enormous impact on the potential training in the hospital, not only for medical students, but for our teachers, for our consultants, and really for all future doctors. We must make sure that these doctors who are currently working in the public health force and public health system stay and teach.
But there is a lot more that needs to be done. A key performance indicator for hospital ratings should be the quality and quantity of education that a student doctor or a junior doctor is receiving. To increase these benefits and to help train these future doctors within the public system, one of the suggestions that the Australian Medical Student Association would put forward would be that the training for medical students and doctors be identified within the public teaching hospitals' performance and monitoring indications. So for the same reason that a managing director or a CEO of a hospital has to make sure that he or she covers all the objectives before they receive a further pay rise, thanks to the taxpayer dollars, medical education for our students and doctors should definitely be one of these objectives.
Now the option of training students in the private health system appears another way to overcome these problems. But the suggestion raises questions about access of the level of education, access of the opportunities that are given in different private sectors. Currently there are substantial untapped learning experiences available in all private hospitals that are really not being utilised by us as a profession. Educating our future doctors within the private system would significantly supplement the spectrum of service and delivery, and education opportunities which are traditionally only available in these teaching hospitals.
In such specialties such as dermatology or psychiatry, for example, most of the clinical service is actually delivered in the private system. Service delivery in private practice would often include patient consultations before, during and after any medical interventions which would provide a continuum of care and an educational experience that is not characteristically provided in our public teaching hospitals, especially as we see these public systems becoming more acute.
Another solution could be to take the same advice that the medical specialist training task force has recommended to the Australian Health Minister's advisory council. That is to incorporate a network of educational settings with a principal health care service such as a hospital - a public hospital - taking responsibility for the co-ordination of education for all clinical medical students within the network, including our public hospitals, private practices, rural and regional practices, as well as community based practices.
My fellow colleagues, Senator Edward Kennedy once said "each time a man stands up for an ideal or strikes out against an injustice he sends forth a ripple, building a current that can sweep down the mightiest walls of oppression and resistance". This conference today has started this ripple, and now we must move forward and improve the quality and quantity of the teaching of our future doctors. All doctors must campaign for a national medico political commitment to improve education and training inside and outside of our public system. As doctors, we need to recreate an institutional culture that clearly values and supports the professional development and education of our students, our junior doctors, and even our slightly more senior doctors.
The quality and safety of health care in this country are under serious threat and unless there is a substantial improvement in the way education and training is funded and resourced we will have major problems. Now, ladies and gentlemen, we owe this not only to our students and our future doctors, but we really do owe this to our patients and the community. After all, we just don't know how many of these rocks collected during this journey actually do turn into gold and diamond.
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