Preparing the next generation of doctors is a complex multistage process. Around the world, many different agencies are involved in education and training – hospitals, universities, professional societies, government health departments, licensing boards etc. The approaches and systems that underpin the graduate medical education around the world have evolved from a variety of local historical, professional and societal influences.
At a time when many health systems are changing rapidly and biomedical knowledge is expanding quickly, many jurisdictions are struggling to develop or redevelop their graduate medical education programs.
Three broad domains are important to consider when systems are organizing (as is often the case in emerging economies) or reorganizing (as occurs in many developed economies) their approach to training the next generation of doctors. These are:
Governance
Governance is a formally established set of processes for making decisions and ensuring that they are implemented. In some international jurisdictions, the major structures of governance are professional societies where as in others, where public hospitals are key training locations, agencies of government take a lead role of oversight and governance.
The general elements of good governance in any organization apply equally well to the oversight of graduate medical education. They include:
- Efficiency and effectiveness
- Responsiveness to the needs of all stakeholders
- Transparency in operations
- Acceptance of the imperative for accountability
- Consensus building and participatory decision-making
Funding
Depending upon the international jurisdiction, the funding for graduate medical education is variably complex and always influenced by a variety of considerations. The factors that influence the extent and origin of funding for training the next generation of doctors include:
- The state of the national or state economy;
- The extent to which hospital care and medical care is privatized;
- Historical arrangements with the funding agencies that are government based (e.g. Medicare funding of graduate medical education in the US);
- The rising cost of delivering healthcare;
- Current and projected future workforce supply and demand, both at the local hospital level as well as at a regional and national level;
- Attractiveness of training in the various postgraduate disciplines.
In many systems around the world, the basic salary and benefits of trainees in hospitals has been covered or subsidized without application of additional fees to the trainees. However, there are many hidden costs for trainees particularly when external training organizations mandate didactic programs for which fees are charged and, often substantial examination fees. In many systems there is an under recognition of the need to adequately fund education and training enterprise beyond simply the salaries of trainees. Clinicians who are actively involved in leading programs and delivering training and providing support require protected time which must be funded. Many systems around the world are confounded by significant cross subsidies between clinical, education and research budgets.
Practical and Operational Considerations
There are many operational considerations in maintaining a successful graduate medical education system. While the particular aspects that are relevant for a given system are dependent upon a range of local and contextual issues, some common features worthy of consideration include:
- Sharing guidelines and benchmark information within and across disciplines and training sites – promotes efficiency and effectiveness;
- Development of shared curricular planning and faculty development expertise, particularly between universities and freestanding training agencies – avoids duplication;
- Common standards for supervision of trainees, educational infrastructure, service/ training balance, support for clinical doctors as educators across training sites – promotes equality across disciplines and efficiency within training sites;
- Appropriate systems of formative and summative assessment of junior doctors;
- Appropriate mechanisms for monitoring, evaluation and provision of feedback to training sites – maintains and enhances quality of training;
- Programs for preparing a selected subset of trainees as future roles as leaders of clinical medicine and the health system – encourages development of a cohort of clinicians as leaders, individuals who develop a robust understanding of organizations and systems;
- Special consideration to training in special geographical regions (e.g. underserved communities; regional, rural and remote communities) – ensures adequate interest in workforce distribution;
- Need for a reliable information management system that links education and training programs with workforce planning – ensures that the training programs meet society’s needs over time;
- Opportunities for research during training – this might be in basic sciences, clinical medicine, population-based research or health systems research.
Those of us working in the implementation of new graduate medical education programs or the redesign of existing programs have long realized the importance of taking into account these many factors when embarking upon substantial change initiatives in graduate and postgraduate education.
These thoughts are based on a longer article about the Australian postgraduate medical education system originally published in the MJA 2005; 182: 177-180.