The role of universities in Australasian emergency medicine training.
Emergency medicine (EM) is an increasingly challenging discipline in which to work and train. Community expectations of EM services are rising, and emergency clinicians face a growing burden of complex and chronic disease. As a reflection of ongoing advances in scientific and educational knowledge, EM training curricula have expanded in both breadth and depth.1 There are also more medical graduates than ever before, and competition for specialty training places is increasing.2 It is timely, therefore, to consider whether current models for the delivery of postgraduate medical education (PGME) are fit for purpose. In a demanding training and service environment are colleges – acting through clinicians, hospitals and health services – best placed to deliver specialty education? Is there a role for universities? These issues are considered in the accompanying articles by Roberts and McCarthy,3, 4 and this article provides further background to the debate. Under the Australasian system of medical training, the role of universities has traditionally been confined to professional entry degree programmes. Hospitals and prevocational medical education councils have been primarily responsible for the early postgraduate years, and medical colleges for specialty education. This is in contrast to nursing, where universities have a more established role in providing clinically focused postgraduate education. There are isolated examples of universities contributing to PGME. In EM, for instance, ACEM's ‘alternate pathway’ for the Trainee Research Requirement (TRR) allows trainees to complete approved university subjects in research methods. Most trainees now meet the TRR via this route,5 with some applying the credit attained towards a higher degree (such as a Master of Public Health). Certain colleges require completion of a Master's degree as part of their training programmes, but clinical placements are usually managed separately. Examples include public health and medical administration.6, 7 Although trainees in these disciplines have to complete subjects in specified areas, Master's programmes do not have to map to the relevant college curriculum. Only one college has a higher degree directly linked to its training programme. In Victoria, all Royal Australian and New Zealand College of Psychiatrists trainees undertake a Master of Psychiatry through the University of Melbourne. The course is designed to meet the College's education requirements, and is timetabled so that psychiatry trainees can attend on a weekly basis.8 The role of universities in providing PGME in sub-specialty areas is more established. Many trainees and fellows, usually of their own volition, seek to advance their knowledge by completing coursework-based postgraduate qualifications. Examples relevant to EM clinicians are listed in Box 1. In North America and parts of Europe, universities play a more prominent role in PGME. Vocational training is de-centralised such that individual universities (which often operate health services) are responsible for local specialty training programmes. These must conform with the requirements of the relevant accreditation authority.9-11 The UK model more closely resembles Australasia's. EM training is overseen by the Royal College of Emergency Medicine, but delivered locally by a postgraduate deanery or equivalent.12 The UK is also home to an MSc in EM, which offers an ‘academic qualification for nurses and physicians working in emergency contexts’.13 Teaching is web based, with the option of face-to-face sessions at Manchester Metropolitan University. Course content is based around a virtual hospital with online lectures, tutorials and discussion forums.13 Similar programmes exist in certain other disciplines, including paediatrics14 and paediatric EM.15 Australasian universities have launched several programmes targeting specialty trainees.3 Of relevance to EM, the University of Sydney now offers a Masters of Critical Care Medicine, designed for ‘doctors interested in emergency medicine, anaesthetics and intensive care medicine’.16 The degree aims to help participants to become ‘well-rounded, analytical and successful clinicians’ and includes a focus on basic scientific knowledge required for the ACEM primary examination.16 The Royal Australasian College of Surgeons (RACS) has recently become affiliated with an MSc in Surgical Sciences offered through the University of Edinburgh.17, 18 The degree is a ‘flexible, part-time online Masters course designed to meet the needs of the modern surgeon in training’.17, 18 The syllabus is directly linked to the surgical training curriculum in the UK. Anecdotally, some Australasian trainees have enrolled in order to assist with their preparation for the RACS surgical primary examination. There have also been incursions at the subspecialty level. An example is the Australian School of Advanced Medicine (ASAM) at Macquarie University, promoted as the ‘first school of its kind to offer sub-specialty, post-fellowship training in a private teaching hospital on a university campus’. Courses include a Master of Advanced Medicine and a Doctor of Advanced Surgery.19, 20 University interest in contributing to PGME is likely to grow. Although it would be possible for a university to apply to the Australian Medical Council for accreditation as a provider of specialty education, this is unlikely to occur in the foreseeable future. Philosophically, universities might not see themselves in the business of providing specialist education, but rather in the domain of further education.21 Courses targeting specific specialty and sub-specialty areas might continue to emerge as adjuncts to college programmes. In the face of increasing job competition, such courses might be attractive to trainees and fellows seeking to expand their knowledge and credentials. There are several potential benefits to increasing university engagement in PGME. Under the current model, EM specialty training is delivered through hospital-based programmes, which incorporate structured off-the-floor education sessions and opportunistic bedside teaching. Both can be compromised by clinical demands and the persisting perception that service and training are dichotomous entities.20 Current arrangements require senior clinicians to provide didactic teaching as well as clinical supervision. Some consultants feel underprepared for these roles, and remain frustrated by a perceived lack of organisation of clinical teaching programmes.22, 23 Outsourcing elements of the formal education syllabus to external providers without service delivery responsibilities might result in more effective off-the-floor learning. It might also improve consistency in teaching and assessment outcomes between hospitals. Universities have extensive experience in delivering higher education and might be able to address some of the barriers to effective clinical teaching, including suboptimal teacher training and inadequate administrative support.24 They also have expertise in adult learning, and capacity to implement flexible delivery modalities such as online lectures, tutorials and discussion forums. Unlike most hospitals, universities are likely to be able to attract educational academics capable of driving pedagogical reforms. That said, colleges continue to enhance their educational infrastructure and are increasingly demonstrating innovation in PGME. ACEM, for instance, has a newly updated curriculum framework, package of online learning tools and a suite of workplace-based assessment instruments. Some EM physicians have encouraged greater links between training and service delivery as well as colleges and universities. Skinner has suggested that, ‘Development by Universities and specialist colleges of core and elective training modules, with clearly defined curricula and outcomes, would facilitate part-time and interrupted training, and could be used to build explicit accreditation and credentialing systems’.25 Under this type of model, subjects could be accredited towards higher degrees, which might be beneficial for some trainees in enhancing future career opportunities. Previous articles have outlined the challenges for trainees seeking to participate in EM-related short courses.26 Many of these barriers (including cost, availability of leave, travel and competitive enrolment) are likely to apply to university programmes. Course fees for trainees might be significant. Outsourcing components of PGME to institutions that are unfamiliar with specialty training curricula might result in suboptimal delivery and outcomes. In addition, there are limits on the number of clinical competencies that could reasonably be acquired through coursework-based programmes that do not include a clinical placement component. There are also potential issues related to the interface between health services and universities, but the extent to which these are relevant depends on the type of model. Medical schools already face challenges in delivering clinically based professional entry programmes, and rely heavily on relationships with public and increasingly private hospitals. Whether the goodwill implicit in these partnerships could extend to specialty education is uncertain. Effective clinical education ultimately relies on motivated clinicians providing workplace-based supervision and teaching. These efforts commonly go unrewarded, and it is unclear if clinicians would provide the same support for university, as opposed to college, training programmes. This consideration is critical as universities might struggle to appropriately remunerate sufficient faculty to provide high-quality clinically focused PGME. Financial considerations are particularly pertinent in the context of activity-based funding reforms and moves to quantify (and limit) the costs involved with clinical education. A lack of clinical academics might also limit the feasibility of greater university involvement in PGME. Only a limited number of clinicians are willing to assume educational leadership roles, and the same people who currently contribute to college programmes would likely be called on to contribute to university offerings. Models of PGME must evolve alongside advances in educational and scientific understanding. This will require ongoing dialogue between trainees, clinicians and educators, including discussion of institutional capacities, financial implications and human resources. In the setting of expanding numbers of medical graduates and an increasingly competitive job market, the supply of, and demand for, clinically focused higher degrees might grow. This might create additional options for trainees looking to further develop their knowledge and qualification base. It is also feasible that selected components of specialist education could be delivered via university courses, but these are unlikely to incorporate clinical placements. Developments such as these might create challenges for the governance and coordination of specialty education. There will always be finite resources available for PGME. Whatever evolves, it is critical that specialty and continuing medical education structures ensure that Australasia's specialists are capable of delivering high-quality care to patients. Ultimately, the means is less important than the end. The authors acknowledge the contribution and oversight offered by Associate Professor Geoff Couser while writing this article. JJ, RM, JLF and AP are section editors for Emergency Medicine Australasia.
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