Who’s in charge?

In the United Kingdom, medical interns are known as “the lost tribe”. Here in Australia there are signs that our interns are also falling through the cracks …

START talking to the stakeholders in the world of medical internships and one thing becomes very clear, very quickly — nobody really wants to be in charge.

In October last year, Professor Andrew Wilson, director of the Menzies Centre for Health Policy at the University of Sydney, and his co-author Dr Anne-Marie Feyer, a board member at WentWest Medicare Local and a research lead at the George Institute for Global Health, handed their final report from the Review of Medical Intern Training to the Federal Government.

The Review found that the current system of internship in Australia “is clearly not performing as well as it should”.

“A number of important health system changes, together with structural deficiencies in the current model, mean it no longer fits the purpose of meeting the long-term health needs of the community.”1

The problem, in a nutshell, is that interns are spending their year almost exclusively in public hospitals, working in the acute care system, a situation that not only, in the words of Wilson and Feyer, “doesn’t reflect modern health care, it impacts negatively on the quality of the learning experience”.

Add to that the fragmented nature of the pathway from medical school to internship and vocational training, the mosaic of employers, professional Colleges, and other stakeholders involved and it is little wonder Australian interns are feeling the pinch.

Professor Brendan Crotty, executive dean of the Faculty of Health at Deakin University, says the solution is “blindingly obvious”.

“The central point is that there needs to be some kind of coordinating body which takes ownership of the medical internship system,” Professor Crotty tells the MJA.

“Nobody really owns it, and the pessimistic view is that nothing in the Review is going to happen. It’s a very difficult time and there’s a lot of political pressure. Meanwhile, we’re slipping further and further behind [other countries].”

The Australian Medical Council (AMC), according to its mission statement, exists to “ensure that standards of education, training and assessment of the medical profession promote and protect the health of the Australian community”.2

The AMC is currently conducting a “minor review” of the national standards for intern programs.

So, is the AMC the right body to run intern programs nationally?

“No,” Professor Crotty, who was appointed to chair the AMC working group conducting the review, says. “The AMC is an accrediting body, not an educational one. It can’t run intern programs, and shouldn’t.”

Professor Crotty believes Australia is approaching the situation in the UK where, he says, interns are known as “the lost tribe”.

“We can continue the way we have been, with none of the issues being addressed, where the interns are getting pitiful exposure to ambulatory care.

“New Zealand has made enormous strides in the PGY1 and PGY2 years because the Medical Board of New Zealand took it over.”

So, is the Medical Board of Australia the body to take ownership of the intern programs?3

Not according to its Chair, Dr Joanna Flynn.

“It depends on what sort of view you have about how big a problem there is, and our view is that it’s not very big,” Dr Flynn tells the MJA.

“The MBA takes the very pragmatic view that because of the [nature] of medical practice there is a stark difference between being a medical student and being a doctor, and therefore there needs to be a period of transition.

“I don’t personally believe that we need to overgovern [the intern year]. We have become better at identifying the people who are struggling, and that’s a question not just about interns but about primary medical education generally.”

Dr Flynn agreed that there was a need to broaden internship training beyond the public hospital, acute care setting.

“We certainly support [that view]. The problem is the nature of the healthcare system; that states provide the acute health care and the Federal Government supplies the funding. It’s very hard to create a coordinated [approach].

“It’s not a job for the MBA.”

Perhaps the Confederation of Postgraduate Medical Education Councils (CPGMEC) is the right body for the job?4

Problematic, says Professor Crotty.

“It could be some sort of organisation that was a consortium [of stakeholders] and the CPGMEC [might be a good candidate] but it was defunded by the Abbott/Hockey Government and is really struggling.”

Medical schools are naturally powerfully members of the medical education sector. Are they the ones to step up to the internship plate?

While not saying no specifically, the CEO of the Medical Deans of Australia and New Zealand (MDANZ), Ms Carmel Tebutt, tells the MJA that any progress forward needs “much consultation” in what is a complex space.5

“[The MDANZ’s] primary focus is on ensuring that graduates are ready to take on their internship and the data tells us that [almost 80%] agree or strongly agree that their degree is preparing them well,” Ms Tebbutt says.

“We engaged strongly with the review [of medical intern training]. One of the recommendations was to consider a 2-year internship in which the final year of their undergraduate training would be the first year of their internship.

“We have some interest in that model, but it would be a matter for individual medical schools. It would be easier in some courses than for others. It would be difficult in the 4-year courses, for example.”

Professor Wilson tells the MJA that although the overall governance of the medical intern programs was “outside the terms of reference” there was no question that who takes responsibility was “a key issue” to any reform of the system.

“At the end of the day someone has to take carriage of it,” he says.

“It’s a challenging environment, conducted in a whole range of different settings, with different kinds of governance.

“There is a dissonance between the ownership of internships and the lack of ownership by the people who employ the interns. There’s a degree of passivity from the employers.”

One of the barriers to change is the fragmented nature of the regulations from state to state to territory, Professor Wilson says. If things are to change substantially, everyone has to change.

“And that’s a nightmare. That’s why [in the review] we moved away from getting rid of internships altogether and the 2-year model.”

Should the professional Colleges extend their domain? That suggestion, according to several stakeholders, speaking anonymously, meets very strong resistance from junior doctors.

For now, at least, the recommendations of the review are languishing in the bowels of the Australian Health Ministers’ Advisory Council with little chance of anything coherent emerging before the 2 July Federal Election.

Meanwhile, final-year medical students anticipate or dread their approaching internship year. The president of the Australian Medical Students’ Association, Elise Buisson, says in some ways the intern review has missed the point.

“We’re particularly interested in capacity building,” she tells the MJA. “[The review] avoids the key issue — there should be a clear pathway to the workforce with appropriate numbers of medical students, appropriate number of available internships, and an appropriate number of jobs at the end of it.

“Nobody has responsibility for the career progression of an individual.

“We’re looking forward to [what comes next].”

A Perspective on reform of the medical internship, by Dr Susannah Ahern, Associate Professor Peter Morley and Professor Geoffrey McColl, can be found on page 374 of this issue of the MJA.