Prevocational medical education is a critical phase in the continuum from medical undergraduate to vocational training, and the lack of a defined curriculum outlining the prevocational learning objectives has been an impediment to effective and efficient vertical integration of medical education in Australia.1
The Australian Curriculum Framework for Junior Doctors consolidates the work of a national core curriculum project led by the Postgraduate Medical Council of New South Wales (now part of the NSW Institute of Medical Education and Training [IMET]) and funded by the Australian Government Department of Health and Ageing’s Medical Training Review Panel.2
Phase 1 of the project, completed in November 2004, included circulating a questionnaire to junior medical officers (JMOs) throughout NSW to outline their current clinical experiences and to identify their future learning needs. On the basis of the JMOs’ responses to the questionnaire, a draft national core curriculum was developed, overseen by a national project steering committee. Phase 2 was intended to validate the draft curriculum nationally, and develop strategies for implementation. Initial progress was slow because of lack of agreement among the states. To move the project forward, a national meeting of key stakeholders was convened in October 2005 and the Confederation of Postgraduate Medical Education Councils (CPMEC) became actively involved in developing and implementing a new curriculum framework.
In November 2005, CPMEC convened a writing group to produce a draft document that would be subjected to comprehensive review and consultation involving a wide range of potential users and key stakeholders. The writing group membership was not constituted on the basis of equal representation of states, territories or key stakeholder groups but rather on the necessity to bring together a group of people with a common interest and breadth of experience in postgraduate medical training and development.
The writing group met on four occasions between February and May in 2006 and reconvened in October 2006 to consider the preliminary feedback and amend the first draft of the curriculum framework in response to that feedback. A number of key principles underpinned the development of the draft curriculum framework. These are discussed below.
The project team sought to understand and reflect the needs of a wide range of stakeholders involved in prevocational medical training, including patients and the community, junior doctors, other hospital and practice staff, health departments, universities, professional colleges and associations.
Building on work undertaken in Australia and overseas, the writing group critically appraised existing prevocational curricula, in particular those developed or published by the:
Mindmapping software (MindManager Pro 6, Mindjet Corporation, San Francisco, Calif, USA) was then used to represent these curricula in a standardised, branching tree format.8,9 The same software was used to create a blank framework that was readily able to be restructured and progressively populated with the content of the Australian Curriculum Framework for Junior Doctors.
Reference was also made to other relevant documents, in particular the National Patient Safety Education Framework10 and the Committee of Deans of Australian Medical Schools Indigenous Health curriculum.11
The curriculum framework structure that emerged comprised three major areas (clinical management; communication; and professionalism). Each area was subdivided into three to six categories, and each category was further subdivided into four to seven topics. For every topic, a set of three capabilities has been defined. Capabilities may describe knowledge elements, skills or behaviours. An example of the structure of the curriculum framework is shown in the Box.
The entire Australian Curriculum Framework for Junior Doctors comprises 63 topics and is presented in this article (Australian Curriculum Framework for Junior Doctors). Eleven of the Clinical management topics, under the categories of Patient assessment and Patient management, refer to a list of common problems and conditions with which prevocational trainees should become familiar. The five topics relating to Skills & procedures are associated with a list of skills and procedures that should be mastered in the prevocational years.
The curriculum framework supports continuous learning from undergraduate training through to prevocational and vocational education and training, underpinned by the principles of adult learning. These include the need to respect prior learning and experience, and provide clear learning outcomes, regular feedback on performance, and opportunities for reflection.
It focuses on practice-based learning, taking place as much as possible in the context of the learner’s current work or professional environment. The curriculum framework is intended to exploit the rich opportunistic learning environment that the workplace provides.
The curriculum framework will enable individual learners to manage their own progression. Some interns may have mastered all the capabilities by the end of their internship, while others will require a longer period.
Members of the writing group recognised the importance of presenting the curriculum framework in a format that would be accessible to and usable by a wide range of stakeholders. The use of a world-wide-web interface allows all of the areas, categories and topics to be displayed on a single screen. Clicking on a topic opens up a dialogue box with a description of the three capabilities identified for that topic. There is also a provision to include links to peer-reviewed learning and assessment resources through the Internet.
A printable version of the curriculum framework has also been published and is available for download from the CPMEC website.
The curriculum framework aims to integrate learning at every opportunity. Each clinical encounter will incorporate a variety of capabilities from across the curriculum framework. It was designed to enable educational managers to support and positively reinforce the integration of prevocational training throughout the whole organisation, and also encourage innovative strategies such as interdisciplinary and team-based learning. Vertical integration across the medical education spectrum is another key aim of the curriculum framework, and a number of medical schools and colleges have indicated their interest in undertaking this work.
The curriculum framework describes required learning in terms of performance elements. This provides a useful starting point for practice-based training that relies on performance or competency-based assessment. However, developing practical, effective, valid and acceptable assessment tools remains the greatest challenge in the implementation of the curriculum framework.
Prevocational doctors are expected to be actively supervised in the workplace. Supervision is a crucial element to achieving many of the competencies within the curriculum framework. It is expected that, over the 2–3 years of prevocational training, there will be a progressive increase in the level of individual clinical responsibility and a corresponding reduction in the level of supervision that is required.
The draft Australian Curriculum Framework for Junior Doctors was made accessible through the CPMEC website from August until October 2006. The website included a feedback mechanism whereby users could generate an email to CPMEC and provide feedback on any aspect of the curriculum framework. Written feedback was also sought from hospitals, universities, professional colleges and key stakeholder organisations. Three hundred and forty comments were received over the initial 3-month consultation period. Thirty-five per cent were supportive, 53% expressed reservations, and 12% identified critical concerns.
In October 2006, the writing group met again to review the feedback. Of the 340 issues raised, 81 (24%) were able to be resolved through minor modifications to the content of the curriculum framework. However, a significant number of critical issues still remained, particularly in relation to implementation and assessment. The revised version of the curriculum framework was launched at the 11th National Prevocational Medical Education Forum in Adelaide on 31 October 2006, and received strong support.
A steering group will oversee the further development and implementation of the curriculum framework. This group and its subcommittees will guide the implementation process, identify learning resources that can be used in association with the curriculum framework, and consider issues relating to assessment. The steering group includes broad representation from postgraduate medical councils, doctors in training, medical students, and a range of peak bodies.
Key priorities over the next few years will include:
Undertaking a mapping process to identify elements and themes common to the Australian Curriculum Framework for Junior Doctors and university, professional college, and other curricula.
Reviewing positions, rosters and opportunities for teaching in hospitals, practices and other clinical settings in the context of the curriculum framework.
Identifying valid and reliable assessment tools that can be used in the workplace without placing undue burdens on junior medical staff and their supervisors. In the first instance, this may be achieved through the development of standardised term assessment reports that refer to the major headings of the curriculum framework.
It is essential that junior doctors themselves are closely involved in this work, and that adequate resources are allocated by the federal, state and territory governments to support the implementation of the Australian Curriculum Framework for Junior Doctors.12
The Australian Curriculum Framework for Junior Doctors is available at the CPMEC website (http://www.cpmec.org.au/curriculum).
Example of the structure of the curriculum framework
Patient management (category)
Management options (topic)
Understand the management options for the listed problems and conditions (capability — knowledge)
Develop, implement and evaluate a plan of management relevant to a patient’s problems or conditions (capability — skill)
Understand the importance of considering different management options (capability — behaviour)
Australian Curriculum Framework for Junior Doctors — Clinical Management
Safe Patient Care Systems Understand the complex interaction between the healthcare environment, doctor & patient Risk & prevention Know the main sources of error & risk in the workplace Adverse events & near misses Understand the harm caused by errors & system failures Public health Understand the key health issues of your community Infection control Understand prudent antibiotic/antiviral selection Radiation safety Know the risks associated with exposure to radiological investigations & procedures Medication safety Know the medications most commonly involved in prescribing & administration errors Patient Assessment Patient identification Know the stages of a verification process to ensure the correct identification of a patient History & Examination Know the modes of presentation of the listed problems and conditions Problem formulation Know the possible differential diagnoses relevant to a patient's presenting problems or conditions Investigations Identify & understand the investigations relevant to a patient's presenting problems or conditions Referral & consultation Understand the criteria for referral or consultation relevant to a particular problem or condition Emergencies Assessment Understand the abnormal physiology & manifestations of critical illness Prioritisation Understand the principles of medical triage Basic Life Support Understand the theory of basic airway management, ventilatory & circulatory support Advanced Life Support Practice advanced airway management including the use of laryngeal mask Acute patient transfer Understand the risks inherent in patient transfer | Patient Management Management Options Understand the management options for the listed problems & conditions Therapeutics Understand the actions, indications, contraindications & adverse effects of medications Pain management Understand the hierarchy of therapies & options for pain control Fluid & electrolyte management Demonstrate a knowledge of patient fluid & electrolyte requirements in all age groups Subacute care Know the services available to patients for subacute care Ambulatory & community care Know the services available to patients outside of the inpatient setting Discharge planning Know the elements of effective discharge planning e.g. early, continuous, multidisciplinary Common Problems & Conditions LIST OF COMMON PROBLEMS & CONDITIONS This list includes acute and chronic conditions and, unless otherwise specified, applies to patients of all ages.The listed conditions are neither EXHAUSTIVE nor MANDATORY. They are provided to GUIDE learning and the construction of suitable junior doctor terms. Skills & Procedures Decision-making Know the indications & contraindications for the listed procedures Informed consent Understand the principles of informed consent Preparation & anaesthesia Provide appropriate sedation and/or premedication Procedures Arrange appropriate equipment & understand its use Post-procedure Monitor the patient & provide appropriate analgesia & aftercare LIST OF SKILLS & PROCEDURES Doctors should be able to provide safe treatment to patients through competently performing certain procedural and/or assessment skills. |
Australian Curriculum Framework for Junior Doctors — Communication
Patient Interaction Context Understand the impact of the environment on communication, e.g. privacy, location Respect Treat patients courteously & respectfully, showing awareness & sensitivity to different backgrounds Providing information Understand the principles of good communication e.g. active listening, the role of information overload Meetings with families or carers Understand the impact of family dynamics on effective communication Breaking bad news Understand loss & bereavement Open disclosure Understand the principles of 'open disclosure' Complaints Understand the factors likely to lead to complaints Managing Information Written Understand & comply with organisational policies regarding timely and accurate documentation Electronic Understand the uses & limitations of electronic patient information & decision-support systems Prescribing Know how to accurately communicate prescriptions Health records Understand legal/institutional requirements for health records Evidence-based practice Know the principles of evidence-based practice & hierarchy of evidence Handover Understand the importance of handover in patient safety & continuity of care Working in Teams Team structure Identify the different types of healthcare team e.g. medical team, multidisciplinary stroke team Team dynamics Understand the characteristics of effective teams Teams in action Understand & respect the roles & responsibilities of team members Case presentation Understand the structure of an effective case presentation |
Australian Curriculum Framework for Junior Doctors — Professionalism
Doctor & Society Access to healthcare Understand how physical or cognitive disability can limit access to healthcare services Culture, society & healthcare Understand the social, economic & political factors in patient illness Indigenous patients Understand the impact of history & the experience of Indigenous Australians on presentations Professional standards Understand the legal requirements of being a doctor Medicine & the law Understand the legal requirements in patient care e.g. Mental Health Act, death certification Health promotion Understand environmental & lifestyle risks to health & advocate for healthy lifestyles Healthcare resources Use healthcare resources wisely to achieve the best outcomes Professional Behaviour Professional responsibility Know the professional responsibilities relevant to your position Time Management Understand how time management impacts on patient care & hospital function Personal well-being Understand the personal health risks of medical practice e.g. fatigue, stress, needle-stick injuries Ethical practice Recognise the ethical complexity of practice & follow professional & ethical codes Practitioner in difficulty Know the support services available Doctors as leaders Understand the leadership role that may be required of a doctor Teaching & Learning Self-directed learning Identify & address personal learning needs Teaching Identify varied approaches to teaching & learning Supervision Understand the elements of good supervision Career development Know the career options available within medicine |
Australian Curriculum Framework for Junior Doctors — Common Problems & Conditions
Doctors should be able to appropriately assess patients presenting with common, important conditions, including the accurate identification of symptoms, signs and/or problems and their differential diagnosis and then use that information to further manage the patient, consistent with their level of responsibility:
| Abdominal pain Asthma Cough Addiction (smoking, alcohol, drug) Anaphylaxis Bleeding in the 1st trimester Breathlessness Cardiac Arrhythmias Chest pain Child abuse Chronic Obst. Pulmonary Disease Coma Cognitive or physical disability | Constipation Deliberate self-harm Delirium Dementia Depression and anxiety Diabetes: new cases/complications Diarrhoea Disturbed or aggressive patient Domestic violence Dysuria &/or frequent micturition Elder abuse Envenomation Falls, especially in the elderly | Functional decline or impairment Gastrointestinal bleeding Genetically determined conditions Headache Heart failure Hypertension Ischaemic heart disease Injury Joint disorders Leg ulcers Limb ischaemia Liver disease Loss of consciousness | Minor trauma Multiple trauma Neoplasia Non-accidental injury Non-specific febrile illness Pneumonia/respiratory infection Poisoning Post-operative care Psychosis Pyelonephritis and UTIs Reduced urinary output Renal failure Septicaemia | Sexually Transmitted Infections Seizure disorders Spinal disease Stroke / TIA Subarachnoid haemorrhage Substance abuse Tiredness/Anaemia Upper airway obstruction Urinary Incontinence Weight gain Weight loss |
Australian Curriculum Framework for Junior Doctors — Skills and Procedures
Doctors should be able to provide safe treatment to patients through competently performing certain procedural and/or assessment skills (ADV. = ADVANCED i.e. more likely to be learnt in PGY2 or above):
General MeasurementBlood pressure measurement Pulse oximetry reading Temperature measurement Intravenous Venepuncture Intravenous cannulation Intravenous infusion set up Intravenous drug administration Intravenous fluid & electrolyte therapy Diagnostic Blood sugar estimation Blood culture Wound swab Respiratory Oxygen therapy Nebuliser/inhaler therapy Therapeutics Anticoagulant prescription/monitoring Antibiotic prescription/monitoring Insulin prescription/monitoring Injections Intramuscular injections Subcutaneous injections Joint aspiration or injection (ADV.) | Cardiopulmonary 12 lead electrocardiogramArterial blood gas sampling Peak flow measurement Spirometry Pleural effusion/pneumothorax aspiration Central venous line insertion (ADV.) Gastrointestinal Nasogastric tube insertionRectal examination Faecal occult blood analysis Anoscopy/proctoscopy (ADV.) Abdominal paracentesis (ADV.) Neurological Glasgow Coma Score estimationNeck stiffness testing Focal neurological sign identification Papilloedema identification (ADV.) Lumbar puncture (ADV.) Mental Health Mini-mental state examinationPsychiatric Mental State Examination Suicide risk assessment Alcohol withdrawal scale use Application of Mental Health Schedule | Women's Health Fundal height assessmentFoetal heart sound detection Urine pregnancy testing Speculum examination Endocervical swab / PAP smear (ADV.) Gynaecological pelvic examination (ADV.) Child Health Infant respiratory distress assessmentInfant/child dehydration assessment Apgar score estimation Newborn examination (ADV.) Neonatal CPR (ADV.) Surgical Scrub, gown & gloveAssisting in the operating theatre Surgical knots & simple wound suturing Local anaesthesia Simple skin lesion excision Wound management Suture removal Complex wound suturing (ADV.) Ear, Nose & Throat Throat swabAnterior rhinoscopy Anterior nasal pack insertion Auroscopy/otoscopy External auditory canal irrigation Ext. aud. canal ear wick insertion (ADV.) | Opthalmic Visual field assessmentVisual acuity assessment Direct ophthalmoscopy Eye drop administration Eye bandage application Eye irrigation Eyelid eversion Corneal foreign body removal Intraocular pressure estimation (ADV.) Slit lamp examination (ADV.) Urogenital Bladder catheterisation (M&F)Urine dipstick testing Urethral swab Trauma Primary trauma surveyIn-line immobilisation of cervical spine Cervical collar application Pressure haemostasis Volume resuscitation Peripheral neurovascular assessment Plaster cast/splint limb immobilisation Joint relocation Secondary trauma survey (ADV.) Intercostal catheter insertion (ADV.) |
- Ian S Graham1,2
- Andrew J Gleason3
- Gregory W Keogh4,5
- Deborah Paltridge6
- Ian R Rogers8
- Merrilyn Walton9
- Caroline De Paola4
- Jagdishwar Singh10
- Barry P McGrath10,11
- 1 Postgraduate Medical Council of Victoria, Melbourne, VIC.
- 2 SED Health Consulting, Ballarat, VIC.
- 3 The Alfred Hospital, Melbourne, VIC.
- 4 NSW Institute of Medical Education and Training, Sydney, NSW.
- 5 Prince of Wales Hospital, Sydney, NSW.
- 6 St Vincent’s Health, Melbourne, VIC.
- 7 Sir Charles Gairdner Hospital, Perth, WA.
- 8 University of Western Australia, Perth, WA.
- 9 University of Sydney, Sydney, NSW.
- 10 Confederation of Postgraduate Medical Education Councils, Melbourne, VIC.
- 11 Monash University, Melbourne, VIC.
All the authors were members of the writing group and had their travel and accommodation expenses for writing group meetings paid for by the New South Wales Institute of Medical Education and Training, Medical Training Review Panel National Core Curriculum Project. Ian Graham was contracted as a consultant to the project to facilitate the meetings and design the draft curriculum framework.
- 1. McGrath BP, Graham IS, Crotty BJ, Jolly BC. Lack of integration of medical education in Australia: the need for change. Med J Aust 2006; 184: 346-348. <MJA full text>
- 2. Medical Training Review Panel — ninth report. Canberra: Australian Government Department of Health and Ageing, November 2005: 87. http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-workforce-education-mtrp9thr.htm (accessed Feb 2007).
- 3. Postgraduate Medical Council of New South Wales. Core curriculum for PGY1s and PGY2s. Sydney: PMCNSW, 2004.
- 4. Postgraduate Medical Council of South Australia. Intern curriculum framework. Adelaide: PMCSA, 2005.
- 5. Postgraduate Medical Council of Western Australia. Western Australian junior doctor curriculum — guidelines for teaching and learning: postgraduate years 1 and 2. Perth: PMCWA, 2006.
- 6. Foundation Programme Committee of the Academy of Medical Royal Colleges, in co-operation with Modernising Medical Careers in the Departments of Health. Curriculum for the foundation years in postgraduate education and training. 2005. http://www.dh.gov.uk/assetRoot/04/10/76/96/04107696.pdf (accessed Feb 2007).
- 7. Frank JR, editor. The CanMEDS 2005 physician competency framework. Ottawa: The Royal College of Physicians and Surgeons of Canada, 2005. http://www.rcpsc.medical.org/canmeds/CanMEDS2005/CanMEDS2005_e.pdf (accessed Feb 2007).
- 8. Grayson H. Concept mapping and curriculum design. Chattanooga: The University of Tennessee at Chattanooga, 1998. http://www.utc.edu/Administration/WalkerTeachingResourceCenter/FacultyDevelopment/ConceptMapping/ (accessed Feb 2007).
- 9. Van Neste-Kenny J, Cragg CE, Foulds B. Using concept maps and visual representations for collaborative curriculum development. Nurse Educator 1998; 23: 21-25.
- 10. Australian Council for Safety and Quality in Health Care. The framework documents. National patient safety education framework, 2005. http://www.patientsafety.org.au/pdfdocs/national_patient_safety_education_framework.pdf (accessed Feb 2007).
- 11. Phillips G, on behalf of The Project Steering Committee. Committee of Deans of Australian Medical Schools. CDAMS Indigenous health curriculum framework. Melbourne: Onemda VicHealth Koori Health and Community Development Unit, University of Melbourne, 2004. http://www.medicaldeans.org.au/pdf/CDAMS%20Indigenous%20Health%20 Curriculum%20Framework.pdf (accessed Feb 2007).
- 12. Gleason AJ, Daly JO, Blackham RE. Prevocational medical training and the Australian Curriculum Framework for Junior Doctors: a junior doctor perspective. Med J Aust 2007; 186: 114-116. <MJA full text>
Abstract
The Confederation of Postgraduate Medical Education Councils launched the Australian Curriculum Framework for Junior Doctors in October 2006.
The curriculum framework:
balances the major areas of clinical management, communication and professionalism, and highlights the importance of an integrated approach to prevocational learning and teaching;
supports practice-based, opportunistic and continuous learning, and specifies performance and supervision requirements for junior doctors; and
has been published in both Internet and printable versions, to make the document accessible and easily usable by junior doctors and supervisors.
The implementation of the curriculum framework will be overseen by a steering group that includes representatives from key stakeholder groups, including junior doctors and medical students.