Leaders in Medical Education

Dr. Terry Brown, Chair of the Confederation of Postgraduate Medical Education Councils (CPMEC) Australia

Osmosis Team
Jul 11, 2016

Terry Brown qualified as a Specialist in Emergency Medicine and Critical Care Medicine in the UK in 1996 and became a Staff Specialist in the Emergency Department at the Royal Hobart Hospital, Tasmania in 2002. He is the Director of Clinical Training (IMGs) at the Royal Hobart Hospital, an Associate Professor at The University of Tasmania, and the outgoing chair of the Confederation of Postgraduate Medical Education Councils (CPMEC), which coordinates prevocational training matters in Australia and New Zealand.

You are a specialist in emergency medicine and critical care medicine with experience in both the UK and Australia. What prompted your interest in this area? Can you share a little more about your background in medicine?

I’ve always been a generalist at heart. At medical school (in the UK) I was very interested in General Practice for this reason and that was my original career choice. After internship I competed a 3 year training program in General Practice, only to realise that it wasn’t for me. There were two main reasons for this: at the time in the UK, many GPs had 5 minute appointments for patients and it seemed to me that there was nothing useful that could be done in that time. Secondly, I had really enjoyed my ED rotations during my GP training, particularly the acutely unwell patients, and I found that the opportunity to look after such patients wasn’t really available in metropolitan General Practices. I think I also missed the camaraderie of Emergency Medicine.

I think in hindsight that I was always meant for Emergency Medicine, but at that time in the UK (mid 80s) it didn’t really exist as a specialty. The few A&E consultants that I met seemed to have got the job by failing at something else (usually surgery) and playing golf with someone influential. After my GP training was complete I took a post as a resident in ED (or A&E as it was then) and I was fortunate to meet my first real mentor, a newly qualified female (!) Consultant Emergency Physician. She not only gave me information about training in Emergency Medicine, she provided the first useful feedback about my performance that I had ever received, and encouragement to pursue a career in EM.

I subsequently spent several years training in EM, predominantly in the UK but with a year in Australia in 1994. My time in Australia highlighted the difference in EM between the two countries. In the UK, EM was still a fledgling specialty that was fighting to be taken seriously. The clinical consequences for this were that we had a very restricted scope of practice (not providing sedation for example, despite most of the trainees having anaesthetic experience). Australian Emergency Medicine was more established, and I was able to do much more for patients than I’d previously been allowed to in the UK.

On my return I was very keen to keep using my resuscitation skills, so I looked for a consultant position that would allow me to do so. At the time there were only 2 EM Intensivists in the UK, but fortunately one of them was a good friend and was also working at my local hospital. I was lucky enough to get a position there as an EM/intensivist and spent 6 years there before moving to Australia for good. I wasn’t keen to do further training in Intensive Care Medicine in order to be recognized as an Intensivist in Australia, and Australian EM practice allowed me to do all of the interesting ITU stuff in the ED anyway, so I dropped the ITU aspect of my practice. This also allowed me to expand my interest in medical education. The variety of Emergency Medicine and the camaraderie are what really makes the job rewarding. I have been working in this area for 30 years now and I can confidently say that I still see something new on every shift that I work.

As the current Chair of the Confederation of Postgraduate Medical Education Councils (CPMEC) Australia and with positions as director of clinical training, you are intricately involved in medical education. What could medical schools do to better prepare students for a career in medicine?

This is an interesting question that is very topical at the moment. There is a perception among senior clinicians that current graduates aren’t as work ready as we were. I think there are a couple of reasons for this: partly it’s the old ‘not as good as in my day’ flawed perception, but the increased emphasis on patient safety and risk minimization has had the unintended consequence of keeping students away from actually doing anything with real patients. In the past, final year students would do a lot of the things that interns currently do, including making mistakes with patient care and learning from them. That doesn’t really happen now, which is a good thing for patients but poses a problem for preparing graduates for practice. There is also the opinion, expressed by several senior figures in the university environment, that the role of the medical schools is to ensure the students get a degree rather than produce a work-ready doctor.

I think there is a middle ground between protecting patients and preparing graduates. Both North America and New Zealand provide good examples of how to achieve this, by allowing senior students graded responsibility for their own patients. In terms of what Australian medical schools could do, I think that the first thing is to agree on a standard for what constitutes a reasonable ‘preparedness for practice’ module to be delivered in final year. At the moment there is considerable variation in what different medical schools provide, with some offering a 3 month ‘capstone’ experience and others merely paying lip service by offering a one week module.

The harder question is what exactly does ‘work readiness’ actually mean. One of the recommendations of the recent National Review of Intern Training in Australia was to improve the work readiness of medical graduates. Unfortunately, no-one seems to agree on what exactly ‘work readiness’ means in practice, which makes achieving this something of a challenge. A recent survey of North American clinical supervisors asked them what they saw as the commonest deficiencies in work readiness amongst their graduates. The 3 top answers were time management, knowing when to ask for help, and getting on with the nurses. I think a survey of Australian supervisors would produce similar results, which at least gives us an idea of the gaps in the current undergraduate curricula.

What advice would you give medical students and junior doctors for choosing a training pathway in medicine?

The most important advice is to make sure you are well informed about career prospects. We have been woefully inadequate in Australia in gathering this information and providing it to students and doctors in training. There have been some improvements recently, with the work done by the National Medical Training Advisory Network (NMTAN) but this has fizzled out somewhat since the government’s decision to remove funding from this body and incorporate it into the Health Department. Some jurisdictions have produced useful information (like HETI in New South Wales) but overall the information nationally is fragmented and hard to access.

I think that the UK serves as a good example of how to do this better. Through their Centre for Workforce Intelligence, they produce information about career prospects and job availability (including competition ratios) for specialties and geographical areas. We have some work to do before we can emulate this here.

In the meantime, my advice would be to get as much information as possible: what are the training requirements for that specialty, what is the likelihood of jobs being not only available but available where I want to work etc. Once you have that information you then need to decide what is important to you: is it the specialty or the place you want to live? What if you can only have one or the other? We are now seeing specialists qualifying with no jobs to go to (or at least jobs that they want to go to), mainly because of the disparity between rural and metropolitan Australia in terms of jobs available (specialism vs generalism) and lifestyle choices.

You have significant experience with medical simulation technology. What are the most promising innovations in this area and how do you think they will impact future education and training?  

I think simulation is an interesting area. I believe that it is an important educational modality but I do have some reservations about it. Although there is a face validity to its effectiveness, there is actually very little published evidence to support its effect on subsequent behavior or patient care (in fairness, that is true of most interventions in medical education). I think there has also been a temptation to see it as a panacea for decreased clinical exposure, with governments and institutions spending millions of dollars on equipment that ends up in a store cupboard somewhere, or gets used for training that could equally well be done with lower cost equipment. My biggest concern however is the over-emphasis on high-fidelity equipment at the expense of sound educational practice. It is very easy for an institution or individual to purchase simulation equipment, which then comes with technical instructions on how to use it but no advice or training in how best to incorporate it into an educationally sound experience. The training needed to effectively use simulation as an educational intervention is variable in availability and quality, with the result that it is often under-utilised or poorly utilized.

For me, the most promising intervention in the simulation area is the recognition that less is more. The days where people would rush out to get the next generation mannequin as if it were the new iPhone are hopefully on the wane. All of the research in this area (including a 2007 Best Evidence in Medical Education review) shows that the capabilities of the mannequin are far less important than the performance of the instructor when it comes to achieving a good educational outcome. Similarly, the recognition that shorter, more frequent low fidelity frequent simulation sessions probably produce as good, if not better, results than longer, high fidelity, fully-immersive sessions, means that there is greater opportunity for clinical teachers to make better use of the modality.

If you could change two or three things about the Australian health care system, what would they be?

The first thing I would do is to unify the delivery of healthcare under one system of governance and funding, rather than the current divisive and inefficient Federal/State model. I believe that this would be more efficient and hopefully less politicized than the current system.

I would also hope that there would be reform to the current system of funding/reimbursement of medical care. I think that the emphasis on procedures and specialism does not reflect the reality of most health care delivery, which is the non-procedural management of chronic disease. I think the current funding structure is one of the reasons why Australia has an oversupply of procedural specialists and an undersupply of generalists.

Finally, I think that there needs to be greater emphasis on primary care and prevention strategies. It is clear from international literature that not only does this improve health outcomes for a population, it is also considerably cheaper.

Do you have any final thoughts regarding the medical profession as a whole?

I think that we are slowly maturing as a profession and recognizing that the ‘old’ authoritarian system is not suitable for a modern, educated population (or the current generation of students and young doctors). The recent focus on junior doctor wellbeing, bullying and harassment, gender issues, open disclosure and shared decision making all give me hope that we are traveling in the right direction for our trainees and our patients. Finally, for all of the challenges we face in this job, I still wouldn’t swap it for anything else. The opportunity to help people when they are at their most vulnerable is incredibly rewarding, and the experience of working alongside colleagues of all grades who are caring and talented is wonderful, if somewhat humbling