A Strategic Study of Postgraduate
Medical Training: Baseline Report
March 2011
© Health Workforce Australia
This work is Copyright.
It may be reproduced in whole or part for study or training purposes.
Subject to an acknowledgement of the source, reproduction for purposes other than those
indicated above, or not in accordance with the provisions of the Copyright Act 1968, requires the
written permission of Health Workforce Australia (HWA).
Enquiries concerning this report and its reproduction should be directed to:
Health Workforce Australia
Information, Analysis and Planning
GPO Box 2098
Adelaide SA 5001
Telephone:
Email:
Internet:
1800 707 351
iap@hwa.gov.au
www.hwa.gov.au
Suggested citation:
Health Workforce Australia 2011: A Strategic Study of Postgraduate Medical Training: Baseline
Report
Strategic Study of Postgraduate Medical Training - Baseline Report
Page i
Foreword
Health Workforce Australia (HWA) was established to address the challenges of providing a
skilled, flexible and innovative health workforce that meets the needs of the Australian community.
Our goal is to deliver research, policy and programs and to ensure that governments and health
sector leaders are informed, engaged and supported in equipping our health workforce to meet
current and future challenges.
Health Workforce Australia’s remit includes conducting research and implementing strategies to
bolster the health workforce in order to achieve the aim of self sufficiency in the supply of health
professionals by 2025. One of these strategies will be to build on the recent investment in
increasing university places for medicine and other health disciplines. The flow-on effects are seen
in the rates of medical graduates and postgraduate trainees entering the workforce now and in the
midterm.
The Strategic Study of Postgraduate Medical Training project has investigated the factors
impacting on postgraduate medical education. The expansion in the number of medical graduates
entering the health system in the next decade will increase demand upon training positions and the
clinicians who oversee their supervision and training. The significant increase in the number of
medical graduates expected to enter the health system from 2012 necessitates an improved
understanding of the potential impact to intern (postgraduate year 1 (PGY1)), post-graduate year 2
(PGY2) and registrar training programs in order to assist jurisdictions, health services and
education providers effectively plan for the future.
This report considers the potential impact of this increase in trainee doctors along with the potential
advantages they could bring to medical teams in teaching hospitals as they move through the
supervision pathway. By understanding the issues facing medical teams, we can inform the ideal
configurations of supervisors and trainees in the workplace and support planners to adapt the
health workplace to make the best use of changes in the workforce. The modelling tool (scenarios
generating tool) developed during this study will assist in determining the number of professional
entry, prevocational/new graduate and postgraduate/vocational places for each area in each of the
years between 2012 and 2025 within the development of the conceptual model for the National
Training Plan for Doctors, Nurses and Midwives. The tool is available and will be useful to hospital
administrators, health care units and those involved in the planning for health services provision
and training programs. Training for the tool by HWA will begin in 2011 and continue to be available
upon request. To access the tool or training, please contact Health Workforce Australia’s
Information, Analysis and Planning team at iap@hwa.gov.au or 1800 707 351
The Hon James McGinty
Chairman, HWA Board
March 2011
Strategic Study of Postgraduate Medical Training - Baseline Report
Page ii
Contents
Foreword ............................................................................................................................................ ii
Contents............................................................................................................................................ iii
Preface.............................................................................................................................................. iv
About Health Workforce Australia ..................................................................................................... iv
About the Project .............................................................................................................................. iv
Acknowledgements ............................................................................................................................v
Project Reference Group .................................................................................................................. vi
1
Executive summary .................................................................................................................. vii
2
Introduction ................................................................................................................................ 1
3
Project methodology .................................................................................................................. 4
4
General observations from site visits ......................................................................................... 5
5
Sector level observations........................................................................................................... 9
6
Speciality unit observations ..................................................................................................... 16
7
Approaches to junior medical staff training .............................................................................. 28
8
Implications and approaches to modelling ............................................................................... 29
9
Development of a medical workforce scenario tool ................................................................. 31
Acronyms ........................................................................................................................................ 36
Strategic Study of Postgraduate Medical Training - Baseline Report
Page iii
Preface
About Health Workforce Australia
Health Workforce Australia (HWA) is an initiative of the Council of Australian Governments
(COAG), and has been established to address the challenges of proving a skilled, flexible and
innovative health workforce that meets the needs of the Australian community, now and into the
future. HWA was established following the development of a $1.6Bn National Partnership
Agreement (NPA) on Hospital and Health Workforce Reform by the Commonwealth and State and
Territory Governments in November 2008.
HWA reports to Health Ministers and will operate across health and education sectors to devise
solutions that integrate workforce planning, policy and reform with the necessary and
complementary reforms to education and training. HWA’s functions include:
The provision of comprehensive, authoritative national workforce planning, policy and
research advice to Ministers, Governments and key decision makers in the health and
education sectors.
Improving and expanding access to quality clinical education placements for health
professionals in training across the public, private and non-government sectors. This will be
achieved through programs that expand capacity, improve quality and other diversity in
learning opportunities. This also includes a national network of simulated learning
environments (SLE’s) to enhance the quality, safety and efficiency of clinical training.
Developing and implementing a national program of health workforce innovation and
reform. This will encourage the development of new models of healthcare delivery, facilitate
inter-professional practice and equip health professionals for current and emerging
demands on the health care sector.
Facilitating a nationally consistent approach to international recruitment of health
professionals to Australia.
About the Project
This project is part of the Health Workforce Australia’s work plan. The project’s findings will inform
jurisdictions of the impact associated with delivery of prevocational, postgraduate and specialist
medical training and feeds into the development of a tool that planners can use to assess capacity
and configuration of the medical team at a hospital level.
Strategic Study of Postgraduate Medical Training - Baseline Report
Page iv
Acknowledgements
HWA wishes to acknowledge and thank KPMG for their help in the conduct of this project and
production of this report. This project was conducted with the assistance of the former National
Health Workforce Taskforce and the members of the Project Reference Group (listed on following
page). HWA also wishes to acknowledge the participation of key project participants who were
interviewed, who willingly gave their time and shared their knowledge and insights during the
consultation process. These participants include:
Australasian College for Emergency Medicine
Confederation of Postgraduate Medical Education Councils
Royal Australasian College of Physicians
Royal Australasian College of Surgeons
The following nine hospitals/health services:
John Hunter Hospital (NSW)
Logan Hospital (QLD)
Orange Base Hospital (NSW)
Peninsula Health (VIC)
Royal Brisbane and Women’s Hospital (QLD)
Royal Darwin Hospital (NT)
Royal Hobart Hospital (TAS)
Sir Charles Gairdner (WA)
Western Health (VIC).
Strategic Study of Postgraduate Medical Training - Baseline Report
Page v
Project Reference Group
Jurisdiction
Member
Position
Organisation
Commonwealth
Prof Judy Searle
Principal Medical
Adviser, Workforce,
Education and Training
Health Workforce Division
Department of Health and Ageing
South Australia
Prof Geoff Thompson
Chair
South Australian Institute of Medical
Education and Training
Western Australia
Prof Louis Landau
Director of Medical
Workforce
Health Department of Western
Australia.
Chair, Postgraduate
Medical Council of WA.
Queensland
Dr Susan O'Dwyer
Clinical Director
Clinical Workforce Solutions and
Medical Workforce Advice and
Coordination, Queensland Health.
Tasmania
Assoc. Prof Terence
Brown
Chair, Postgraduate
Medical Education
Council of Tasmania
Postgraduate Medical Education
Council of Tasmania
Northern Territory
Mr Peter Satterthwaite
Director Medical
Services and Education
Royal Darwin Hospital
and
Dr Sara Watson
New South Wales
Dr Linda MacPherson
Medical Advisor
Workforce Development and
Innovation, NSW Department of Health.
Victoria
Prof Emeritus Ken
Hardy AO
Senior Medical Advisor
Workforce Leadership and
Development, Department of Health,
Victoria
Strategic Study of Postgraduate Medical Training - Baseline Report
Page vi
1
Executive summary
This report presents the method and findings of a study to investigate the impact of real and
potential change to workforce configurations on service delivery, teaching capacity and cost using
a number of scenarios for postgraduate medical training in five medical specialties: emergency
medicine; cardiology; general surgery; general medicine; and geriatric medicine. The findings were
designed to allow extrapolation of scenarios at a jurisdictional and national level, and assist with
local workforce planning for health services.
This report aims to:
present the findings of the first phase of the project;
summarise project findings to date and present the implications for planned modelling
activity;
provide a brief description of the project methodology;
present a description of high level observations and findings by hospital type and by
speciality;
provide a discussion of the various approaches to training the junior medical workforce and
identification of the implications for modelling; and
provide an introduction to the scenario tool which was developed during the second phase
of the project.
Key findings and recommendations in the report include:
Several key themes have emerged around what initiatives and policies currently do, or
could do in the future, to best support the training and supervision of junior medical staff.
For example, the importance of a structured and comprehensive orientation program, the
availability of scholarships and awards and access to external courses and simulation
facilities.
The project sought to identify scenarios for postgraduate medical training for modelling the
impact of real and potential changes to the workforce configurations to affect service
delivery, teaching capacity and cost over time. The findings demonstrate that:
there is little consistency across the organisations and specialities reviewed as to the
relative contribution of different classifications of medical staff (between consultant
specialists and registrars) to training and supervision;
Strategic Study of Postgraduate Medical Training - Baseline Report
Page vii
it is difficult to identify absolute values of relative output between senior and junior
medical classifications to assess the relative value of throughput between them; and
apart from the contribution by specialist consultants and senior registrars, the service
delivery output of a clinical unit is more a function of a rostered medical team than it is
to any individual classification level.
As a result, while a model of medical workforce capacity and output can be developed,
many of the variables are unlikely to be able to be predetermined or “hard coded” into the
model. Instead these variables are user defined. For this reason, the next phase of the
project will involve the development of a medical workforce scenario tool rather than a
model to assist various stakeholder organisations in assessing the impact and benefit of the
increased numbers of medical postgraduates over time.
The scenario tool will aim to:
assist to inform jurisdictions of the impact associated with delivery of prevocational,
postgraduate and specialist medical training and consider the implications associated
(e.g. workforce capacity for service delivery and training capacity) with increased
numbers of medical postgraduates over time;
assist to inform future jurisdictional decision making and planning; and
provide an improved understanding of configurations and likely impacts for current and
alternative medical training and work practices.
The scenario tool will allow exploration of the impact of real and potential change to
workforce configurations on service delivery, teaching capacity (with a focus on overall
medical profile) and for postgraduate medical training by medical specialties.
As the scenario tool will require the input of information by the user, it is anticipated the
scenario tool will be applicable to all medical specialities and for a site or health service
level of investigation. The structure of the tool will be designed to guide the user through a
process of entering relevant profile information and then consideration of the implications of
projected change to staff numbers, change to level of training support available/ required,
and to capacity to deliver service output.
The scenario tool is to be made available, together with training in its use by HWA, to
jurisdictions and other bodies and organisations involved in the training of post graduate
medical trainees.
Strategic Study of Postgraduate Medical Training - Baseline Report
Page viii
2 Introduction
This report presents the method and findings of a study to investigate the impact of real and
potential change to workforce configurations on service delivery, teaching capacity and cost using
a number of scenarios for postgraduate medical training in five medical specialties: emergency
medicine; cardiology; general surgery; general medicine; and geriatric medicine. The five
specialities were chosen to reflect a cross section of different training and service delivery
arrangements, anticipated impact of increased numbers of medical graduates and possible
changes to second year postgraduate (PGY2) training and other potential changes in specialist
medical college training programs. The findings were designed to allow extrapolation of scenarios
at a jurisdictional and national level, and assist with local workforce planning for health services.
The project can be viewed in the context of an increased number of medical graduates entering the
hospital system – with implications to cost, supervision and training load, and service delivery
capacity. Due to an increase in medical schools and the number of domestic medical students, the
number of domestic graduates has increased from 1,914 in 2009, to an anticipated 2,667 in 2011
and 3,108 in 20141.
2.1 Project aims and objectives
The aims of the project were to:
assist to inform jurisdictions of the impact associated with delivery of prevocational,
postgraduate and specialist medical training through a variety of models and any
implications these scenarios may have;
assist to inform future jurisdictional decision making and planning;
provide an improved understanding of configurations and likely impacts for current and
alternative medical training and work practices; and
inform ongoing work of HWA. The report is intended to allow HWA to develop indicative
analyses of the national impact of modelling scenarios on projected numbers of new
graduates entering the health system from 2011 onwards. In particular, the work from this
study will inform development work on the National Training Plan for doctors, nurses and
midwives, to be conducted in 2011.
1
Medical Training Review Panel 13th Report 2010, Commonwealth of Australia Table 2.10 p.13
Strategic Study of Postgraduate Medical Training - Baseline Report
Page 1
The objectives of the project were to use a number of scenarios for postgraduate medical training
to:
model the impact of real and potential changes to medical workforce configurations on
service delivery, teaching capacity and cost in health service medical teams and
postgraduate medical training;
investigate how these configurations interact with, and impact upon each other, and identify
the impacts of these interactions to inform health workforce planning;
identify how alternative models for PGY2 would impact upon current health service medical
team configurations and work practice; and identify the associated costs, economic and
training impacts of the alternative models; and
permit the extrapolation of modelling at a jurisdiction and national level.
2.2 Project scope
The project consisted of two high level phases:
Phase 1 – to identify current work practices and configuration of prevocational and
vocational training within agreed medical speciality program areas; and
Phase 2 – using a number of scenarios for postgraduate medical training, model the impact
of real and potential changes to workforce configurations to service delivery, teaching
capacity and cost.
Nine hospital sites across Australia were identified, with support from jurisdictions, to represent
three broad hospital settings – metropolitan, outer suburban and major regional. For the purposes
of de-identification, the hospitals are referred to as a code rather than hospital name. For example,
the metropolitan hospitals are referred to as M1, M2 and M3, outer suburban as O1, O2 and O3,
and major regional hospitals as R1, R2 and R3.
2.3 Report structure
This report presents the findings of the first phase of the project, and has been informed by
consultation with strategic stakeholders, the relevant staff from each of the nine participating
hospitals and the collection of capacity, activity and staff profile data from some hospitals. The
report reflects views of stakeholders interviewed, including clinicians and administrators at hospital
sites. Where views were echoed by more than one individual these have been expressed as a
theme, and comments highlighted as anecdote where appropriate. Comments made and views
expressed by those interviewed have not been verified or validated.
The report is designed to summarise project findings to date and present the implications for
planned modelling activity. The report includes:
Strategic Study of Postgraduate Medical Training - Baseline Report
Page 2
a short description of the project methodology;
a description of high level observations and findings by hospital type and by speciality;
a discussion of the various approaches to training the junior medical workforce and
identification of the implications for modelling; and
an introduction to the scenario tool.
The second phase of the project resulted in the development of a scenario tool which allows the
modelling of alternative workforce configurations and their impact on output and training capacity. It
was found that the development of the tool, rather than working through specific scenarios was a
more valuable outcome from the study. The scenario tool is available from HWA for jurisdictions,
administrators and others who have a requirement to model alternative medical workforce
configurations. The scenario tool will also form an important input to the National Training Plan for
doctors, nurses and midwives, being developed by HWA in 2011.
Those interested in the scenario tool should contact the Information, Analysis and Planning
workgroup at HWA on 1800 707 351 or hwa@hwa.gov.au.
Strategic Study of Postgraduate Medical Training - Baseline Report
Page 3
3
Project methodology
Figure 1 presents the method used to undertake the Study. A review of current work practice and
configuration of training was completed to produce a baseline set of information to assist future
modelling work.
Figure 1: Project activities
Interviews were conducted and data requested from all nine hospitals. The information gathered
through this process has yielded an improved understanding of the implications of introducing an
increased number of graduate doctors into the hospital system. Some high level consistencies
across specialities were identified. As anticipated, the quantitative information sourced via
interview regarding the relationships between PGY1/2, resident (PGY2+), registrar and consultant
varies. Sometimes a quantitative relationship cannot be identified, (i.e. numbers, or ratio of service
activity by staff category) but a qualitative description of the efficiency relationship is possible.
This is illustrated in the summary table presented in Appendix A.
Strategic Study of Postgraduate Medical Training - Baseline Report
Page 4
4 General observations from site visits
4.1 General findings
List Each participating health service was highly supportive of the project, recognising the
need to better understand the implications of increasing the junior medical workforce for the
sector;
There is strong recognition by those interviewed of the need to invest in the future medical
workforce, and an understanding that any potentially negative impacts and challenges in
the short term are likely to be followed by longer term benefits associated with a more
sustainable workforce;
Medical workforce data systems are often not sophisticated and sometimes record
information in an inconsistent way; however there are examples of improving medical
rostering systems at the unit level. Few sites were able to deliver the full suite of data
requested;
There is a range of variation across jurisdictions as to the degree of collaboration and use
of a centralised approach to placement of PGY1s through key coordination roles for
postgraduate medical education. These coordination roles support agreement on the
number and distribution of PGY1s across the year;
There is recognition by those interviewed that the incoming medical workforce is changing,
and that recent graduates are more discerning regarding postings, more likely to be mobile
and may be less willing to undertake weekend and after hours work;
Not all hospitals impose a fixed promotional structure through the medical career structure
(i.e. from PGY1 – PGY2 to Registrar levels);
It is anticipated that the increased volume of new PGY1/2s will result in less availability and
greater competition for specialist postings, and that increased competition for specialities
and postings will impact on career decision making with a wider range of options
considered, including the speciality chosen to pursue and the location of training
considered; and
While some career medical officer roles exist in the hospitals interviewed, the future role,
value and interest in this position is unclear.
Ability to assess the relative value / contribution of junior medical staff to patient outcomes
Most stakeholders found it difficult to describe the relative value and productivity between
staff levels in a quantitative way in terms of output;
Strategic Study of Postgraduate Medical Training - Baseline Report
Page 5
Commonly the roles, activities and perceived value were described as quite distinct,
particularly PGY1 to PGY2, registrar to trainee and consultant; and
A spectrum of team approaches were described, and these approaches seem to have
positive implications for active roles and relative contribution of junior staff. It is noted that
traditional direct service relationships were also described, particularly in metropolitan
hospital sites (noting that ratios of consultants, registrars and residents varies considerably
across settings).
Alternative approaches to supporting additional postgraduate postings
A number of alternative approaches to supporting additional postgraduate postings were identified
during the consultations, including:
increasing the range of accredited clinical postings, for example into palliative care and
general practice, and consideration of training opportunities within emerging models of
care, such as Hospital in the Home. However, there is recognition that it can be challenging
to maintain adequate clinic exposure and supervision in non-traditional rotations and
clearer direction was requested about whether alternative care settings can be accredited;
introduction of training programs which enhance existing clinical postings such as the More
Learning for Interns in Emergency (MoLIE) program2; and
changing rostering policies to allow for greater coverage of after hours and weekend shifts,
which has the potential to create savings in overtime expenditure (which may be off-set by
increased FTE cost) as well as potential to provide a superior training environment (via two
day shifts).
Some consistent concerns about increasing the number of graduates were raised by stakeholders,
including:
dilution of the training experience caused by reduced clinical exposure and skills training,
leading to reduced competence and safe career progression (or the need for extended time
periods to reach the level of competence required);
2
A Queensland initiative initially developed at Royal Brisbane Hospital which aims to increase the capacity
to train additional PGY1s through providing quality case-based learning grounded in clinical practice. The
program includes up to four hours a week of dedicated teaching time with clinical educators, in addition to
allocation of supervision times.
Strategic Study of Postgraduate Medical Training - Baseline Report
Page 6
the challenge of providing appropriate supervision to junior staff (particularly in the next few
years), the implications for trainee and advanced trainee supervision responsibilities and
the subsequent impact on their own training and supervision;
concerns that the introduction and strict adherence to safe working hours has already led to
a reduction in clinical exposure and associated achievement of competency; and
creating a ‘bottle-neck’ in the midterm, as more junior staff compete for limited specialist
training positions.
Future role of International Medical Graduates (IMGs)
There is a general view that IMGs have highly individual training and supervision needs,
and that they sometimes require greater initial investment and orientation than local
graduates.
There is recognition that the need to recruit IMGs is likely to diminish as a result of the
increase in local graduates.
Many stakeholders have asked whether the increase in local graduates will add to the
overall number of postings or will simply displace IMGs, leading to no significant net gain.
IMGs are most valued in the specialties and locations with less competition for postings
(e.g. geriatric medicine and major regional settings).
4.2 Implications for modelling
Strategic and policy level factors likely to impact upon modelling and the ability to project the future
medical workforce include:
the overall number of PGY1s entering the medical workforce per year;
the number of IMGs and the proportion of postings likely to be filled by domestically trained
graduates in the future, and the number of existing IMGs likely to be displaced by
domestically trained graduates over time;
growth in Registrar college and specialist training posts (including ESTP, general practice,
PGPPP places3);
3
Expanded Specialist Training Program (ESTP), Prevocational General Practice Placements Program
(PGPPP)
Strategic Study of Postgraduate Medical Training - Baseline Report
Page 7
the degree of budgetary pressure and access performance pressure being applied to
hospitals to meet service delivery requirements;
the degree of medical staff attrition and transitioning to the private sector (at variance to
anticipated rates);
the challenge/ perceived challenge as to extent to which private hospitals are able to
manage privacy and patient consent arrangements; and
jurisdictional industrial awards and medical Enterprise Bargaining Agreements (EBAs).
Strategic Study of Postgraduate Medical Training - Baseline Report
Page 8
5 Sector level observations
5.1 Metropolitan hospitals
Factors relating to metropolitan hospitals affecting the medical workforce profile
Key factors identified at the metropolitan sites include:
the larger workforce (compared to outer suburban and major regional hospitals) means
there is a critical mass which enables greater scope for structured training programs,
particularly at departmental level;
less Visiting Medical Officers (VMOs) consultants (compared to outer suburban and major
regional hospitals) means there is a stronger basis for consistent and supportive
supervision and training; and
there is a greater degree of specialisation of services, which is appropriate for service
volumes and attractive to PGY2s and residents (PGY+2).
Metropolitan hospital approaches to supervision and training
Common themes identified at metropolitan sites include:
an increased likelihood of maintaining a traditional ratio to support supervision (noting that
ratios of consultants, registrars and residents varies considerably across settings);
an increased opportunity to introduce team based rosters to provide consistent
relationships, support, supervision and mentoring between consultants, registrars, residents
and PGY1s;
greater opportunity to support designated medical educator roles within the departments
(particularly in emergency departments) because of the relative size of the workforce;
more comprehensive structured mandatory learning programs than smaller sites, including
weekly education sessions, Grand Rounds, time protected learning and access to
simulation facilities;
more structured training support and mentoring programs (including specific programs for
IMGs) and an emphasis on comprehensive orientation programs;
structured assessment programs at commencement of the rotation, mid and end of term,
often including work based and formal assessment; and
Strategic Study of Postgraduate Medical Training - Baseline Report
Page 9
a capacity to support hierarchical training structures with less consultant led training and a
greater reliance on registrars providing supported training.
Capacity to accommodate additional junior medical staff
Key findings at metropolitan sites include:
significant growth in the number of PGY1 and PGY2 placements over the past three years;
and
concerns that growth in numbers of junior medical staff have diluted the training
experience, clinical exposure, infrastructure and support, particularly for PGY1s.
Nature of work conducted by junior medical staff
Key findings at metropolitan sites include:
in most specialities PGY1s contribute little to patient diagnosis or treatment, but rather are
involved in supporting clerical/administrative roles, documentation, and basic patient care4;
and
PGY2s and above have an increasing role in patient care, and are seen as very valuable
within the service delivery model.
Alternative approaches to training and supervision:
Some common approaches and suggestions at metropolitan sites include:
increasing the range of clinical postings into settings such as palliative care, private
hospitals and renal care units; and
introduction of highly structured and resource intensive programs to support training and
supervision within existing postings (for example MoLIE).
4
It is recognised that during this time significant ‘tacit’ learning is occurring on the job
Strategic Study of Postgraduate Medical Training - Baseline Report
Page 10
5.2 Outer suburban hospitals
Factors relating to outer suburban hospitals affecting the medical workforce profile
Key factors identified at the outer suburban sites include:
hospitals experiencing significant growth in activity across specialties and a greater burden
on senior medical staff to meet service delivery demands, resulting in a diminishing
capacity to provide supervision and training to junior staff;
greater difficulty attracting graduates than in metropolitan tertiary centres;
less ability to provide the necessary infrastructure, specialisation, supervision and training
programs to support the junior workforce;
a larger proportion of VMO consultants, resulting in less consistent and supportive training;
less specialisation, meaning that junior medical staff have broader clinical exposure and
opportunities for practical skills training and experience; and
as clinical unit profiles become smaller, there is greater centralised responsibility for
supervision (PGY1s and 2s in particular are managed through central medical workforce
units), with PGY3s and 4s becoming the responsibility of the clinical unit.
Outer suburban hospital approaches to supervision and training
Common themes identified at outer suburban sites include:
outer suburban hospitals are placing a greater emphasis on structured training and support,
and alliances with training organisations, as a way of attracting and retaining quality staff;
there is a stronger emphasis on senior medical staff ‘train the trainer’ programs;
outer suburban hospital departments are less equipped than metropolitan sites to provide
comprehensive, time protected, structured education and training programs and there is a
stronger emphasis on hospital level coordinated training programs;
capacity issues and service delivery demands can affect attendance at formal education
opportunities;
structured feedback, mentoring and assessments are conducted (pre/mid/post term),
however are proving more difficult to support financially given the administrative and time
pressures involved (for all participants);
Strategic Study of Postgraduate Medical Training - Baseline Report
Page 11
most sites have semi-formal mentoring programs in place, and there is a growing role for
peer support programs for junior medical staff; and
IMGs are more common in outer suburban hospitals, and they are usually supported
through hospital level programs which may include additional orientation, individualised
training and education and often introductory courses aimed at increasing cultural
proficiency and enhancing understanding of the Australian healthcare system.
Capacity to accommodate additional junior medical staff
Key findings at outer suburban sites include:
there are limitations in accommodating additional PGYs associated with the current level of
funding provided to support graduate placements;
physical limitations associated with infrastructure and bed numbers are seen as the critical
factors impeding expansion of the junior workforce;
there are concerns that the senior workforce is already at capacity in terms of appropriate
provision of supervision, but recognition in some departments that the supervision burden is
a reasonable trade off for an extra resource; and
increasing the junior workforce makes it more feasible for clinical units and the wider
hospital to invest in more structured training programs.
Alternative approaches to training and supervision:
Some common approaches and suggestions at outer suburban sites include:
splitting the standard workday into two shifts to accommodate more staff on the roster (and
minimise time period of after hours);
exploring out of hospital training opportunities, for example private hospital for Surgery
placements, however serious concerns exist regarding privacy and consent which can
impact on patient flow;
considering the role of supervision and mentoring by senior non-medical staff; and
expanding the use of simulation, and enhancing formal education opportunities to ensure
that the PGY training experience is not adversely effected by any increases in numbers and
potential loss of clinical exposure.
Strategic Study of Postgraduate Medical Training - Baseline Report
Page 12
5.3 Major regional hospitals
Factors relating to major regional hospitals affecting the medical workforce profile
Key factors identified at the major regional sites include, the:
traditionally more generalist nature of clinical service delivery;
responsibility to provide outreach medical support to regional areas; and
heavy reliance on VMO consultants within the senior medical staff profile.
Major regional hospital approaches to supervision and training
Common themes identified at major regional hospital sites include:
PGYs experience a greater level of clinical exposure through direct patient care than in
other settings, although exposure to speciality care is often limited;
a limited capacity for PGYs to prioritise training over service delivery due to staff
constraints;
greater difficulty implementing team based rostering to provide consistent supervision and
support; and
a strong recognition that regional services have a greater incentive and responsibility to
enhance junior medical staff training and supervision support to ensure the retention of staff
and to enhance future recruitment options (which are often limited).
Capacity to accommodate additional junior medical staff
Key findings at major regional hospital sites include:
there is a general view that major regional hospital sites can accommodate increased
graduates without a significant loss of clinical exposure;
increasing the overall medical workforce has the potential to decrease overtime and provide
a safer and more sustainable work environment for existing senior staff;
there are opportunities to enhance the formalised education and training arrangements if a
critical mass was achieved through increasing the junior workforce; and
Strategic Study of Postgraduate Medical Training - Baseline Report
Page 13
the greatest potential may be at PGY1 and 2 level, as medical staff will wish to seek
specialist training at larger sites as they progress (for all or segments of specialist training,
particularly more senior accredited training positions).
Alternative approaches to training and supervision:
Some common approaches and suggestions at major regional hospital sites include:
as with other hospital types, exploring alternative placements such as outpatient clinics and
out of hospital training opportunities;
expanding current work models to incorporate team based approaches to rostering to
maintain a personal approach to service delivery and training; and
expanding the use of simulation training and technology based resources to enhance the
training experience.
5.4 Implications for modelling
The SETTING level factors and variables that influence the development of the model, either
directly or indirectly, regardless of speciality include:
Size
: Hospital size (volume of throughput activity, number of inpatient beds);
Location: Hospital location, setting and nature of services (metropolitan, outer suburban,
regional, rural);
Type
: Nature / acuity level of services provided (teaching; tertiary);
Part of an Area Health Service : Whether the hospital is part of a larger health service;
Organisation-wide growth rate : General indication regarding growth in elective /
emergency activity to assess scope to increase medical workforce profile;
Approved posts per speciality : Number of approved term rotations (PGY1s, PGY2s,
residents, hospital medical officers (HMOs), registrars);
Term rotations
year);
: Number of term rotations for PGY1s (5 term year), HMOs (4 or 5 term
Medical Profile
: The distribution of medical workforce profile (No. of specialists,
consultants, advanced trainees, registrars, PGYs);
Strategic Study of Postgraduate Medical Training - Baseline Report
Page 14
Proportion of specialist full time
compared to VMO numbers;
: The proportion of full time (hospital employed) staff
Structured medical career path : Nature of medical staff progression structure – Degree
to which the hospital imposes a fixed progression from PGY1 through to registrar;
Fixed staff roster : Extent to which hospitals maintain fixed rosters between consultant :
registrar : junior medical staff coverage;
Funding
: Funding amount and nature of funding to support PGY1, HMO posts;
Educational positions
: Number and nature of educational staffing and support
programs employed by hospitals to support junior medical staff training, assessment and
mentoring;
Medical Student numbers : Volume and nature of hospital undergraduate student
programs (competing for learning time);
Alternative clinical placements : Extent to which the hospital is able to introduce new /
alternate clinical placement settings for PGY1 and resident posts;
Transfer to Vocational training %
vocational training programs;
: Proportion of postgraduate trainees transferring to
Transfer to Specialist position %
specialist positions;
:Proportion of senior registrars transferring to
Teaching vs. Service per classification % : Proportion of senior medical staff time
spent on service delivery vs. teaching, degree of structured training; and
Output relative value per classification % : Proportion of service delivery output
between junior medical staff by comparison to senior medical staff.
Note - it is suggested that those variables denoted with an (
level of detail.
Strategic Study of Postgraduate Medical Training - Baseline Report
) are also relevant at a speciality
Page 15
6 Speciality unit observations
This section describes the key findings, summarises the key themes and implications for modelling
in relation to the five specialities considered during phase one of the project; cardiology,
emergency medicine, general medicine, general surgery and geriatric medicine.
6.1 Cardiology
Speciality unit factors likely to affect the medical workforce profile
There are several features of Cardiology departments which are likely to have an impact on the
medical workforce profile such as5:
size and activity (throughput and number of beds) of the unit;
sub speciality activities such as Interventional cardiology provided through inpatient and
outpatient care, Coronary Care Units (CCU), Cardiac Catheter Laboratories (CCL);
degree of privatised activities (CCL, outpatients); and
the proportion of full time and sessional/VMO consultants.
Current supervision and training:
Common themes around supervision and training in Cardiology which were identified include:
individual sites have different approaches to allocating activity to PGYs and to supervising
this activity;
the capacity to provide formal training and education programs is limited at smaller
locations;
there are limited numbers of senior medical staff, given the relatively smaller size of
Cardiology units compared to general units. For this reason any additional training and
supervision requirement is seen as a significant burden, with the potential to have a
negative impact on service delivery; and
there is some speciality level training which occurs particular to the sub-speciality nature of
unit, however there is a reliance on hospital training structures.
Relative activity of medical staff
The following observations were made about relative activity of medical staff in cardiology:
5
Recognising that different team profiles impact on the roles of PGYs
Strategic Study of Postgraduate Medical Training - Baseline Report
Page 16
PGY1s have a diminished role in providing direct patient care, and rotation through the unit
is largely a learning experience;
there is a significant difference between the contribution of a PGY2 to service delivery
compared to a PGY1. PGY2s are able to undertake supervised patient care. The difference
plateaus after progression to PGY2; and
the role of PGY1s in direct patient contact is slowly growing, however most activity relates
to assistance with clerical, administrative and documentation work which frees up senior
staff.
Capacity to accommodate additional junior medical staff
Key findings for Cardiology include:
there are mixed views about the capacity to absorb additional PGYs into cardiology,
however most sites would welcome additional junior medical staff, particularly PGY2s;
most hospitals recognise the importance of investing in the junior medical workforce even if
they provide only minimal contribution to service delivery. For specialist units like
cardiology, rotating junior medical staff promotes the specialist nature of the services
delivered and promotes interest for future recruitment in the field of practice; and
sites see opportunities for increased output if the entire staff profile is also adjusted
accordingly (within the limitations of the bed number).
Alternative approaches to training and supervision
Some common approaches and suggestions from cardiology include:
consideration of opportunities to change traditional medical profile structures and rosters to
accommodate additional PGYs (e.g. by rostering two shifts per day -. day and evening);
and
exploring the potential for PGYs to contribute to community based/out of hospital models of
care. (There is however strong recognition that this requires attention to developing
appropriate models of supervision and training for these settings).
Variation by hospital types
Size rather than geographical setting seems to dictate the role and acceptance of PGY1s
and PGY2s in cardiology units.
Larger units have a greater number of senior medical staff able to support and
accommodate existing and additional supervision and training requirements.
Strategic Study of Postgraduate Medical Training - Baseline Report
Page 17
A higher proportion of VMOs compared to full time senior staff has a negative impact on the
unit’s capacity to provide consistent and supportive training and supervision for junior
medical staff.
Implications for modelling
The cardiology SPECIALITY level factors and variables that can potentially to influence the
development of the model include:
Volume/ Throughput: Elective verses emergency admissions, outpatient attendances,
Interventional cardiology throughput.
Types of Cardiology services: The mix between ward level, CCU, telemetry beds, CCL,
other interventional units, electrophysiology and echo activity will determine the extent to
which senior medical staff support and supervise junior medical staff.
Public mix: The mix of public verses private interventional services conducted by the unit.
Standalone unit: Extent to which the cardiology unit (and therefore profile and roster) is
separately managed (or managed within the general medical unit).
Cardiology medical profile classifications:
Non-vocational staff: PGY1 through PGY4
Vocational staff: registrar basic / advanced physician training year: basic physician
training year 1 through 3, advanced (year 1 through 3)
Full-time specialists
Visiting Medical Officers.
6.2 Emergency medicine
Speciality unit factors likely to affect the medical workforce profile
There are several features of emergency medicine which are likely to have an impact on the
medical workforce profile such as:
size and activity (presentations, number of cubicles, additional observation / assessment
capacity) of the unit;
Strategic Study of Postgraduate Medical Training - Baseline Report
Page 18
sub speciality activities and the composition of the department, including the nature of
streaming, acute assessment units (managed by the emergency department (ED) versus
general medicine), paediatrics, trauma status, access to diagnostic imaging and telemetry;
the inclusion of nurse practitioners and care coordinators and the proportion of Fellows of
Australasian College for Emergency Medicine (FACEMs) within the overall staff profile; and
recognition that the focus on improving ED performance targets is placing greater demands
on ED staff to meet service delivery requirements.
Current supervision and training:
Common themes around supervision and training in emergency medicine which were identified
include:
the role of PGY1s and registrars and the level of supervision provided differs between
streams of care in EDs. Fast track and observation units are more likely to be staffed with
senior medical staff;
there are different approaches to team structures and supervision at different sites,
including team based rostering at some hospitals;
direct supervision is often provided by registrars, with consultants providing oversight;
approaches to providing and protecting formal education and training opportunities vary
between sites; and
the larger size of the ED medical workforce profiles makes it viable to employ clinical
education registrars to directly assist with junior medical staff training and mentoring
support programs.
Relative activity of medical staff
The following observations were made about relative activity of medical staff in emergency
medicine:
emergency medicine articulated the clearest and most regimented medical workforce
structure of the five specialties explored, in terms of the relationship between senior and
junior medical staff cover;
the contribution of PGYs increases over time, however it takes longer to operate
independently in the emergency setting than in other specialties; and
most EDs report that PGYs slow service delivery, however a small number report that they
are crucial to operations.
Strategic Study of Postgraduate Medical Training - Baseline Report
Page 19
Capacity to accommodate additional junior medical staff
Key findings for emergency medicine include:
emergency departments generally reported that PGY1s contribute little to service delivery,
and are largely supernumerary and often considered to require a significant supervisory
commitment, particularly in peak times;
the majority of EDs report they do not have capacity to increase the number of PGY1s; and
others reported that increasing their numbers would create additional supervisory
commitment which could only be managed by recruiting additional senior staff to ensure
that supervision, administration and formal training can continue to be provided.
Alternative approaches to training and supervision
Some common approaches and suggestions from emergency medicine include:
consideration of opportunities to change traditional medical profile structures and rosters to
accommodate additional PGYs, for example by rostering two day shifts (as suggested in
other specialties); and
reviewing rostering policies would allow for additional PGYs to be absorbed into
departments without decreasing clinical exposure;
involving senior nursing staff in supervision and training; and
increasing administrative support to reduce the burden on clinical staff.
Variation by hospital types
While in other specialties larger metropolitan hospitals were less likely to report that they
could accommodate additional PGYs, in Emergency medicine, two of the three
metropolitan sites reported that they could increase their training and supervision. This may
be linked to these units having higher proportions of senior staff able to support supervision
and training.
In at least one case the implementation of a highly structured and resourced training
program was linked to a more positive view of increasing PGYs.
Implications for modelling
The emergency medicine SPECIALITY level factors and variables that are likely to influence the
development of the model include:
Volume / Throughput: number of emergency presentations, emergency admission rates.
Strategic Study of Postgraduate Medical Training - Baseline Report
Page 20
Types of Emergency Department services: Numbers of cubicles, streaming of activities
between discharge, admission, trauma, access to radiology, paediatric services.
Observational / Assessment units: Whether the ED (as opposed to general medicine)
manage/oversee any short stay medical/surgical observational and assessment beds.
Emergency medicine medical profile classifications:
Non-vocational staff : PGY1 through PGY4
Vocational Staff : registrar basic / advanced physician training year : basicpPhysician
training year 1 through 3, advanced (year 1 through 4)
Full-time specialists
Visiting Medical Officers.
6.3 General medicine
Speciality unit factors likely to affect the medical workforce profile
There are several features of general medicine which are likely to have an impact on the medical
workforce profile such as:
size and activity (presentations, number of medical unit and medical assessment beds,
outpatient clinic activity); and
sub speciality activities, such as the nature of sub specialties managed by general
medicine, acute Medical Assessment Units (MAUs) and sub acute medical units.
Current supervision and training:
Common themes around supervision and training in general medicine which were identified
include:
general medicine is the speciality most likely to provide formal training and education
programs, including lectures, tutorials and protected learning time; and
supervision is usually through the traditional apprenticeship model, with both registrars and
consultants supervising junior staff.
Relative activity of medical staff
The following observation was made about relative activity of medical staff in general medicine:
Strategic Study of Postgraduate Medical Training - Baseline Report
Page 21
there is a significant difference between the contribution of a PGY2 to service delivery
compared to a PGY1. PGY2s are able to undertake supervised patient care. The difference
plateaus after PGY2.
Capacity to accommodate additional junior medical staff
Key findings for general medicine include:
there is a general view that sites could accommodate more PGYs if commensurate senior
staff are also employed, however this may not provide an associated increase in output,
because units are already operating at full capacity within the limitation of bed numbers and
facilities; and
general concerns about increasing PGYs may lead to less clinical exposure and skills
training opportunities, which in turn has the potential to have a negative impact on
competency and progression.
Alternative approaches to training and supervision
Some common approaches and suggestions from general medicine include:
moving away from the traditional staff supervision ratios towards larger team based
rostering; and
enhancing community based training opportunities to allow PGYs to play a greater role in
the emerging community based models of care.
Variation between hospitals types
As a general rule major regional and outer suburban sites are more likely to be willing to
absorb additional PGYs into general medicine.
Sites see different ways to absorb additional PGYs through focusing them in acute
admitting teams or into general wards to free up registrars.
Implications for modelling
The general medicine SPECIALITY level factors and variables that are likely to influence the
development of the model include:
Volume/ throughput: number of admissions, inpatient beds, outpatient sessions
Degree of specialisation: whether medical units have general or sub speciality
designations
Types of unit services: numbers of inpatient beds, assessment beds
Strategic Study of Postgraduate Medical Training - Baseline Report
Page 22
Observational / assessment units: Whether general medicine (as opposed to ED)
manage/ oversee any short stay medical/ surgical observational and assessment beds
General medicine medical profile classifications:
Non-vocational staff : PGY1 through PGY4
Vocational staff : registrar basic / advanced physician training year: basic physician
training year 1 through 3, advanced (year 1 through 3)
Full-time specialists
Visiting Medical Officers.
6.4 General surgery
Speciality unit factors likely to affect the medical workforce profile
There are several features of surgery departments which are likely to have an impact on the
medical workforce profile such as:
size and activity (throughput, beds, number of operating theatres, numbers of medical units,
outpatient clinics); and
sub speciality activities, such as the nature of sub specialties managed by general surgery.
Current supervision and training:
Common themes around supervision and training in general surgery which were identified include:
registrars play a key role in supervision in surgery; and
the higher proportion of full time and sessional/ VMO consultants.
Relative activity of medical staff
The following observation was made about relative activity of medical staff in general surgery:
it is very difficult to quantify relative activity in surgery because the roles undertaken by
different levels are not comparable, however the administrative work undertaken by junior
staff is critical.
Capacity to accommodate additional junior medical staff
Key findings for general surgery include:
Strategic Study of Postgraduate Medical Training - Baseline Report
Page 23
most sites reported that they could absorb additional PGYs, however there are significant
concerns associated with maintaining sufficient clinical exposure, linked to a concern that
strict adherence to safe working hours has already had a negative impact on exposure and
therefore achievement of competence; and
it is not until staff reach Registrar level that they are able to contribute to operating theatre
throughput, therefore additional junior PGYs would probably not increase actual output (in
the short term).
Alternative approaches to training and supervision
Some common approaches and suggestions from general surgery include:
partnerships with the private sector, which are seen as a viable option in general surgery;
and
reviewing rostering policies would allow for additional PGYs to be absorbed into
departments without decreasing clinical exposure.
Variation by hospital types:
Smaller surgery departments in major regional hospital sites are more likely to be generalist
in nature, whereas larger metropolitan surgical departments are highly specialised, and
therefore there is a decreased range of cases allocated to general surgery.
Implications for modelling
The general surgery SPECIALITY level factors and variables that are likely to influence the
development of the model include:
Volume/ throughput: number of admissions, inpatient beds/bed days, outpatient sessions,
emergency vs. elective theatre sessions, day procedures and endoscopy procedures.
Degree of specialisation:
designations.
whether surgical units have general or sub speciality
Types of unit services: numbers of inpatient beds, surgical assessment beds, short stay
beds.
Observational / assessment units: does general surgery (as opposed to ED) manage /
oversee any short stay surgical observational and assessment beds.
General Surgery medical profile classifications:
Non-vocational staff : PGY1 through PGY4
Strategic Study of Postgraduate Medical Training - Baseline Report
Page 24
Vocational staff : registrar surgical education and training year 1 to 5
Full-time specialists
Visiting Medical Officers.
6.5 Geriatric medicine
Speciality unit factors likely to affect the medical workforce profile
There are several features of geriatric medicine departments which are likely to have an impact on
the medical workforce profile such as:
size and activity (throughput, beds, number of sub acute beds); and
sub speciality activities such as separation from broader sub acute care, relationship with
rehabilitation services, access to extended care facilities, access to Aged Care Assessment
Services (ACAS) and the role of general practice in supporting medical care.
Current supervision and training:
Common themes around supervision and training in geriatric medicine which were identified
include:
PGYs (especially PGY2+) are usually an integral part of the model of care in geriatric
medicine and do most of the direct patient care work;
several hospitals provide geriatric care across multiple sites, particularly in outer suburban
locations, and this creates challenges for supervision and maintaining regular formal
training and education programs; and
there is recognition that IMGs can be uniquely valuable, particularly in areas with higher
proportions of culturally and linguistically diverse (CALD) patients.
Relative activity of medical staff
The following observations were made about relative activity of medical staff in geriatric medicine:
there is a significant difference between the contribution of a PGY2 to service delivery
compared to a PGY1, as PGY2s are able to operate with more independence. The
difference plateaus after PGY2;
Strategic Study of Postgraduate Medical Training - Baseline Report
Page 25
junior staff operate at a lower level of efficiency and competence (as would be expected),
requiring varying levels of supervision and consultation with more senior staff to progress
with assessment and treatment; and
relative activity is very difficult to quantify in geriatric medicine because the roles
undertaken by junior staff usually constitute a large portion of direct patient care, and senior
staff provide oversight.
Capacity to accommodate additional junior medical staff
Key findings for geriatric medicine include:
although there is an initial investment/ commitment associated with orientation and basic
competency, there is a general view that junior staff are valuable and additional junior staff
could be accommodated; and
additional staff could lead to improved service delivery and possibly improved throughput of
patients.
Alternative approaches to training and supervision
Some common approaches and suggestions from geriatric medicine include:
increasing the PGY role in community/home/residential care settings; and
providing more formalised, time protected, training and education programs to support
junior staff.
Variation between hospital types:
Outer suburban sites are most likely to report that IMGs are valuable, probably due to
limited capacity to recruit staff generally and also due to higher proportions of CALD
patients.
Major regional sites rely heavily on junior staff and have difficulty maintaining a senior
workforce.
Implications for modelling
The geriatric medicine SPECIALITY level factors and variables that are likely to influence the
development of the model include:
Volume/ throughput: number of admissions, inpatient beds, outpatient sessions.
Degree of specialisation: whether the geriatric medicine unit is a designated unit or part of
sub-acute service.
Strategic Study of Postgraduate Medical Training - Baseline Report
Page 26
Sub-acute campus: whether the Geriatric medicine service is part of an acute or subacute campus (split across both).
Types of unit services: access to inpatient beds, aged care assessment services, nursing
home/transitional/ integrated care.
Geriatric medicine medical profile classifications:
Non-vocational staff: PGY1 through PGY4
Vocational staff : registrar basic/ advanced physician training year: basic physician
training year 1 through 3, advanced (year 1 through 4)
Full-time specialists
Visiting Medical Officers.
Strategic Study of Postgraduate Medical Training - Baseline Report
Page 27
7
Approaches to junior medical staff training
A number of key themes have emerged around what initiatives and policies currently do, or could
do in the future, to best support the training and supervision of junior medical staff:
the importance of a structured and comprehensive orientation program;
hospital wide and departmental training programs, including broad learning and education
opportunities such as:
lunchtime training sessions
Grand Rounds
university clinical rounds
journal clubs
Mortality and Morbidity meetings
clinical audits
utilising electronic resources and online services;
providing scholarships and awards;
providing access to external courses;
consultant mentor programs for PGY1s, particularly on first rotation;
junior medical staff forums and peer support programs;
enhancing and formalising the role of nursing staff in providing training and supervision to
PGY1s (recognising team based approaches tend to formalise multidisciplinary roles in
training and supervision);
time protected clinical meetings and training opportunities;
access to simulation facilities and sessions;
speciality based skills testing and remedial training; and
department based medical education registrars.
Strategic Study of Postgraduate Medical Training - Baseline Report
Page 28
8
Implications and approaches to modelling
The project sought to identify scenarios for postgraduate medical training for modelling the impact
of real and potential changes to the workforce configurations to affect service delivery, teaching
capacity and cost over time.
The findings demonstrate that:
there is little consistency across the organisations and specialities reviewed as to the
relative contribution of different classifications of medical staff (between consultant
specialists and registrars) to training and supervision;
it is difficult to identify absolute values of relative output between senior and junior medical
classifications to assess the relative value of throughput between them; and
apart from the contribution by specialist consultants and senior registrars, the service
delivery output of a clinical unit is more a function of a rostered medical team than it is to
any individual classification level.
As a result, while a model of medical workforce capacity and output can be developed, many of the
variables are unlikely to be able to be predetermined or “hard coded” into the model. Instead these
variables are user defined. For this reason, the next phase of the project will involve the
development of a medical workforce scenario tool rather than a model to assist various stakeholder
organisations in assessing the impact and benefit of the increased numbers of medical
postgraduates over time.
The responsiveness, and degree of interest expressed by hospital representatives interviewed in
the initial phase of this project, suggested there is value in developing an indicative projection
model, even if relative values cannot be included (i.e. will require user defined variables).
Discussions with the Reference Committee explored the following aspects of a scenario tool:
the anticipated user/s of the scenario tool recognising that the materiality of certain
parameters will change if the tool is used for National and State projections as opposed to a
hospital site/ health service or further still, at a clinical unit speciality level;
a review of the influencing factors identified in this report and the extent to which they were
considered relevant and material in the development of the model;
confirmation of the anticipated output of the tool and the extent to which the tool should be
developed specifically with regard to the speciality units chosen for this project or be
adaptable to a wider workforce population and other speciality areas;
Strategic Study of Postgraduate Medical Training - Baseline Report
Page 29
the relationship between the input factors noted in this report and the extent to which they
affect the outputs of the tool.
Strategic Study of Postgraduate Medical Training - Baseline Report
Page 30
9
Development of a medical workforce scenario tool
This section provides an introduction to the development of a medical workforce scenario tool. The
scenario tool is designed to assist medical workforce and related service planning at a jurisdictional
and local service level, including at an individual speciality level. The development of the scenario
tool can be viewed in the context of an increased number of medical graduates entering the
hospital system – with implications for cost, supervision and training load, and service delivery
capacity.
The scenario tool will aim to:
assist to inform jurisdictions of the impact associated with delivery of prevocational,
postgraduate and specialist medical training and consider the implications associated (e.g.
workforce capacity for service delivery and training capacity) with increased numbers of
medical postgraduates over time;
assist to inform future jurisdictional decision making and planning; and
provide an improved understanding of configurations and likely impacts for current and
alternative medical training and work practices.
The scenario tool will allow exploration of the impact of real and potential change to workforce
configurations on service delivery, teaching capacity (with a focus on overall medical profile) and
for postgraduate medical training by medical specialties. The baseline report explored five
specialities:
cardiology;
emergency medicine;
general medicine;
general surgery; and
geriatric medicine.
As the scenario tool will require the input of information by the user, it is anticipated the scenario
tool will be applicable to all medical specialities and for a site or health service level of
investigation. The structure of the tool will be designed to guide the user through a process of
entering relevant profile information and then consideration of the implications of projected change
to staff numbers, change to level of training support available/ required, and to capacity to deliver
service output.
The scenario tool will be made available, together with training in its use by HWA, to jurisdictions
and other bodies and organisations involved in the training of post graduate medical trainees.
Strategic Study of Postgraduate Medical Training - Baseline Report
Page 31
Appendix A – Summary table of hospital level relative activity relationship
Speciality
Information
Hospital site
M1
Hospital level data provide?
Cardiology
Relative
activity
relationship
described?
Relative
activity
relationship
M2
X
Difficult to
assess
meaningfully
Postgraduate Medical Training Study - Baseline Report
M3
O1
O2
X
E
Qualitative
Quantitative
Quantitative
PGY2s are
much more
productive
and useful
than PGY1s
PGY1s and 2s
contribute to
1 or 2 pt
discharges
per week
PGYs
contribute
25% to
overall
Consultant
output
PGY1s are
50% as
effective as
advanced
trainees
Advanced
trainees are
80% as
effective as
Consultants
E
O3
X
Difficult to
assess
meaningfully
R1
X
R2
X
Difficult to
assess
meaningfully
Quantitative
(not at PGY
level)
Difficult to
assess
meaningfully
PGY1s slow
activity
PGY 2s are of
some value
PGY 3 are of
significant
value
Registrars
undertake
70% - 80% of
Consultant
workload
R3
X
Difficult to
assess
meaningfully
X
No response
Quantitative
Qualitative
Page 32
Speciality
Emergency
medicine
Information
Relative
activity
relationship
described?
Relative
activity
relationship
Hospital site
M1
M2
M3
O1
O2
O3
R1
R2
R3
Qualitative
Quantitative
Qualitative
Quantitative
Difficult to
assess
meaningfully
Qualitative
Quantitative
Difficult to
assess
meaningfully
Qualitative
PGY1/2s slow
service
delivery
Absence of
PGY1/2 would
increase
service
delivery
PGY1s are
crucial to the
model of
care
PGY1 will see
1 patient
each hour
Reg/PHO will
see 2 or 3
Consultant
will see 5-6
(already had
workup)
PGY1s have
no positive
input, they
slow service
delivery
Number of
pts staff can
discharge in
an 8 hour
shift:
PGY1 2-3 pts
HMOs 4-5 pts
Registrar 8-10
pts
PGY2/3 tend
to be more
motivated
and
productive
Registrar
output less
variable than
PGY groups
Number of pts
staff can
discharge in
an 8 hour shift:
PGY1 4-5 pts
PGY2 & 3 5-8
pts
Registrar 8-10
pts
Consultant 812 pts
Postgraduate Medical Training Study - Baseline Report
PGY1s
considered
supernumerary
and undertake
almost no pt
contact work
Page 33
Speciality
General
medicine
Information
Relative
activity
relationship
described?
Relative
activity
relationship
M1
Qualitative
M2
Quantitative
PGY2
compared to
PGY1 have
much greater
level of
independence
Registrar has
greater
autonomy
PGY2 50%
more
efficient than
PGY1
Registrars
50% more
efficient than
PGY2
PGYs have
no real
clinical
productivity
Without PGYs
there would
be a major
clinical
admin
burden
Postgraduate Medical Training Study - Baseline Report
M3
Difficult to
assess
meaningfully
O1
Quantitative
PGY2s twice
as
productive
as PGY1s
No
difference
between
PGY2s & 3s
Registrars do
different
things so
can’t
compare
Consultants
are maybe
20% more
productive
than
Registrars
Hospital site
O2
Difficult to
assess
meaningfully
O3
Difficult to
assess
meaningfully
R1
Quantitative
R2
Quantitative
R3
No response
Quantitative
Qualitative
A PGY1 does
30% work,
supervised
70%(registrar)
Resident more
effective than
PGY1 (60/40)
Registrar to
consultant
80/20
PGY1 to
Registrar = >
2 to 1
PGY2 to
Registrar = < 2
to 1
Page 34
Speciality
General
surgery
Information
Relative
activity
relationship
described?
Hospital site
M1
M2
M3
O1
O2
O3
R1
R2
R3
Difficult to
assess
meaningfully
Difficult to
assess
meaningfully
Qualitative
Difficult to
assess
meaningfully
Difficult to
assess
meaningfully
Qualitative
Difficult to
assess
meaningfully
Quantitative
No response
Quantitative
Qualitative
Relative
activity
relationship
Geriatric
medicine
Relative
activity
relationship
described?
Only post
PGY1 add
value to
service
delivery
Difficult to
assess
meaningfully
Relative
activity
relationship
Postgraduate Medical Training Study - Baseline Report
Qualitative
Productivity
equivalence
hard to
assess
PGY2s have
more
valuable
service role
than PGY1s
Difficult to
assess
meaningfully
Quantitative
Estimate that
.3 Registrar
position
would be
freed up per
additional
PGY1
With a .2 - .3
knock on
effect for
Consultants
Difficult to
assess
meaningfully
Although
doing
different jobs,
PGY2s are
able to do
more in real
productivity
terms than
PGY1s
Registrars are
highly
variable but
can help with
OT
throughput
Difficult to
assess
meaningfully
Registrar 1/3
as productive
(with
requirement
supervision)
as Consultant
(on limited
scope)
Qualitative
Qualitative
Junior staff are
task driven,
led by more
senior staff
Registrar can
largely work
independently
PGY1s
provide the
basic patient
care
necessary to
run the
inpatient
beds
Not relevant
to talk about
comparative
outputs
No response
Quantitative
Qualitative
Page 35
Acronyms
ACAS
Aged Care Assessment Services
ACEM
Australasian College for Emergency Medicine
ACFfJD
Australian
Doctors
CALD
Culturally and linguistically diverse
COAG
Council of Australian Governments
CCL
Cardiac catheter laboratories
CCU
Coronary care units
EBA
Enterprise Bargaining Agreement
ED
Emergency department
ESTP
Expanded Specialist Training Program
FACEM
Fellow of Australasian College for Emergency
Medicine
FTE
Full time equivalent
HMO
Hospital Medical Officer
HWA
Health Workforce Australia
IMG
International medical graduate
MAU
Medical assessment unit
MoLIE
More learning for interns in emergency
NHWT
National Health Workforce Taskforce
NPA
National Partnership Agreement
PGPPP
Prevocational
Postgraduate Medical Training Study - Baseline Report
Curriculum
General
Framework
Practice
for
Junior
Placements
Page 36
Program
PGY
Postgraduate Year
RACGP
Royal Australian College of General Practitioners
RACP
Royal Australasian College of Physicians
RACS
Royal Australasian College of Surgeons
SLE
Simulated Learning Environment
VMO
Visiting Medical Officer
Postgraduate Medical Training Study - Baseline Report
Page 37