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From: Rescuing Medical Education Conference
Stamford Sydney Airport
O'Riordan St (cnr Robey St), Mascot
18 February 2005

The Politicisation Of Specialist Medical Training - Who Should Set The Standards?

Professor Donald Sheldon
Chairman, Council of Procedural Specialists
Former Chairman, Board of Continuing Professional
Development and Standards, Royal Australasian College of Surgeons

CHAIRMAN: I think what needs to be said about Don is that he is a busy, practising surgeon at Royal Prince Alfred Hospital, Sydney. He has registrars, Fellows and residents whom he teaches and with whom he works. He therefore is very much a hands-on surgeon

PROFESSOR SHELDON: Thank you, and thank you to the ADF for the invitation to speak this afternoon. I jotted down a couple of extra comments I thought I'd make before commencing my talk which is called the politicisation of specialist medical training - who should set the standards?

Listening to some of the discussions this morning I was reminded of a conference I attended in Chicago a few years ago on behalf of the College of Surgeons - our College of Surgeons. The conference was called "The Credentialing of Medical Practitioners" and it was addressing a number of the issues we discussed today, but even a broader front. This is not just a state or a national issue, it is now an international issue. It was highlighted there that in South America particularly, medical schools are popping up all over the place with very dubious training programmes, and people are coming out with degrees from universities all round the world - moving around the global village and demanding that their qualifications be accepted in other institutions.

So as well as, I think, today considering the importance of some sort of national integration of standards of undergraduate and post graduate education, we'll have to eventually look internationally as well.

The other point that popped up this morning, that reminded me of an episode I had a few years ago, when I took a new group of students. They were all Asian students which, in the Prince Alfred intake, is not all that surprising. There's a very large representation of Asian people doing medicine. But this group I had great difficulty coming to terms with. I thought I was a good tutor but no matter how hard I tried I couldn't get any response from them, I couldn't bring them out, I didn't seem to be able to motivate them, and I thought I was losing my touch.

One of these people was so reticent that I - in desperation - went to the sub-dean and said, look, this individual is not going to make the grade, he's going to need help. I think it's time he was counselled and perhaps redirected into a different career pathway. It was only at that stage that I was informed that the group I had were all fee paying students. They were paying $26,000 a year for their course, and we were still - and still do - giving them their fairly extensive clinical tutorials in an honorary capacity. Not that I begrudge that for a moment, but I think it's important that people are aware of what I think is a strange anomaly and it raises the question of how strongly the universities are going to adhere to local standards if the risk of offending international fee paying students is threatened. So while we're talking about the setting of standards I think it's probably important we keep that sort of information in front of us.

My remarks today are basically centred around the training of surgeons, since that's my area of expertise, and about which I'm reasonably well informed. I believe, however, these observations apply to other disciplines of medicine.

The Royal Australasian College of Surgeons was founded in the early 1930's by a group of eminent surgical practitioners in this country and New Zealand. The aim was to ensure that those practitioners who wished to perform surgical operations were adequately trained, had appropriate experience and had passed the proscribed examinations held by the college. They were not motivated by a closed shop mentality, nor was there any attempt to exclude legitimate candidates from sitting for the examinations. The standards demanded were necessarily high and in the public interest, have remained so.

Our college had no government mandate for its creation, but was subsequently afforded Royal patronage. The Prince of Wales is the current Patron of the college. This is in contra-distinction to the Royal College of Surgeons of England which was established by Royal Charter - a most impressive document outlining the roles and responsibilities of the organisation, and ordained by the King. There are no formal obligations to the State by our college, however. Our college's role was to set the standard, examine the candidates, issue diplomas to the successful, and encourage research and scholarship. At no stage has there been an obligation to train or graduate specific numbers of surgeons or to conform to some contrived workforce requirement. If the candidates do not meet the standard he, or she, fail the test.

It is also important to realise that virtually all the teaching is performed pro bono and gratis by the Fellows of the College. Practising surgeons train their junior colleagues in their hospitals, and tutors and examiners give freely of their time to ensure the maintenance of these standards.

It therefore came as somewhat of a surprise that the ACCC saw fit to accuse the college of running a monopoly that breached anti competitive legislation, and was potentially vulnerable to fines of $10 million per breach. Many of us saw this as a misdirected activity, and believe that the college should surely be exempt under the public interest exclusions that exist under the act. It seemed anomalous that the government health insurance monopoly, Medicare, was deemed to be in the public interest, whilst an institution committed to the welfare of surgical patients in a not-for-profit model could be deemed in breach by the ACCC.

To avoid prosecution the college has had to modify its procedures and comply with on-going controls and regulations imposed by this government instrumentality. Needless to say, there now exists specific selection criteria into training programmes, and state demands for the number of trainees that the college must accept, so that perceived man power supplies are met, are current.

Surgical training involves the acquisition of large amounts of knowledge plus the technical skills to perform complex surgical manoeuvres. This takes time. It also takes a suitable number of patients on whom trainee surgeons can operate, under the supervision of their mentors. There has to be hands-on training opportunities for the candidate to become experienced and competent. The college correctly requires that each candidate maintain a log book of his or her operations before that individual can be deemed safe to operate independently in the community. It would be irresponsible of the college to graduate candidates whose surgical experience was one appendix and two ingrown toenails, to take an extreme example.

Conflict has arisen whereby the states are demanding the college train more surgeons to fill workforce requirements. There have been allegations that the college training programme is the cause of hospital surgical waiting lists, by not providing enough surgeons. However, everyone knows that the waiting list problem is due to the inadequate theatre availability, and access to hospital beds for the existing workforce, who could do the work quite readily with the manpower we have in place, if the facilities were provided

The political machinations to blame the College of Surgeons for the failure of the health service are blatantly dishonest and misleading. The motivations of the State, in the broadest sense, to control medical practice and training are complex. You could spend a day on those issues alone.

The current arrangement we have in Australia really is a failed attempt to introduce a British National Health model in this country. In Britain, the Specialist Training Authority, or STA, is a government instrument that determines how many specialists are required. The Treasury allocates the estimated finance, and the colleges are then instructed to process the necessary workforce. This is a model I think we do not want to see in this country. We now see that Britons are having to go to Europe to contracted hospitals because the NHS cannot service the demand. Our system is headed down the same pathway unless there is a change of philosophy and policy.

If the government and the ACCC really believe the college selection and training programmes represent an unfair monopoly perhaps the solution is to establish a government training institution, based on principles they accept, and thus encourage competition for surgical aspirants. In the meantime, the college should be helped to maintain the high standard of training, its rigorous exam system and its continuing professional development programmes.

Hospitals and health services need guidance so that the current workforce is efficiently deployed to maximise the use of existing personnel and facilities. Surgical standards should not be compromised to fulfil dubious manpower demands by inefficient health services.

As surgeons, we welcome a whole industry that has grown up committed to assisting in the maintenance and enhancing of surgical standards and practice. The NH&MRC develops practice guidelines based on evidence based medicine. The New South Wales Health Department has established the Institute of Clinical Excellence, or ICE, in co-operation with the National Safety and Quality Council. The Australian Council on Health Care Standards has devoted time and expertise in promoting health care standards across the board.

All these activities demand huge amounts of time and resources - financial resources and time of the clinicians - and this is expended on quality assurance programmes like the mortality and morbidity meetings most of us now hold at least every two weeks in our hospital departments.

It is a great failure of the system, in that the ultimate quality assurance safeguard - as we heard this morning - the post mortem examination, has largely been abandoned by our health systems and hospital administrations. All the other quality programmes are trivial compared with the rigor of independent post mortems, and if the authorities are serious about quality control, and improved safety in the health service delivery, that anomaly has to be addressed.

Thank you, Mr. Chairman