Competency Based Training in Medical Education

Australian Medical Council - competency based training workshop
Sydney 21 April 2009

This week I participated in a workshop with the Australian Medical Council (AMC) that to consider the degree to which competency based training is currently used and how it could be used to improve medical education across the continuum from undergraduate to continuing professional development for those practicing independently.

There is considerable momentum behind the move toward Competency Based Training (CBT). Consumers have long held the view that medical education needs to focus on the broader notion of what it means to be competent and that consumers have a role in developing the standards.

The AMC is to be commended for bringing together such a variety of professionals who have expertise and interests in developing the education of medical professionals. The participants were described by Ian Frank, CEO of the AMC, to be "everybody who is anybody in medical education". There were around 75 participants as well as AMC staff who made it all happen. They included medical schools, state and commonwealth health departments, medical students association, medical boards, and representatives of Colleges, (including CEOs, Presidents, Past Presidents and Chief Examiners). And one consumer representative (me).

The AMC convened a plenary session during which three speakers focussed on different elements. Professor David Prideaux, Profession of Medical Education at Flinders Medical School, Prof Royce Sadler, Professor of Higher Education at Griffith University and expertise in formative assessment and learning and Peter White, CEO of Royal Australian and New Zealand College of Obstetricians and Gynaecologists. I think there was scope to include the consumer perspective of competence in this section and I know a number of consumer advocates who could have contributed to this session. I would encourage the AMC to be more inclusive of consumers and the consumer perspective in workshops such as this one.

Prof Prideaux referred to Lawrence Stenhouse’s work from the 1970s in which four functions of education were identified: training (skills and procedure); instruction (facts and protocols); induction (thinking and reasoning) and initiation (professional milieu, or the vibe). CBT fits well with the functions of training and instruction. You can define the skills, procedures and facts, then test the level of attainment with a range of reliable and valid assessment tools. CBT does not work well to measure the functions of induction and initiation. An outcomes approach needs to be developed for these.

Professor Sadler reflected on the political and historical roots of CBT and how competence is a word people warm to but is not easy to define. He also spoke about the difficulty in determining the appropriate degree of specificity. If the list of competencies is too atomistic they can lose sight of what you are trying to achieve: competent doctors.

I found that there is a reasonable degree of common ground between doctors and consumers on what competency means: that a doctor is safe to practice independently and that they possess the insight to reflect on their practice and know when they have reached the limit of their expertise and knowledge. The difficulty is in defining the technical aspects of competence in such a way that the explicitly refer to the holistic view of competency. There was emphasis placed on the need to take a holistic view of competence rather than reduce this to the specific elements. These broad attributes and competencies can be articulated but there is significant difficulty in assessing and determining the degree to which competencies have been acquired. Prof Prideaux spoke about the need to get terminology right. Competency based training works best at the macro level and warned against reducing competency to small chunks. While the more specific the skills the more easily they can be measured you run the significant risk of losing the big picture and the degree to which the trainee or practitioner has attained the global competencies. To date undergraduate medical education has managed to fend off the move to the technical competencies with a focus on inquiry learning, case studies, patient centered authentic learning and development of clinical reasoning.

One of the concerns participants expressed strongly was the potential for CMT to reduce the amount of time it takes to complete the training to become a doctor. The push for CBT it seems is from government who see that reduction in the time spent in training may alleviate the workforce shortage issues. There seems to be agreement in the profession that this is not necessarily the best thing for the quality of doctors. Doctors work off pattern recognition and by seeing lots of clinical cases they develop the ability to recognise symptoms. Their concern is that a reduction in the time taken to complete the training may compromise their level of experience.

Take away messages

• There is a need to get the terminology right and to define what is meant by competence, a competent practitioner and competency based training
• There is a preference for a program of assessment rather a number of high stakes tests. This could include progress testing, clinical reasoning, work based assessment and global rating of students by experienced clinicians.
• Educational panaceas come and go. In the enthusiasm (and pressure) to adopt CBT do not lose sight of the big picture: medical education needs to deliver to the profession and the public people who are competent in doing what they are trained for.

The debate is an excellent opportunity to look at what medical education is all about. Consumers need to be involved with this and I would encourage Colleges and the AMC to engage with the consumer movement.

GP Task Force

The GP Taskforce has been charged with the responsibility of investigating options and innovations for improving access to primary health care in the ACT and reporting back to the ACT Legislative Assembly in September 2009 with its recommendations.

The Taskforce is jointly chaired by Ross O'Donoughue, Executive Director, Policy Division, ACT Health and Dr Clare Willington, GP Advisor to ACT Health. Ms Janne Graham is the consumer representative on the Task Force and is being supported by HCCA. Further details of membership is available online.

The Terms of Reference include the review and consolidation of work already undertaken by the ACT and Commonwealth governments on access to primary care services in the ACT and the exploration and recommendation on legislative options to protect the rights of patients and the health workforce. It also includes consideration and recommendations on provisions to improve access to primary care services for vulnerable populations, including the aged, people with mental illness and the isolated.

The GP Taskforce has had reasonable coverage in the Canberra Times, Sydney Morning Herald and the ABC.

Response to Walk-in Centres Discussion Paper Feedback Report

The Minister for Health, Katy Gallagher, this week released the Feedback Report from the community consultation process. The Walk in Centres - Discussion Paper Feedback Report (02 April, 2009) (PDF File - 516k) is available online.

The HCCA Submission in response to the discussion paper is available online. We also posted to the HCCA blog on this.

HCCA strongly supports additional community based primary health care – the Walk-in Centres have the potential to be a valuable complement to existing services.

The ACT Health Feedback Report has reported on both the possible benefits and concerns that submissions expressed. A number of the concerns relate to the lack of specificity in the possible models of care and locations. This was certainly a concern we expressed in our submission. We would like to see a number of issues addressed early in the development of the walk-in centre concept including:

• Will there be out of pockets costs for consumers in accessing the service?
• Will the centres have an on-going treatment role?
• If not, what range of services will be provided and how will this be determined?
• And what processes will be in place to ensure consumers experience a seamless transition between services such as GPs, ED and community based services?

HCCA believes that while the feedback indicates overwhelming support for the concept of the centres, the next stage should be the identification and development of walk in clinics with models of care and services that are appropriate to the communities to be served.

The consultation process on the centres so far has been encouraging. There remains, however, considerable work to put the concept into effect. Consultation is a critical element in the planning of such community facilities. HCCA urges the Government to continue close consultation with the community, consumers and health care providers in the further development and implementation of the centres.

The offer of partnerships from a number of organisations is a positive sign that provides a basis for the Government to move forward.

HCCA sees the need for extensive monitoring of the effect of walk-in centres on those issues that concerned respondents, such as the impact on the existing health workforce and community pharmacies and GP practices. The monitoring should also provide the basis for a proper evaluation of the introduction of walk-in centres. We would also like to see evaluation on the appropriateness and effectiveness of the care provided to consumers.

HCCA would like to see the services provided to be tailored to the needs of the community at the specific location. The workforce options of multidisciplinary teams, nurse-led or GP practice teams need to be explored in relation in individual walk-in centres so that the service model meets the needs of the community.

The Minister’s response to the Feedback Report is generally positive although we would have liked to see stronger commitment to further consultation with consumers in establishing the models of care and to evaluation of the walk-in centres.

HCCA looks forward to further involvement with the Government in the development and implementation of walk-in centres.

Reflections on Private Health Insurance

Recently we have had a number of members ask about the value of private health insurance for their particular circumstance. We are not able to provide specific advice about this but have pointed members to a range of online materials that could further inform them.

The Private Health Insurance Administration Council (PHIAC) has produced a booked let Insure? Not Insure? that is available in html version and Pdf (455kb). This document has a useful list of questions to ask your insurer such as:

• Will my hospital cover provide benefits for all procedures or types of treatment?
• Which hospital treatments will not be covered by this policy?
• Is ambulance cover included with my hospital cover?
• Which operations are considered elective?

The website for researching private health insurance products is run by the private health insurance ombudsman's office, and consumers associated with the Consumers' Health Forum assisted that office to make the website as user friendly as possible.

The Consumers Health Forum of Australia has completed work on private health insurance with a focus on key initiatives under the private health insurance reforms. These initiatives include: informed financial consent arrangements; the consumer information website administered by the Private Health Insurance Ombudsman; the introduction of broader health cover; and the review of prostheses listing arrangements.

One of the issues affecting consumers we identified last year was ambulance cover. ACT residents do not receive free ambulance service unless they hold an ACT Pensioner Concession or Health Care card. ACT residents are however, covered for ambulance services provided within the ACT as a result of a road traffic accident – through the road rescue fee levied on vehicle registration. Medicare does not cover the cost of ambulance services. Private health insurance policies usually cover ambulance services – but we suggest you check with your health fund.

The Health Minister Roxon was very clear at the recent AHCRA summit that the Private Health Insurance rebate is here to stay but we wonder whether given the current budget issues and the renewed call for need to address middle class welfare how long the government can sustain this. We will be interested to see the federal budget.

With the private health insurance rebate it stops being only a health decision but rather becomes more of an economic one. However the financial benefits only outweigh the direct costs for those people who are medium to high income earners.

A submission to the National Health and Hospitals Reform Commission by Peter Collins, previously NSW Liberal Minister for Health, makes interesting reading:

“… An idea for making the health system work properly. Calculate what Medicare levy percentage would be required from year to year the would need to be applied to everybody’s income so as to completely cover all medical expenses that are currently covered by both the Medicare public system and the private health system and then completely remove the private health insurance system. This way all costs would be covered, everyone would be covered and everyone would pay for the system at a rate at which there income level can support.
This may seem simplified but I believe the system at present is complicated with the private health system and quite often people just can’t afford private health insurance and probably can even less afford it if they are in need of the coverage because of poor health.”

The Private Health Insurance Administration Council (PHIAC) has published the results of the annual survey of privately insured persons for hospital treatment benefits by State and Territory as at 31 December each year from 1998 to 2008. These tables provide the statistics (i.e., the numbers of people who are covered by private health insurance) but do not provide analysis.

AHCRA Summit March 2009: response to the NHHRC Interim Report

Last week I attended the Australian Health Care Reform Alliance (AHCRA) Summit in Melbourne.

The purpose of the Summit was to develop the AHCRA response to the Interim Report of the National Health and Hospital Reform Commission. The Summit was very well supported by the membership of the Alliance with clinicians, academics, lobby groups and consumers present. There were a range of presentations and then discussion groups based on a range of questions central to the presentations (called World Cafe conversational process).

On Day 1 Dr Christine Bennett (Chair, NHHRC) provided an overview of the Interim Report and we had the opportunity to ask questions. Dr Joanne Holt, Secretariat to the Commission participated for the two days of the Summit and was very interested to hear a range of views.

Participants were very supportive of proposals for one national health system (rather than the eight systems funded by nine governments we currently have) and the much stronger focus on primary health care.

Equity was a theme that resonated strongly through all discussions and presentations at the summit. This is hardly surprising given that AHCRA holds dear the notion of equity and has been a strong advocate that any reform must ensure equity. This principle was expressed strongly regarding the equity (and efficiency) of the private health insurance rebate.

The Summit recognised that the effect of the social determinants of health on health outcomes was crucial and should be a priority in public policy planning and would like to see the NHHRC reflect this more strongly. Professor Leonie Segal, a health economist form university of South Australia, spoke about the equity and efficiency of our health system. Professor Fran Baum, Member of the World Health Organisation Commission on the Social Determinants of Health spoke about linking health policy to the social determinants of health and health equity. She shared a quote from Dr Margaret Chan, Director General of the World Health Organisation on the need to embed the social determinants of health in all government policy:

“The Commission's main finding is straightforward. The social conditions in which people are born, live, and work are the single most important determinant of good health or ill health, of a long and productive life, or a short and miserable one. … This ends the debate decisively. Health care is an important determinant of health. Lifestyles are important determinants of health. … But, let me emphasize, it is factors in the social environment that determine access to health services and influence lifestyle choices in the first place”.

This quote resonated strongly with participants and framed much of the discussion at the Summit.

Meaningful community engagement was another theme that emerged. We were privileged that Dr Mick Adams (Chair, NACCHO) and Paula Arnol (Danila Dilba Health Service) were able to participate and share their experience of aboriginal community controlled health services. Rom Mokak (CEO, Australian Indigenous Doctors' Association). They spoke about the need for capacity development to ensure communities are able to engagement meaningfully in identifying health needs, planning, monitoring and evaluating policies and services, developing and implementing governance structures and sustaining this level of engagement. Paula Arnold spoke about the Katherine West Health Board as an example of successful community engagement.

Comprehensive Primary Care is promoted in the Interim Report as the necessary reform in the Australian health system. There was considerable discussion about what the essential elements of comprehensive primary care. The NHRRC defines primary care quite simplistically as "the first level of care". Participants drew on their own experiences as consumers, clinicians, researchers and policy makers to flesh this out. This included universal accessible health care, community based services and the importance of continuity of care. Professor Claire Jackson (Chair of the Primary Health Care Strategy Expert Reference Group) and Professor Michael Kidd (Dean, Flinders Medical School) in their presentation on primary care drew our attention to the definition contained in the National Aboriginal Health Strategy (1989) as they considered this to include the essential elements of comprehensive primary care.

“Essential health care based on practical, scientifically sound, socially and culturally acceptable methods and technology made universally accessible to individuals and families in the communities in which they live through their full participation at every stage of development in the spirit of self-reliance and self-determination.”

Participants argued for the inclusion of oral health into primary care rather than continue the strangely entrenched separation of oral health (including dental) in the proposed establishment of Denticare. We argued for step-up Step-down facilities to be included in comprehensive primary care rather than continuing to see this as transition care and by default being attached to the acute setting.

Super clinics and comprehensive primary health care

The government is committed to 31 super clinics. The strong message was that communities need to be involved in establishing these clinics to ensure that the comprehensive primary care services will meet the needs of the community. Concerns were expressed also around safeguarding these centres from the further corporatisation of primary care. The community must be enabled to play a critical role in the selection of providers through the tender process and then the ongoing monitoring the performance of these super clinics.

Regional Health Authorities

Participants agreed that the health system should be driven by population /consumer/community needs, not by those of providers. One way this can be strengthened is acceptance of the NHHRC Option B, to establish regional health authorities. This option had strongest support from participants. The regional health authorities would have funding allocated on basis of demonstrated need of the community. A population size of approx. 100,000 to 500,000 would allow local responsiveness, but have a critical population mass to support primary and secondary services.

Funding models

There was considerable agreement bet ween participants that the most equitable and efficient way to fund health care is through a universal health system funded through taxation. Participants expressed the view that the system needs to move away from fee-for service payments and consumer payments, towards a blended system with significant payments for the total health care needs of a population, based on voluntary enrolment.

The presentations are available online at the AHCRA website.