Problems with GEMPs (article)

[UsydGrad]

Again, I recommend flipping through all the proceedings of this conference.

http://www.adf.com.au/archive.php?doc_id=120


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

Emerging Problems With Graduate Medical Education: An Academic Surgical Perspective
Professor John Preston Harris
Lecturer, Sydney University Medical School

CHAIRMAN: The last speaker on this session today is Professor John Harris, who is a Profession of Vascular Surgery at Royal Prince Alfred and shares the division of surgery

PROF HARRIS: The usual preamble, these views I'm about to express are personal ones and don't reflect either my department or my university but I'm offering them in a constructive sense, that they may add value to the discussion today and I'd really like to offer this from the perspective of an academic who is active clinically for a variety of ways, through my own college and through my own university, being active in educational matters.

I'd like to touch a little bit on some themes that have already been addressed this morning, a little bit on the aims of medical education, talk a little bit about trends and outcome, touch on the issue of student assessment, ranking and honours, raise to your attention the implications of age, and proffer a few suggestions.

If you look at the opening paragraph in the Australian Medical Council - of the goals and objectives of basics medical education - it encompasses the things that doctors might do and it is basically a pot pourri of all things to all men. Lost somewhere in there is that doctors must be able to care for individual patients by treating illness. And I think one of the things I'd like to come to is that the emphasis on one-on-one doctoring is one of the things that has been diluted in the current process.

We have already seen this in the review that Helen gave of the programme at the University of Sydney where there are four broad themes on basic clinical sciences - community and doctor, patient/doctor, personal and professional development. But in there somewhere or other is the ability of a doctor to care for an individual patient.

We have already heard a little about this survey undertaken by three non clinicians comparing the outcome of the traditional medical programme, the undergraduate medical programme before the introduction of the graduate medical programme in 2001. I guess one of the things - this is the dynamic of curriculum change which is probably healthy. I would argue that some of these benefits basically reflect the holistic aspect of medical care and may be achieved just with increasing maturity and age, which I'll come to in a moment. But the key things really are that the things that score lowest in this survey - and you're looking at the issue related to the graduate medical programme - really is on patient management and understanding science.
So I think we should reaffirm the aims of medical education which basically, in my view, should be to prepare young doctors to serve the Australian community as clinicians, and lesser but important aims of the doctor as a social engineer and the doctor as a scientist and researcher.

I think there are some people being badly hurt by the existing programme. With the graduate medical programme, if someone has a vocation to undertake medicine, they undertake a pre-med degree which may be arts, science or whatever. Then if they pass that and they get through the GAMSAT and all the other hurdles they may enter medicine and embark on a four year medical programme. However, if their vocation was to do medicine and they embark on this dog leg of doing a three year pre-med degree, which may not have been their choice had they known they weren't getting into medicine, they miss out. They are not represented and I don't know what the implications of this are for their own opportunities which have been lost and some time wasted.

You could argue that the entry point to the graduate medical programme now is essentially coming through medical science, and that the other broader pathways that were meant to be part of this programme are dropping aside. So in a sense you are having three years of basic clinical science before the entry into the graduate programme, and I think some of the potential advantage of the broader based entry has been lost.

As we've moved with the graduate medical education, we've moved away from the bedside teaching that many of us grew up in, where the relationship was between the individual clinician and student, that we had more than our share of didactic lectures and basic science, but we approached the bedside with that background and we learnt the basics of history taking and physical examination. Now rather than the bedside, the students are usually assembled in a tutorial room with self directed learning, focusing on problem based learning, usually with a non clinician facilitator, and an emphasis on societal skill and lifelong learning. In the 1960's 75% of clinical training was round the bedside. In the US it was less than 16% in the late 1990's. I suspect it might even be lower in some of our settings.

So in ascendency we have the role of the medical educator, we have increased use of computer based health care educational resources and an emphasis on the public health rather than the medical practitioner. And in decline is the clinical based teaching, the clinical content of the modern curriculum, and I draw your attention to a particular concern which is world wide and not unique to Australia - the decline of the role of university clinical academic departments and the decease of interest in the academic career paths.

Using anatomy as a quick example, traditional undergraduate dissections basically are no longer sustainable in our medical schools for cost, time constraints, loss of really experienced and skilled staff, and innovative programmes have been offered as an alternative. If we look at the various clinical schools in New Zealand and Australia, only three - and two of those are in New Zealand - still offer dissection. If you look at the shift, when we went through we did about 500 hours of undergraduate anatomy which you could argue is probably excessive, but I contend that the 65 hours at the moment is probably too little, and certainly less than our science or chiropractors are doing.

cont. (too long to post)

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[UsydGrad]

The implications - medical litigation based on anatomic error not just by surgeons, by basic clinicians, is becoming of concern, certainly in the UK, and Reg McKey has made the comment which I'll leave for you to read that, fundamentally future doctors may be proficient in general and societal aspects of medicine but it would seem their knowledge of the basic facts of anatomy, physiology and pathology may be wanting. And I think that reflects some of the concern leading up to the implementation of this particular symposium. Again, it's getting the balance right. I would agree that the anatomy learnt in 500 hours of dissection is excessive but I would contend what we are doing at the moment is minimalistic and we've basically potentially thrown the baby out with the bath water.

The implications of medical manpower will be touched on later. I want you to watch this number in the top right hand corner of the slide. The number of practising doctors in Australia, the ratio of specialists to general practitioners which is about .81 at the moment, and the distribution of --- these are the major specialties in Australia. If you look at that and then you look at your curriculum, the pattern of clinical practice is not reflected in the makeup of the curriculum which we currently offer our students. And from a surgical perspective I'd point out that it's still a pretty important discipline.

This is the one I wanted you to watch. There's a dip there in 1995/96 related to the introduction of the GMP programmes, but there's been a steady increase in the number of medical school commencements, with 1700 odd in 2004. Overseas trained doctors coming through the AMC process - 519, an increase. This particularly concerning one, where temporary resident doctor arrivals are up over 3,000, and I have ethical concern about a society like ours being so dependent on external sources of medical manpower.

To touch a little bit on student assessment, rank and honours - in the five year programme that I went through honours was based on cumulative success in subjects so there was an incentive to exceed and excel in subjects. In the current programme you can put up your hand to do a programme for honours which is unrelated to your core programme and in my view is distracting from the main programme, and it is possible for a very mediocre student to get honours. Further, there is now no university medal so we don't reward excellence in our programme, and between 1997 and 2002 that was reflected in the year book being dropped, and I'm sure many of you will remember how valuable that document becomes in years looking back on your medical training. It has now thankfully been reintroduced.

With surgery - and I point out that our graduates come out of our programme still MBBS, the surgical content - the general surgical content - is covered in a 32 week block with 16 topics which involve one lecture and one tutorial, and there is some clinical exposure through an integrated clinical attachment to a ward.

One of the problems we've got, and we talked a little bit about assessment - this is formative assessment of last year's Year 3 surgery, and the bulk of students did fine. But attendance for this formative assessment is voluntary and only 31 turned up. The results are anonymous, and there were 11 students whose performance was unsatisfactory, and I don't know who they are. It is left up to that individual student to seek remedial preparation before their barrier exam.

So in the absence of ranking, and with a fail/pass or a satisfactory/unsatisfactory system, how do you sift out the poor student and how do you reward the good student. In the absence of objective criteria how do you fairly rank people for residency placement, selection into speciality training, and award honours.

I'd like to talk a little bit about age. When I went through you did the Leaving Certificate and then you went into medicine, and basically the medical course at that time was six years, which is eleven. With the HSC there is an additional year, with pre-med there's three, with the graduate medical programme there's four. Students often take a break during this time for good reasons and they travel or whatever. But the result of it is that their mean age of graduation is 29, and if they've then got to do a four to seven year specialty programme they enter their definitive vocation at 33 or 36. If you look at the working hours of doctors you can see the effective professional lifetime of a medical practitioner basically starts to taper off after 55 or so. So if we've got folk coming into definitive vocations at 33 or 35, the return that society is getting for that training is not what it might perhaps be. The curve is not a normal distribution. This is the breakdown of ages from graduation of the Sydney Graduate programme. The implications of that, of someone coming in at that age, are extreme, being equivalent in terms of HEX placements - again must cause concern.

In my view there are implications of age. 14% of people are over 35 at graduation. I believe that affects their vocational choice and has implications because of the length of specialty training, and they have a short effective practice life and you have to wonder about the return to the taxpayer. For the individuals caught up in this process, I think it has implications for their financial wellbeing, for housing and for family. For surgeons, if you are looking at hand/eye skills, elite performance really relates to the age at which you are first exposed to something and the amount of practice. Our Surgeon-in-Chief in the college has estimated it takes 10,000 hours to become a competent surgeon. With musicians of course, if they don't start learning by 5 or 9 they're not going to make it. I contend that you're not expecting people to learn surgery at 5 or 9, but I don't believe they should be learning surgery in their 30's, as the initial start to that profession.

The editor of the Medical Journal of Australia, I think, encapsulates I guess what a lot of us are feeling about this process, and I'll just read it. "And herein lies the rub. Despite continued calls for educational research that matters, the medical education community has yet to report solid evidence to support the intentions of these resource intensive changes. The profession, hardened by evidence-based medicine movement, expects no less." And that was written in 2004.

So the way forward. I think we need to re-emphasise clinical training in our programme as the prime role of our preparation of doctors who serve the community. The other aspects of training and professional behaviour are important but not as important. I think we need to base our curriculum more on feedback from the students and from doctors in practice about what they need to learn from our universities and our training programmes. I think there needs to be a fusion of resources and skills between our colleges and our universities and I think we need to think about our medical school entry based upon realistic projections of work-force needs in this country, and not poach off other places which I think, in my mind, raises ethical issues. I think we need to look at seriously shortening medical education and look at early streaming of medical training. Then we need to use these newer education tools, in terms of skill centres, simulators and instruction things, but also to look at ways in which students can be greatly exposed to patients, and the mentor system we heard about earlier is a good way to do that.

Finally, I draw to your attention the impending demise of clinical academic departments which, at the end of the day, may be the most major issue that we need to face. Thank you very much.

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[flindophile]

I attended that conference.

You should have posted some of the discussion about why the GEMP programs were started in the first place. While there is controversy about the GEMP programs, I hardly think there is a consensus on this topic. It may be true that the GEMP programs have swung too far in the direction away from hard science; however, I doubt that many people would advocate returning to the preGEMP curriculum.

The deemphasis on the hard sciences in the GEMP programs is an area of concern. It struck me that many of the complaints regarding the GEMP programs are not founded on impressions rather than data. There is a vague sense that students have a different knowledge base and that they are trained differently; however, there is no data to show that this is an impact on overall capabilities. Unfortunately (or perhaps fortunately) Australia does not have standardized national exams so it is difficult to make comparisons between training methods. Also, most people recognize that standardized tests like the USMLE only assess certain dimensions of competence. It is unclear whether significant differences exist and, if they do, whether they matter.

The conference also discussed changes in funding which have decreased the teaching time available. This was also a major area of concern.

Any organizational change creates winners and losers -- and it is reasonable to expect those whose political capital has declined to complain. Thus, the conference was heavily attended by anatomists who have been rendered "less valuable" by the new curricula. This is to be expected.

I think the GEMP programs have pleny of room for improvement but I think the title "Rescuing Medical Education" is silly and alarmist.

 

[UsydGrad]

It is often acknowledged that GEMPs came into being to give Whites a better chance to pursue medicine.

When Australia abandoned its "Whites Only" immigration policy for fear that its population would wither away, many people from Asian nations immigrated to Australia. Their kids went to school in Australia. Many of these kids did very well, acheiving high HCS scores out of proportion to their representation.

When HSC scores were the primary basis for admission to medical school, they went to medical school. And these medical schools filled up with the children of Asian immigrants. (So, something had to be done! Enter the GEMP movement.) Many were pushed by their parents (some of whom had pretty difficult lives) to take advantage of the opportunity to go to medical school.

I know many excellent doctors who, when asked why they went to medical school, will tell you that their parents pushed them and they never really gave it much thought at the time but they are happy with the outcome. What is wrong with parents wanting "better lives" for their children?

I think comments of GEMP devotees (and others) about the "old" system being populated with Asians with tape recorders needing translators are a bit offensive and even racist. These "Asians" were Australian citizens (often Australian born) who went through the Australian school system and scored high on the HCS. If by chance any of these brilliant 17 or 18 year olds had any difficulty with English, that could have been easily remedied in a short period of time! Anyway, many are now registrars and clinicians and I have yet to meet any that have a problem with English.

[Change does not have to be a zero-sum game!]

 

[Off2Oz]

"So if we've got folk coming into definitive vocations at 33 or 35, the return that society is getting for that training is not what it might perhaps be."

I'm not overly well versed on the topic USydGrad is speaking to, but I wonder about this excerpt..

Would society benefit more from a bitter engineer who dislikes his field and practices for 30 years than it would from a doctor who enjoys what he does for a mere 25 years? Interesting logic. Makes me wonder about the soundness of the rest of the reasoning.

Blech. I may be a little off topic here. But hey, I just got off a 6 day, 60 hour work week (as an engineer), and I'm both bitter and tired. =)

M.

P.S. This last week was a normal one. =(

 

[Nora]

I hear ya. Who says that every doctor works 30 years and then retires. I've seen young kids 23, 24 finishing medical and professing that they will never practice medicine and I've seen doctors practice till their 70s or 80s. Everyone lies in the middle of this, but it is no longer a given for people to stop working for the perpetual holiday of 30 years since we're living so long nowadays. I'd much rather see a doctor freshly graduated who loves what he does and devoted to his calling no matter the age, than my 38 year old burnt out family doctor who became an MD at 24. He doesn't let a single chance go without telling us how much he looks forward to leaving the profession in a couple of years.

 

[UsydGrad]

While it may be unpalatable to some, the reasoning is incredibly logical. This is also currently a big issue in the United States where there is a bias against older (25+) applicants to medical school for this and/or strongly related reasons (ie. career changing). Could this be why many are ending up as fee-paying international students in Australia where as long as you are paying your way, supporting their system and leaving when you are finished (or a year or so thereafter), age is not really relevant?

I believe the mandatory retirement age in Australia was outlawed in 1995. However, there is a strong social expectation (especially in medicine) that you retire at 65 (to make way for the next generation). I don't think you'll find many Michael DeBakeys in Australia! [A transplanted Texan born 1908, often described as "the father of heart surgery", 60,000 operations (as of 2001), 20,000 of them heart surgeries. I am not aware that he has retired from medicine. Also from Texas, there is Denton Cooley, also a heart surgeon, born 1920, who claims to have done 100,000 operations.] In general, "social expectations" in Australia seem a bit more important than in the US!

What evidence is there that a "bitter engineer" is going to be any less bitter as a doctor? Is a medical career the ticket to happiness? From a social standpoint (and this IS socialized medicine), it is more expensive to train a doctor than an engineer.

"So if we've got folk coming into definitive vocations at 33 or 35, the return that society is getting for that training is not what it might perhaps be."

Would society benefit more from a bitter engineer who dislikes his field and practices for 30 years than it would from a doctor who enjoys what he does for a mere 25 years? Interesting logic. Makes me wonder about the soundness of the rest of the reasoning.

 

[pitman]

It is often acknowledged that GEMPs came into being to give Whites a better chance to pursue medicine.

...only by deluded conspiracy theorists. What a load of crap.

They came into being just as they did (at the same time, mind you) in the UK: 1) to enlarge the pool of future docs via enlarging the pool of candidates (since Australia has been anticipating the current shortages since the '70s and finally got the govt to start doing something about them beyond importing docs); 2) b.c. of understood value of older students w/ degrees + experience; 3) to help lure full-fee N. Americans when apps there were at record highs, and schools here were teetering on bankruptcy (there were some interesting papers going around on this mid-90s when Flinders was slated to become the first grad entry school); 4) as part of the general move in the Commonwealth against the tradition of rigidly defining careers by age 17-19.

 

[pitman]

Could this be why many are ending up as fee-paying international students in Australia where as long as you are paying your way, supporting their system and leaving when you are finished (or a year or so thereafter), age is not really relevant?

If you're speaking for your own alma of years past, then do qualify (and quantify) this claim, otherwise you're reaching: UQ (w/ 2nd largest intake of intl's in Oz) has only 2 int'ls over the age of 30 out of >50 this year (<4%). Last year it had 1 (me, 3%). Hardly supportive of the claim of older students coming here b.c. they're too old for US, nor supportive of the notion that older int'ls are relatively more welcome here b.c. they'll likely leave.

In fact, in my class of over 300, there are about 10 total students over 30 (3%), w/ the ave age = 23... I'd think pretty similar to what's found in US schools. And the two oldest in the class (I believe both in their 40s) are domestic.

I'll ask my friends at USyd to determine the age range of int'ls there, too, if you'd like.

-pitman

 

[pitman]

I believe the mandatory retirement age in Australia was outlawed in 1995. However, there is a strong social expectation (especially in medicine) that you retire at 65 (to make way for the next generation).

There's a shortage of docs here, so not much pressure to "make way for the next generation" for the sake of economy.

Just as in the US, there is some pressure to retire as a doc at a reasonable age, but an important reason is to assure competency in a career abolutely requiring lifelong learning, in a field where so much of the knowledge routinely changes. In *this* sense I'd agree that older docs are being asked to "make way...".

 

[Winged Scapula]

This is also currently a big issue in the United States where there is a bias against older (25+) applicants to medical school for exactly this reason.

I'm not aware of any reliable studies in the US or even anecdotes that older students (25+ as defined by you) are less preferred simply because of their age.

I do agree that students in their late 30s and above probably do face some bias simply because of their age - however, in speaking with faculty it has relatively little to do with the cost-benefit ratio of less years in practice but rather concerns about the ability to physically and mentally keep up with the younger kids.

That said however, the bias in younger/older applicants (ie, < 35) is not likely due to age but rather the fact that a large number of these individual have changed careers (which usually raises some eyebrows), may have had some early academic difficulties or lack of direction which causes Adcoms to think twice.

 

[UsydGrad]

Good point.

It would be quite difficult to do a "study" on this due to legal implications. It would be a problem to admit to age discrimination.

Most older applicants are probably changing careers or changing their mind about which career to pursue. Unless they have done absolutely nothing (or been in jail) and this too might "raise eyebrows". I agree, any bias may not be due to age itself. Bias against career changers (and those with multiple degrees) would effectively be a bias against older applicants.

If older older applicants are unable to "physically and mentally keep up", wouldn't they offer less benefit for the cost incurred training them? After all, that student is taking a space that could have been offered to a student who would be more likely to be able to "physically and mentally keep up" and all that entails.

I find it hard to believe that the perceived future benefit to society in terms of career longevity and contribution to medicine would play no role in the selection process.

I'm not aware of any reliable studies in the US or even anecdotes that older students (25+ as defined by you) are less preferred simply because of their age.

I do agree that students in their late 30s and above probably do face some bias simply because of their age - however, in speaking with faculty it has relatively little to do with the cost-benefit ratio of less years in practice but rather concerns about the ability to physically and mentally keep up with the younger kids.

That said however, the bias in younger/older applicants (ie, < 35) is not likely due to age but rather the fact that a large number of these individual have changed careers (which usually raises some eyebrows), may have had some early academic difficulties or lack of direction which causes Adcoms to think twice.

 

[Winged Scapula]

Good point.

It would be quite difficult to do a "study" on this due to legal implications. It would be a problem to admit to age discrimination.

Most older applicants are probably changing careers or changing their mind about which career to pursue. Unless they have done absolutely nothing and this too might "raise eyebrows". I agree, any bias may not be due to age itself. Bias against career changers (and those with multiple degrees) would effectively be a bias against older applicants.

If older older applicants are unable to "physically and mentally keep up", wouldn't they offer less benefit for the cost incurred training them?

I find it hard to believe that the perceived future benefit to society in terms of career longevity and contribution to medicine would play no role in the selection process.

Obivously a difficult study to design and admitting to age bias wouldn't serve the participants well.

I'm sure there is some bias against older applicants because of fears that they wouldn't contribute as many years to the work force as their younger counterparts. I'm sure those medical students in their 40s and 50s would argue that this wasn't a factor in their acceptance, but I'm sure it was discussed. I just felt that there were so many factors/reasons why older applicants have a harder time getting accepted that we couldn't pin it on their age alone.

 

[UsydGrad]

I just felt that there were so many factors/reasons why older applicants have a harder time getting accepted that we couldn't pin it on their age alone.

Most certainly!

If you seem a sure bet for a Nobel prize, age all the sudden doesn't matter.

 

[UsydGrad]

my 38 year old burnt out family doctor who became an MD at 24. He doesn't let a single chance go without telling us how much he looks forward to leaving the profession in a couple of years.

I've had supervisors like that. It's a bit annoying to have to listen to it.

I don't think your GP should be discussing his personal problems with you. He's the doctor, you're the patient. I'm not sure where you live or what kind or what kind of "plan" you may be on. But, if you are not satisfied with the service you are receiving, you may want to consider changing doctors if you have any choice in the matter.