Introduction
For the newly serving Medical Officer in the ADF (ADF MO), professional progression opportunities are both in rank and in competency level (CL). The requirements for promotion in rank and the means of achieving the requirements are fairly well defined, assessed regularly and supported by the Military infrastructure as the time honoured way of professional progression. This is not well suited for the clinician who must consider maintaining parity with civilian standards. In recent years the Competency Level system has been developed to respond to this dual loyalty in professional development that confronts Medical Officers. It is also employed in other specialist streams in the military for which there are direct civilian standards and comparators of progress.
While a step forward for dealing with competing professional development issues for Medical Officers, this system of progression to a competency level of unsupervised practice is less well supported. This paper examines the pathways, problems and solutions for ADF MO progressing to CL3 – a Medical Officer able to practise unsupervised in primary health care having met and continuing to maintain the requirements of one of the civilian Primary Health Care Colleges in addition to military and military medical training relevant to their rank and position.
Background
In Australia, doctors who wish to pursue a career in primary health care may enter the Australian General Practice Training (AGPT) program funded by General Practice Education and Training Ltd (GPET) and administered through Regional Training Providers (RTPs) based in rural, regional and metropolitan areas of Australia. Of course they may undertake to construct their own program and, after a suitable period of time in practice, attempt the examination; however this path is not supported by provisional vocational registration which a GPET trainee enjoys and the pass rate for the final examination is lower than those being guided through the AGPT pathway.1 The ADF MO will be eligible for Competency Level 2 once they have completed initial officer training, military medical training relevant to their Service, basic emergency management training and a short period of supervised civilian clinical practice. This level (CL2) includes MO who are deployable, being able to practise under remote supervision. They are at this level expected to enter (or have entered) an approved postgraduate training program. The majority will enter postgraduate medical training in primary health care: the AGPT Program towards Fellowship in the Royal Australian College of General Practice (RACGP) or the Australian College of Rural and Remote Medicine (ACRRM). The AGPT program has been constructed to combine education and training with service provision for doctors to progress through a “continuum of education” to “develop their capacity to provide safe and effective medical services to the community”. Thus the AGPT program has two main goals: • to produce competent and confident practitioners able to practise in a variety of settings, including rural and remote areas, and • to provide vocational education and training that assists and prepares registrars to obtain vocational recognition as general practitioners in Australia.2 The AGPT Program supports the ADF requirement for medical, as distinct from military and military medical training, to attain and maintain CL3. It does this by producing confident and competent practitioners able to practise in a variety of settings. Moreover it does it indirectly in that vocational registration in Australia now requires attainment of Fellowship in the RACGP or ACRRM, Colleges, qualifications which specifically meet the ADF requirement for CL3 and require continuing professional development to be maintained, another requirement of CL3.
Doctors choosing to join the AGPT Program apply to both AGPT and a Regional Training Provider (RTP) in their geographic area of Australia. They are interviewed by the RTP using a GPET approved process of multiple mini-interviews and are selected based on merit. Positions are limited on the Program and Regional Training Providers and are capped in the number of Registrars able to be accepted. Australian Defence Force applicants also undergo this process, though are selected as supernumerary Registrars to an RTP. Training is largely experiential, delivered primarily in an apprentice model by accredited supervisors in accredited medical practices and with preapproved courses. The RTP then provides additional educational activities including workshops and visits by external clinical teachers who sit in periodically on consulting sessions with the Registrar in their practice. Philosophically, the program relies upon selfdirected learning as for most adult learning programs. Students are expected to set learning plans guided by the College curricula. They are also guided by Medical Educators in the RTP. The RTP Senior Medical Educator has the final responsibility for verifying that the Registrar has completed training requirements of the Program submitting the Completion of Training (COT) certificate, collated log book and evidence of training to the Colleges for Fellowship. The two Colleges involved, RACGP and ACRRM, set the curricula standards and the end point to determine completion of training and Fellowship.
The Program
The actual Program is basically three years following the Intern Year. At the end of an Australian Medical Intern Year a medical graduate completing sufficient time with appropriate terms in an approved teaching hospital may register as a Medical Practitioner in a State of Australia. Overseas Trained Doctors (OTD) undertake a different pathway which for the purposes of this discussion will not be detailed other than their arrival also at the point of registration as a Medical Practitioner in a State of Australia.
During the Intern Year and next postgraduate year (generally PGY2) the Program requires rotations to be undertaken in Internal Medicine, Surgery and Emergency Medicine with experience in Paediatrics and Obstetrics and Gynaecology. The PGY2 year is referred to as the Core year or Core Clinical Experience, undertaken in a hospital accredited for Intern training. This is referred to as the first year of the Program. Potential Registrars may apply for entry to the Program during their Intern Year, for starting in PGY2, or apply in PGY2 to start the following year. In the latter case they then need to apply through the Senior Medical Educator of their RTP for recognition of prior learning (RPL) for their Core Clinical Year.
Variation in the early Program for ADF Registrars
Some ADF MO are organised to apply during the Intern Year and many apply in PGY2 and then apply for RPL. This is where the first problem arises for the ADF Registrar. AGPT Policy recommends the ADF Registrar undertake three months of supervised civilian general practice during the PGY2 year. This is reinforced by Joint Health Command requirements however, being before a civilian Registrar would normally begin supervised general practice, the ADF Registrar requires particular attention to have this requirement organised and accommodated. As a young doctor yet to be associated with an RTP or even a supernumery Registrar new to an RTP, the level of attention required to accommodate the required organisation and advocacy with training hospitals may not be forthcoming. They then need to try to arrange a civilian GP attachment during their return of Service or thereafter.
The B&A Year
The AGPT Program focuses on the next year (PGY3) when the majority of direct teaching and close supervision occurs. During this year a Registrar would be placed in an accredited training practice with a Supervisor who is on site 80-100% of the time and the Registrar receives three hours of teaching per week during the “Basic Term” in the first six months of this year. In the following term (six months), the “Advanced Term”, the Supervisor is present 50% of the time on site and the Registrar receives one hour teaching per week. During this “B&A” Year, up to four weeks of workshops are delivered by the RTP, covering topics not readily taught by the Supervisor or experiences not received in supervised practice. The Registrar may obtain some of these training on other courses pre-approved by the civilian RTP Medical Educator.
The “Bloody Awful” year for the ADF Registrar?
Of course this third year postgraduate for many ADF MO is their first year of their return of Service. During this year they will undertake initial officer training, military medical courses in health, aeromedical evacuation, underwater medicine, aviation medicine or a combination of these; in addition to emergency medicine courses.
In a very busy year also punctuated by assimilating to military life and being newly introduced to military medical practice after the cocoon of a teaching hospital, the ADF Registrar on the AGPT Program is expected to complete the Basic and Advanced Terms. Needless to say ADF Registrars do not always meet the Program requirements for the B&A Year. Conversely, for civilian Registrars, the B&A year is an intense year of direct support and advocacy by their supervisor, their RTP and the Medical Educators.
Medical Educators
The Policies of the AGPT make much of the role of a Medical Educator as a key person understanding the experience and training needs of Registrars. Further, several specific roles also exist for Medical Educators under the AGPT Policies. In application to the training of ADF Registrars (referenced from AGPT Policies, 2008 as below) these include: – Understanding and considering experience, training and education (s3.1.2.11) – including that obtained during military exercises and deployments – Liaising on behalf of the (ADF) Registrar with relevant Colleges regarding recognition of prior learning (RPL) (s4.1.2.3) – Considering relevance and adequacy of experience and educational activities with a view to approving RPL … (s4.1.2.4) – Determining and assessing the learning needs of the (ADF) Registrar early in training to inform the initial learning plan (s4.2.2) – Assess the structure and content of teaching posts to determine the amount of training time that can be credited to the (ADF) Registrar’s record of training (s5.3.2) – Confirming progression of a Registrar to the next level of training particularly when a term may not have been completed satisfactorily (s4.2.2.6) – Determining appropriate supplementary training to (military) practice experience (s3.1.2.7) – Advising on appropriate extended skills training posts for (ADF) Registrars (s3.1.2.8) – Consultation on discretionary leave requirements for ADF Registrars for Service needs (s3.1.2.9) – With the supervisor, identify, provide feedback and address the areas of concern when a Registrar’s knowledge base or acquisition is apparently not satisfactory (s4.2.2.10&11) – Determining the eligibility of the Registrar for completion of training (with respect to College requirements) in relation to work-based components of the program – which will include a number of military terms and educational experiences (s4.3.2) – Being the first point for discussion of grievances regarding the program and participates in the assessment and review panel (s5.6) Reviewing for exclusion or extension of Registrars in the AGPT program (s5.7 & 5.8)
A Case for Military Medical Educators
Even from the abbreviated list of the tasks for a Medical Educator, their role is evident as being central in understanding the learning experience of the Registrar, guiding them to achieve the stated learning objectives of the AGPT Program.
The AGPT Program recognises that experienced and practicing civilian GPs have a unique mix of educational experience and practical knowledge and experience in the general practice environment to meet this role. Similarly to meet the role for ADF Registrars, Medical Educators and their support structures (the Regional Training Provider) must have that unique mix of educational experience understanding military educational opportunities and practical knowledge and experience in the military practice environment. Notwithstanding the effort and dedication of Medical Educators and RTP, this is not the case for the majority to which ADF Registrars are attached as supernumery Registrars.
Workshops
As discussed, the Program conventionally includes workshops which typically include direct classroom and practical teaching on topics not readily delivered by Supervisors or available in the practice setting. These are organised by the RTP, delivered mostly during the Basic and Advanced terms. For ADF Registrars practicing in the military environment, the topics not readily delivered by Supervisors or available in the military practice setting are notably different to those of a Registrar in civilian General Practice. However, being supernumery the ADF Registrar attends workshops to receive teaching required for civilian Registrars.
More appropriate for the ADF Registrar would be to map the curriculum required within the Program, identify that which is not routinely available in military supervised practice and provide teaching on these topics.
The Subsequent Year
The typical AGPT Program follows the B&A Year with a year of supervised practice, commonly in a new location, with less teaching and supervision. The Supervisor is required on site for at least 25% of the time. There is no routine teaching each week. Often Registrars prepare for the Fellowship examination during this year. Many Registrars will elect to undertake six months of this year in an Extended Skill Term in which they move to a supervised position in a specialised area of practice, such as Obstetrics, Internal Medicine, Emergency Medicine, Skin Cancer Medicine, etc.
For the ADF Registrar now undertaking Service specific specialisation courses such as Aviation Medicine, Underwater Medicine, NBCD, and so on, this should be a great opportunity to complete an Extended Skill Term rarely available to civilian Registrars. However, Extended Skills Terms must be approved prospectively by the Senior Medical Educator of the RTP. In the process, the Medical Educator should assist the Registrar to develop a learning plan identifying learning objectives which they will confirm are met during the Term. If the Medical Educator is not notified of the military course or has no experience or knowledge of the course or the specialised area content, then developing a relevant learning plan and confirming achievement of objectives is difficult if not impossible. In many cases and for many reasons approval of ADF Registrars does not happen and they simply lose this time from the training program despite the value and uniqueness of the experience.
The Subsequent Deployment
Another common happening once an ADF MO achieves CL2 is the opportunity to deploy. Again this is a clinical, professional and personal experience rarely offered to civilian Registrars or medical practitioners. Also again, such a clinical posting requires prospective approval under the AGPT Program, that approval undertaken by the Senior Medical Educator. For those Senior Medical Educators not familiar with the clinical experiences of a deployment, developing a learning plan, approving the experience and particularly approving the supervisory arrangements is extremely difficult. Consequently, again, ADF Registrars may not have this time approved and the time is lost from their Program.
Discussion
So, for the ADF Registrar there is often a difference beween the intended curriculum and the flow of that curriculum into reality. To a degree, the hidden curriculum offered to the ADF Registrar gives some recognition of the requirement to manage him or her with some different policies, they are in fact supernumary to the training provider. Their practice experience and learning opportunities are sometimes worthwhile and included in their program, although it is not routine to have Medical Educators with common practise experiences guide them.
What is the global view of the ADF Registrar curriculum? The AGPT program intends an outcome of competent and confident practitioners able to practise in a variety of settings. But does it produce a doctor able to practise unsupervised in the military environment as is required by the ADF? Well, probably not fully and certainly not efficiently. There is somewhat of a mismatch between the ADF Competency Level policy and the AGPT Program upon which progression (to CL3) is hinged. The intention in matching professional advancement to an existing civilian program is most appropriate though lacking in key resources to marry the desired outcomes of the CL policy and the AGPT Program.
The mismatch between ADF and AGPT outcomes may be reconciled by accommodating some of the military medical learning opportunities and requirements within the Program outcomes. This can largely be done within the discretionary responsibilities (under AGPT policies) of a Senior Medical Educator who is aware of military practise. This is essentially reconciling outcomes to the content of an ADF Registrar’s program and moving towards improving the efficiency of the Program for ADF Registrars.
Conclusion
The ADF has wisely split professional development for MO into military and clinical progression through Rank and Competency Level. Medical Officers though have a difficult time advancing through the required training to clinical Competency Level 3. It is possible to match the content of an ADF Registrar’s training pathway with that of AGPT Program by recognising the worth of ADF clinical training and clinical experiences of deployment while retaining core clinical skill training required of all primary care physicians. Thus relevant content for ADF Registrar training can be matched to outcomes significant for the immediate clinical environment required for ADF practise and enduring outcomes valuable for the primary care doctor either in the ADF or in civilian clinical practice.
How can this be done?
There is a need to have a more comprehensive view of the curriculum suitable for ADF Registrars. Some situational awareness is required by Medical Educators experienced in military practice to develop the ADF curriculum within the AGPT Program. Within discretion permitted by Senior Medical Educators (under AGPT Policy), changes in organisational arrangements and the emphasis of the Program for ADF Registrars could match well to the rich ADF clinical and practical environment. The outcome would be an efficient and well focused curriculum for the ADF Registrar meeting both the requirements for the ADF and those of the AGPT Program – smoothing the corners of the square peg to fit the round hole of opportunity.
