The need to maintain quality and build capacity for emergency medicine training

Abstract

The growing demand for ED training experiences, because of increases in medical student, intern and registrar numbers, highlights key issues for the future of medical training in Australasia.1, 2 ED experiences provide junior doctors with an important and unique experience of generalist medicine, with exposure to a broad range of undifferentiated acute illness and injury not often encountered in other clinical environments.1, 3, 4 However, practical constraints to supervisory capacity and availability of placements in existing teaching hospitals threaten to dilute the value of these experiences. The question is: how best to provide this highly valued emergency medicine experience5 to the greatest number of recipients without diluting quality of the learning or further increasing pressures on busy ED clinicians? The most immediate concern is the number of places available for interns. However, there is a looming potential bottleneck in the training pipeline6 as, in the near future, more early-career doctors than ever will compete for junior medical officer and vocational training positions. Selectively optimising intern experiences in EDs7 and/or limiting trainee placements in accredited EDs is a potential approach to manage growing demand. Limiting placements suggest exclusivity somewhat at odds with the egalitarian values of Australasian emergency medicine. Furthermore, forecasting indicates that Australia will not achieve self-sufficiency by 2025, but continue to rely on overseas-trained doctors to supplement the emergency physician workforce.8 So, capping trainee numbers would seem somewhat ill-considered and avoids addressing the fundamental issue, namely, supporting and expanding supervisory capacity within EDs. Training in clinical settings is essential to medical workforce development. This requires high-quality supervision to facilitate competency development and progression of junior doctors towards independent practice.4, 9 In Australasian EDs, Fellows of the Australasian College for Emergency Medicine (FACEMs) provide a major supervisory role for junior doctors;4 yet there is no doubt whatsoever that capacity for supervision is increasingly constrained.1, 2, 10 Training and workforce data11 support this: in 2008, FACEM to trainee ratio was 1:0.8 and FACEM to intern ratio was 1:2.0; by 2012, the ratios of FACEMs to trainees was 1:1.5 and to interns was 1:2.2. Clearly, the situation is rapidly evolving whereby there are twice as many trainees, as well as more than twice as many interns, as Fellows. The reasons for this are varied and complex, but most critically these statistics demonstrate that supervisory demands on existing FACEMs are becoming increasingly unmanageable. This is further exacerbated as actual supervision of students, interns and registrars in the ED is often delegated to those emergency physicians with an interest and commitment to medical education. This smaller group of FACEMs shoulders much of the burden of supervision, assessments and educational oversight of doctors- and specialists-in-training. Consequently, a tipping point is approaching where required capacity to effectively train the growing cohort of junior doctors exceeds available supervision time of these experienced physicians.12 The contemporary operational paradigm for EDs is challenging for medical education.13 The increasing demand for ED services exceeds population growth14 and government health reform initiatives are driving clinical service delivery models geared to optimise patient flow and benchmarked to time-based targets. These factors impact on the educational experiences in the ED,13, 15 including the ability to expand supervisory capacity to meet the needs of the junior doctor cohort who require emergency medicine training. However, increased quality and access to supervision not only improve education-related outcomes but, importantly, result in better patient outcomes.4 This crucial factor must be considered in terms of the multiple demands on the public health system,16 where service demands currently represent the most significant impediment to adequate supervision of junior doctors working clinically.4 A recent survey of the Australasian College for Emergency Medicine (ACEM) members suggests that most emergency physicians are willing and motivated to provide clinical teaching, but systemic factors, including lack of time, clinical pressures and meeting efficiency targets, are barriers to sustaining or increasing teaching activities.17 With the projected growth in trainee numbers, supervision can no longer continue merely on the enthusiasm and goodwill of ‘volunteer’ individual senior clinicians.18 Rather, it must be appreciated as a vital component of the healthcare system, with clear hospital support in releasing senior clinicians from overburdened workloads4, 19 to ensure the safe clinical practice of junior doctors and development of the future consultant workforce. Therefore, protected clinical teaching time in the ED is essential12, 20, 21 and must be recognised as such by hospital management, rather than a ‘soft target’ for cutbacks in times of budgetary pressure. The pragmatic implications of increasing intern numbers in the Australian healthcare system suggest that emergency medicine terms for interns in alternative ‘non-traditional’ ED settings are inevitable.12 A practical approach to facilitate additional emergency medicine placements for junior doctors is support for innovative prevocational training models in emergency care settings in rural and regional areas. These areas of Australia and New Zealand continue to struggle in terms of achieving optimum medical workforce numbers, yet many metropolitan areas are beginning to report over-supply.8 It seems sensible, therefore, to consider strategies for dealing with this mal-distribution by encouraging training options in rural and regional setting, including potential linkages to rural generalist training pathways.22 Regional and rural settings require support to build educational functions and supervisory capacity. ACEM is contributing to this capacity building for emergency medicine training through a new joint initiative with the Australian Government: the ‘National Program – Improving Australia's Emergency Medicine Workforce’. Through this Program, the Emergency Medicine Education and Training (EMET) network has been introduced to provide a robust structure for co-ordination and delivery of emergency medicine education initiatives throughout Australia. The EMET consists of a network of hospitals and training locations, coordinated through 20 regional hubs, to facilitate delivery of the ACEM Emergency Medicine Certificate and Diploma courses,23, 24 as well as other emergency medicine training activities. At present, over half of all Australian public hospitals, including three-quarters of those in regional and rural areas, are involved in the EMET network. FACEM-led supervision models and educational infrastructure, developed and implemented through EMET, has significant potential flow-on benefits to prevocational training in regional centres. This should be a key component in accommodating emergency medicine training needs for the increasing numbers of junior doctors. The current crisis in the UK emergency medicine workforce25 provides salient lessons to avoid similar outcomes in Australasia. To effectively meet future emergency medicine workforce needs, solutions must not only address recruitment and development of junior doctors, across both urban and rural settings, but also retention of experienced senior consultants.26 Policy initiatives, and associated funding, to facilitate a ‘strategic margin of reserve capacity’27 within the health system are essential to ensure continued safe and high-quality care of patients together with effective supervision for the growing cohort of junior doctors. As the ultimate goal is increasing the emergency medicine workforce to meet the burgeoning acute care needs of the Australasian community, ACEM will continue to advocate for the importance of the educator role13 for emergency physicians working in Australasian EDs and promote National Program initiatives that build capacity for emergency medicine training across the broadest possible range of emergency care settings. AK is CEO of Australasian College for Emergency Medicine and AG is Director of Policy and Research and Deputy CEO of Australasian College for Emergency Medicine.