Adam Cresswell, Health editor From: The Australian July 17, 2010
CHANGES to Australia's system for registering domestic and overseas doctors have quietly come into effect.
The changes took place on the same day earlier this month that disgraced surgeon Jayant Patel was jailed for seven years for killing three patients and injuring a fourth -- changes that advocates claim should prevent such a horrific episode happening again.
The changes -- a new national system of registration covering 10 separate health professions, including doctors, nurses, physiotherapists and others -- will mean that affected health workers will now be able to work in any state, using one set of papers.
The new system substitutes one national registration board for each of the 10 health professions covered, for the previous state-based system, which in the case of doctors involved a separate medical board in every state and territory.
The change was in part triggered by the Patel affair, which came to light in 2005 when allegations of his poor practice were aired in the Queensland Parliament. The case assumed scandalous proportions when it emerged state health authorities were unaware of previous negligence allegations against Patel, despite these being available on the internet.
But while public awareness of the recent change is probably limited to its relevance for the Patel case, and some doctors remain concerned about perceived intrusions into the profession's independence, the changes have implications that go well beyond this.
Despite initial concerns that the switch to national registration might spell the end of the Australian Medical Council, which accredits medical schools and their courses, and medical colleges and their training programs, as well as assessing overseas-trained doctors, the AMC has retained its role for at least another three years. And far from winding down, it is eyeing a busy work schedule.
AMC president Dick Smallwood, a former head of both the National Health and Medical Research Council and the Royal Australasian College of Physicians, as well as a former commonwealth chief medical officer, nominates more standardised training for interns, improved allocation of clinical placements and an increased focus on patient safety as areas the AMC will be pursuing.
Smallwood says a repeat of the Patel case should be impossible under the new registration system, because while the AMC will be in charge of assessing the skills of overseas doctors, as before, the job of accrediting them to work in specific roles in Australia will fall to the new Medical Board of Australia, based on the AMC's advice.
"That should be a big improvement on [having] a variety of medical boards, each of which had their own ideas of what sort of doctors were needed," he says.
"What used to happen is there was a lot of bypassing of the AMC process, when jurisdictions and their medical boards determined there was a need for someone to go into a health service somewhere.
"Bundaberg was a good example of that. That's not going to be possible any more."
While the Australian Medical Association and some other professional bodies have had concerns over the extent to which politicians will be able to interfere in the registration process under the new system -- legislation specifically allows ministers to prioritise staff appointments to fit declared workforce needs -- there is also a requirement that they heed public safety considerations.
Meanwhile, the AMC -- which has long had the medical profession's backing to continue its role -- says it will be focusing on the biggest remaining missing link in the doctor-training process, namely the years when newly graduated doctors start working in public hospitals.
"One of the important disconnects in medical education is the part between the end of medical school and the start of specialist training," Smallwood says.
"The medical board has asked us to advise them on standards for intern training. We set the standards for medical schools and specialist training, but there's that gap in the middle."
Back in 1988 the Doherty report on medical education recommended that the then recently created AMC should oversee junior doctor training.
Smallwood says this did not happen due to resistance from the states, which hated the idea of an external agency having a say in how their public hospitals would be run. "The body of opinion from postgraduate medical councils in each state and territory . . . [says] we really do need a continuum of medical education," he says.
"There's a curriculum framework out there for junior doctors, but what's missing are standards, and accreditation against those standards.
"It's going forward, but it will probably be another couple of years before it's all set."
Meanwhile, the AMC will also be examining the vexed issue of whether a national medical curriculum or a national exit assessment of graduating doctors should be introduced, following a specific request from federal Health Minister Nicola Roxon.
Smallwood says the request was in response to the Australian Medical Education Study, released in January, which uncovered worrying signs many medical graduates felt ill-prepared to handle common conditions. Only 36 per cent of junior doctors said they felt either adequately or well prepared to do wound management, while only 29 per cent of final-year students felt they had been adequately prepared to calculate accurate drug doses.
Smallwood says that while there may be merit in a standard national exit assessment, to supplement the exams and other processes individual universities use to award degrees, a national curriculum would encounter many objections.
"It would be in danger of being too inflexible, stultifying, and would make it very difficult to get the sorts of innovations that are going to be required. If you tried to define what has been called a core curriculum, it would be outdated instantly."
Another cause that Smallwood says he hopes to champion is that of increasing the attention paid to patient safety.
Fifteen years after the Quality in Australian Health Care study found 6 per cent of hospitalised patients would suffer an adverse event, and 50 per cent of these events would be preventable -- and 10 per cent of these preventable events would cause permanent disability or death -- only limited progress has been made to address the problems.
"What's coming out of Boston is a strong view that patient safety needs to be treated as one of the basic sciences in the medical courses," Smallwood says. "The various initiatives to try and grapple with patient safety to date have produced some improvement, but it's still a real concern.
"One of the things the AMC will be reflecting on further is in our standards framework, how we can perhaps give that a fillip."
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