MEDICAL EDUCATION

The new Australian medical schools: daring to be different

Kerrie A Lawson, Mabel Chew and Martin B Van Der Weyden

This is an extraordinary opportunity and very exciting, say the Deans of the new medical schools

ith so many changes in medical education in the past “entirely free of government subsidy and influence”, said Chris Del decade in and overseas, we might have Mar, Bond). The new schools are also bringing an academic Wexpected a period of consolidation and stability. Not so, presence to the medical community in regions where this has for seven new Australian medical schools are now at various stages previously been lacking. of development. Except for the James Cook medical The schools are small, with intakes about, or even slightly below, school in north , which opened in 2000, these are the 80 students per year — sometimes deemed to be the “critical mass” first new medical schools in Australia in 30 years. We talked to the to sustain a medical school (Box). But small size may have DeansThe of theMedical five schools Journal which of Australia are closest ISSN: to 0025- opening to find what advantages (“the Dean might even know your name”, said Paul has been729X happening 6/20 December and what 2004 they 181 hope11/12 to 662-666 achieve. Gatenby [ANU]). All the new schools lack the traditional depart- The©The schools Medical are marked Journal by theirof Australia differences, 2004 not only from most mental structure. They emphasise collaboration, and are harness- of ourwww.mja.com.au established medical schools, but also from each other. These ing teaching and learning resources in innovative ways from within differencesMedical lie Education not in their curricula and courses, which incorpo- their , their local communities, around Australia and rate many recent reforms in medical education, but in the ways the internationally. new schools are structuring themselves and harnessing resources “The emergence of the new schools is clearly being driven by for delivering the curricula, as well as in their priorities and the workforce issues”, said Judy Searle (Griffith). They have a commit- specific qualities they wish to foster in their graduates. ment to fill particular workforce needs, local or national. Because of their responsiveness to local needs and dependence on local resources, each school is unique. What are the new schools and why are they needed? First to open was the Australian National University (ANU) in Canberra, which enrolled its first students in 2004 and is taking Courses and curricula: no need to reinvent the wheel over the Canberra Clinical School facilities from the University of The new schools are incorporating the recent reforms in medical . and on Queensland’s education. All will provide curricula with problem-based, self- Gold Coast, and the University of Notre Dame Australia in directed learning; horizontal integration between disciplines; verti- Fremantle, , plan to take their first students in cal integration between basic and clinical sciences; early exposure 2005, the in 2006, and the University of to patients; and increased emphasis on communication skills, Western Sydney in 2007. A medical school at the proposed Sydney ethics, and personal and professional development. campus of the University of Notre Dame has been announced, but However, the new schools “are not reinventing the wheel”, said its exact status is unclear. Iverson (Wollongong). All are obtaining a curriculum from an We interviewed the Deans of Medicine at ANU, Griffith, Bond established medical school and modifying it for local conditions: and Notre Dame. At Wollongong, the Dean of Medicine, John Griffith from , Notre Dame from the University Hogg, was yet to assume full-time duties, and we spoke instead to of Queensland, the ANU and Bond from the , Don Iverson, Dean of the School of Health and Behavioural and Wollongong from a UK medical school. Iverson explained that Sciences, who has overseen the planning of the new medical Wollongong has turned overseas as it plans a model he believes is school, and to key faculty members. As the Western Sydney school new to Australia — a community-based medical school, which appointed its Dean, Neville Yeomans, in October 2004, and had conducts most of its clinical teaching in the community rather yet to develop the details of curriculum, location and student than in hospitals. This model is most developed in the United numbers, it was not included in our survey. Kingdom. The new schools are fostering diversity, bringing their programs Four of the new schools will also follow the lead of Flinders, to an even broader range of institutions than the traditional Queensland and Sydney in offering a 4-year graduate-entry pro- “sandstone” universities. The ANU is one of Australia’s “group of gram, creating a more equal balance between graduate and eight” research-oriented, capital-city-based universities (and the undergraduate medical programs in Australia. Bond will offer a 5- last of these to open a medical school), whereas the other four year undergraduate course, but this will be similar to the graduate- universities are regional, and two are private — the Catholic entry program, preceded by a “science-heavy, case-based first year” University of Notre Dame and Bond University (the former having to bring school-leavers up to the necessary level, said Del Mar. some Commonwealth-subsidised places, but the latter being The new graduate schools are also adopting the now almost universal criteria for graduate entry — grade-point average in a The Medical Journal of Australia, Sydney, NSW. first degree, performance in the GAMSAT (Graduate Australian Kerrie A Lawson, PhD, Assistant Editor; Mabel Chew, FRACGP, Medical School Admissions Test) and interview. The differences FAChPM, Deputy Editor; Martin B Van Der Weyden, MD, FRACP, from established graduate schools will be in the details: for FRCPA, Editor. example, whether all criteria must be satisfied individually or may Correspondence: Dr Kerrie A Lawson, The Medical Journal of Australia, be combined, and, in particular, the content and weighting of the Locked Bag 3030, Strawberry Hills, NSW 2012. interview. For instance, at Wollongong, the planned weighting [email protected] reflects the school’s aim that 30% of its students should come from

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structures. In keeping with the principle of integrating the disci- plines, the schools are not setting up traditional discrete depart- ments. Nor do they expect to derive all their expertise and resources from within the medical school. Instead, they are drawing on the resources of the parent university and, where necessary, forming collaborations with other institutions, locally THE AUSTRALIAN NATIONAL UNIVERSITY and further afield. Canberra, ACT For example, at Griffith, which already has many health stu- 10-year goals: dents (especially in physiotherapy), the medical school will be one of 11 schools, including dentistry and pharmacy, consolidated into • For the school to hold its own in teaching and a new Health Group. Within this group, academics will be research at the ANU. organised into “discipline clusters”, said Searle. The medical school will draw on clusters in the Health Group and the Science Group • To be seen as the Dean: Paul Gatenby principal source of for subjects such as biochemistry, physiology and microbiology. Alma mater: University of medical graduates for This has the added advantage of allowing cross-fertilisation, said the region. Searle. Where more specialised expertise or resources are required, the school is appointing academics who report directly to the Dean Previously: Associate Dean of • To provide leadership Medicine, Canberra in medical education. (eg, in molecular pathology, anatomy and paediatrics). The univer- Clinical School, and sity has pre-existing excellent “wet” anatomy laboratories, and the Director of ACT school is setting up a pathology laboratory and museum. Pathology Bond, which lacks other health courses, is following the prin- Discipline: Clinical immunology ciple of obtaining expertise through appointments direct to the school — many part-time — and providing resources through collaborations with other institutions. For example, Bond will rent pathology resources from the Queensland University of Technol- a rural, regional or remote background. In addition, the ANU has a ogy, and, for anatomy, the laboratories pathway whereby high-achieving school-leavers enrolling at the for a week of intensive dissection to complement prosected university in other disciplines may be interviewed and guaranteed specimens, computer simulations and high-fidelity medical imag- a place in the medical school when they graduate, provided they ing. Bond is also keen to collaborate with nearby Griffith medical pass the GAMSAT. school. Entry criteria at Bond are similar to those at other undergraduate schools, comprising the UMAT (Undergraduate Medicine and Clinical teaching: doing more with less Health Sciences Admission Test), school academic achievement and interview. Fees are about $45 000 per annum, and Bond, like Availability of patients for clinical teaching is an increasing concern the other new medical schools, is actively seeking support for for medical schools in developed countries, as hospital stays scholarships, particularly for Indigenous students and those from become shorter, patients in hospital tend to be sicker, and, at the East Timor. same time, courses increasingly require early patient exposure. How will the new schools meet this challenge? All are looking at new ways of accessing patients and more Delivering the course: do we need a full deck of cards? efficient ways of conducting clinical teaching, as well as collabora- As new initiatives, the schools have the luxury of first choosing a tions to make best use of available resources. Perhaps most curriculum and then devising the best way to deliver it, unlike innovative is Wollongong, which plans a community-based medi- older schools which had to impose new courses onto pre-existing cal school, where 80% of exposure to patients is in the community

Characteristics of five new Australian medical schools*

Australian National University of Notre University of University Griffith University Bond University Dame Australia Wollongong First intake 2004 2005 2005 2005 2006 Type of course 4-year graduate 4-year graduate 5-year undergraduate 4-year graduate 4-year graduate Student places per year 92 88 ~65 80 80 Commonwealth- 80 80 0 50 72 subsidised (HECS) (includes 5 MRB, (includes 3 MRB, (includes 3 MRB, 11 BMP places)† 6 BMP places)† 7 BMP places)† Fee-paying domestic 0 8 ~55 30 0 Fee-paying international 12‡ 0~10 0 8

* Information was not available from the University of Western Sydney or the proposed University of Notre Dame in Sydney. † Publicly funded places created under the Medical Rural Bonded (MRB) Scholarship Scheme and the Bonded Medical Places (BMP) Scheme carry a requirement for 6 years’ work in rural areas and areas of workforce shortage, respectively. ‡ Approved places, not all filled in 2004. HECS = Higher Education Contribution Scheme.

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been regarded as an “apprenticeship”. Searle sees a need for a better scientific underpinning in Years 3 and 4 of the course, and is investigating how to provide a core academic spine to the curricu- lum. In addition, Griffith is considering how to “do clinical teaching better”. For example, the “1-minute preceptor” is a strategy for clinical teachers to make the most of teaching time BOND UNIVERSITY through effective assessment of the learner’s needs, instruction and Gold Coast, Queensland more efficient feedback. 10-year goals: An innovation at Notre Dame that Bower believes is unique in Australia is a weekly clinical debriefing tutorial, guided by a For their graduates to be: clinician, in which students reflect not on clinical content but on • the most sought after the doctor–patient interactions and the impact of the experience for postgraduate on themselves. This aims to put flesh on the “reflective practi- training; and Dean: Chris Del Mar tioner” and to inculcate a culture of doctors caring for their own Alma mater: Cambridge • readily identifiable by health. University, UK the leadership roles The Deans commonly felt that clinical teachers require better they take. Previously: Professor of support and training. “A lot of curriculum reform has put clini- General Practice, cians offside, but clinicians are our best asset”, said Searle. “We University of need to use them ‘smarter’ and make sure the university provides Queensland adequate administration support.” Wollongong is ensuring the Discipline: General practice quality of its clinical teachers by setting up medical teaching programs. Unfortunately, most of the medical schools (with the possible exception of Wollongong) cannot properly reimburse rather than in hospitals. This will include general practices, clinicans for time with students. specialist rooms and community clinics, such as diabetes and sexual health clinics. “The school will use a good portion of its Information technology budget to offset the income lost by clinicians through taking students, as well as providing an academic rank commensurate Information technology (IT) has facilitated the design of the new with clinical experience”, said Iverson. Furthermore, community schools and is central to delivery of their curricula. Indeed, Bond clinicians are an untapped resource — only about 15% of general will be using the Sydney problem-based course live — Sydney’s practitioners in the region, and even fewer specialists, take stu- web interface, which includes formative assessment, was a crite- dents into their practices, and the local clinical community is rion for its choice. enthusiastic about the plan. The schools are exploring the further potential of IT. For Notre Dame is enlisting private and outer metropolitan hospitals example, the ANU school will be the university’s “guinea pig” for to avoid overlap with the established medical school at the advanced IT presentations (such as generating three-dimensional University of Western Australia. A bonus is the different casemix. “virtual reality”), with the university’s latest facility for this housed “Exposure to patients in the tertiary system alone gives a distorted view of medicine,” said Bower. “Clearly we need tertiary hospitals for areas such as acute psychiatry, major trauma, some paediatrics. But the casemix at private and outer metropolitan hospitals gives a brilliant experience of the sort of medicine faced by most medical practitioners, as opposed to ‘super’ specialists in tertiary hospitals.” Elsewhere, overlap seems inevitable, and schools are collaborat- GRIFFITH UNIVERSITY ing. Bond will share six of Griffith’s seven hospitals, having estab- Gold Coast, Queensland lished together that there are enough student places. At present, 10-year goals: Gold Coast hospitals accept around a hundred overseas students on • To produce “quality” electives (mostly from Europe), but will reduce this to make way for graduates with a good Australian students. Where overlap occurs, clinical teaching will be career foundation. modified to meet the needs of the two student bodies. • To be “community- There is also a move for students to learn basic clinical skills not centric” — part of the on patients, but in simulated environments — clinical skills Dean: Judy Searle wider healthcare laboratories, using models, simulated patients, and clinical teach- Alma mater: Flinders University, community, with a real regional identity. ing associates. These methods are used particularly for intimate SA • To be known for its Previously: Associate Dean, physical examinations, such as breast and pelvis, but are also being research output. applied to a wider range of skills. For example, Bond will have Peninsula Medical School, Exeter, UK • To improve healthcare some experiential learning on the wards in Years 2 and 3, but will in the region. teach basic clinical skills predominantly “in-house” in clinical Discipline: Obstetrics and gynaecology, • To take a leadership skills laboratories. role in medical medical education A concern raised by several of the Deans is the need to improve education. teaching in the clinical placement years, which have traditionally

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Further changes in assessment are mooted. Del Mar praised the North American system of a national licensure examination, although he considers this approach may be too radical for Australia at present.

UNIVERSITY OF NOTRE DAME AUSTRALIA School-specific goals Fremantle and Broome, Western Australia Not surprisingly, all the Deans are ambitious to produce “quality 10-year goals: graduates” who will be in demand for postgraduate training. But To achieve the mission of they are distinguished by their specific goals for their graduates. graduating doctors: For example, Iverson hopes that 60%–70% of Wollongong gradu- ates will choose general practice, and the rest specialist practice, • who will work in areas of unmet need; not in capital cities, but in rural, regional or remote areas. Dean: Adrian Bower Strategies to achieve this include: Alma mater: Liverpool University, • who appreciate that • recruiting people with “strong ties to regional, remote or rural UK medicine is a vocation with a service element; areas” (initially through aggressive recruitment of professionals Previously: Associate Professor already established in a rural or regional area); • who treat their patients and Head of • ensuring the curriculum reflects clinical situations common in Anatomy, with the utmost James Cook respect; and general practice and a full range of the procedures possible in University, QLD general practice; and • who undertake to • Discipline: Neuroanatomy, teach future providing as many general practice placements as possible medical education generations of doctors. throughout the course. At Notre Dame and Bond, the goals for medical graduates reflect the particular philosophies of the universities. All Bond students, in the medical school. Its uses include training in procedural skills, including medical students, are required to study four core such as inserting intravenous lines. subjects — business and entrepreneurship, IT, communication Griffith will integrate IT resources, including interactive pro- (community advocacy rather than the one-to-one communication grams, into its course. The schools will also be teaching students skills usual in medical programs) and law and ethics. This reflects how to make more efficient use of IT, such as personal digital Bond’s origins as a funded by the entrepreneur assistants, in clinical practice, with the proviso, said Bower, “never and a Japanese consortium. Del Mar hopes that the to make patients feel they take second place to the electronic resulting Bond-specific attributes in organisation and administra- apparatus”. tion will create “future leaders in medicine”. Notre Dame aims to produce graduates who will fill areas of Assessment: an international endeavour unmet need and appreciate the Catholic values of compassion, Assessment, like other areas of medical education, is also becom- respect and service. All students study philosophy, ethics and ing more collaborative. The new schools are typically joining theology. The theology course is being modified to increase its international assessment consortia, which provide banks of assess- medical relevance, with more emphasis on human spirituality, ment items and allow comparison between schools. For example, belief systems and their significance in life than on the gospels. the ANU belongs to a Hong Kong-based consortium, and Wollon- Although Catholic ethics will be taught, the requirement is to gong will join a similar UK consortium. understand, not necessarily to espouse, them. Bower wished to put Assessment serves a range of functions, and the Deans empha- to rest the canard that the Catholic ethos will affect education sised the importance of differentiating these and tailoring each about some topics. “Our students will be exposed to all the assessment task to the desired function. In general, the new information necessary to talk to their patients in a non-judgemen- schools will emphasise formative assessment (a learning tool) and tal, respectful and ethical manner about any sensitive issue, such as will use summative assessment only when required (such as abortion, contraception and end-of-life decisions. For example, if a accreditation for progression to the next stage and ranking). woman asks one of our graduates about contraception, they would For instance, Notre Dame will have “lots of formative assess- talk about it in relation to her needs and circumstances. They ment” in Years 1 and 2 and a single, summative examination at the would not say it is an immoral act, which is the Catholic doctrine. end of each year. Similarly, Griffith will have a major barrier at the That in itself would be unethical.” end of Year 3 to ensure students enter the pre-internship year with Notre Dame is also trying to instil the concept of medicine as a adequate competence. Searle believes assessment should reflect vocation with a service component, and students are expected to “real-world” requirements; Year 4 assessment is “around the sorts perform voluntary work for the practices providing clinical place- of behaviour and performance they will need as junior doctors”, ments. “This has further educational value”, explained Bower, “as she said. students learn about themselves, the practice, and their inter- Indeed, the new curricula typically include a professional and actions with others.” personal development theme, which includes communication Searle and Gatenby have specific goals for their schools as well skills, procedural skills and other aspects of fitness to practise. as their graduates. Both wish their schools to take leadership roles These are assessed as academic endeavours against predetermined in medical education and to develop strong research programs (see requirements. In this way, the schools are ensuring their graduates next section). In addition, “developing a regional identity and are equipped for practice with more than just scientific knowledge. providing an academic focus for the local clinical community is

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Research and the tripartite model of academic medicine Although all the schools wish their teaching to be informed by scholarship, they differ in their emphasis on research and their UNIVERSITY OF WOLLONGONG attitudes to the tripartite model of academic medicine, which Wollongong, combines excellence in teaching, research and clinical practice. 10-year goals: For the ANU, research is a priority and a selling point. The To have objective school wishes to take its place within the strongly research-based evidence that this university — the only Australian university consistently ranked community-based model among the “top 50” universities in the world — and to capitalise produces graduates who: on its strengths in anthropology and sociology. Its strategy is to Dean: John Hogg • are competent in enlist staff from the ANU research schools to teach, supervise Alma mater: University of Sydney, clinical practice; student projects, and contribute to developing the faculty. Gatenby NSW • are independent believes that “enquiry-based learning can really only occur in the Previously: Clinical Stream learners; context of a research-rich university. While it is possible to teach Director of Surgery, and medicine in a TAFE, I do not know whether it is desirable.” Northern Illawarra • are committed to Griffith also wishes to develop a research agenda. “That is why Area Health Service, medicine in rural, we are an academic institution”, said Searle. “The appointments we NSW regional and remote areas. make should provide leadership in research as well as around Discipline: General surgery teaching and learning.” Griffith proposes to link with existing strengths and fill the gaps, particularly in translational research and research into health outcomes in primary care and the they hope will yield objective evidence of its educational and community. economic effectiveness. Searle also wishes Griffith to be known as “a strong protagonist Even the Deans with a strong research commitment have of evidence-based practice in medical education”. A frequent reservations about embodying the traditional tripartite model of criticism of the changes in medical education is that they have not academic medicine in all staff. Both Gatenby and Bower empha- been rigorously evaluated. Searle believes that, as randomised sised that it is not necessary for each academic to be a stellar controlled trials of the new courses are not possible, medical performer in all three domains, as long as the organisation as a education must look to evaluative methods from other disciplines, whole meets its obligations. “With the pressures of today it is such as psychology. She hopes that the register for longitudinal impossible for an academic to excel at all three. The polymath follow-up of medical students, which is being set up by the academic is a dying breed”, said Bower. Perhaps this is revealing Committee of Deans of Australian Medical Schools, may answer what was once covert — he was taught by some excellent some of the questions. researchers who were awful teachers. “We need to move to the A lack of resources for basic science research is a current North American model, where a member of staff can elect to follow problem at some schools. To overcome this, Notre Dame is either a research tenure track or a teaching tenure track — developing research partnerships with other institutions (eg, although the latter has to be informed by scholarship.” through part-time appointments). It will also pursue research in areas requiring less infrastructure, such as primary healthcare and epidemiology. The Bond school is not yet undertaking research, Conclusion but sees itself capitalising on the university’s strengths in applied If Australia’s older medical schools are the “department stores” of research; it will provide seed money and statistical support for medicine, providing graduates for many different purposes, then research by clinical teachers as well as university academics. the new schools may be the “boutiques”. They are pioneering new For Wollongong, research is less of a priority than ensuring a ways of delivering a medical education and aim to produce high-quality medical education. Iverson believes Wollongong graduates with qualities unique to their schools. How successful graduates will be as clinically competent as those who went to they are in providing for Australia’s future medical needs will be more research-intensive schools. However, Wollongong’s commu- followed with great interest by politicians, practitioners and nity-based school is an experiment in medical education, which patients. ❏

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