For the past two years AMA(SA) has run its Hospital Health Check, a survey of the doctors in training (DiTs) at the major metropolitan hospitals, to highlight the issues that are important to doctors in training and compare conditions across hospital sites. Given the success of the national Medical Board of Australia’s Medical Training Survey (MTS) in recent years, the AMA(SA) DiT Committee decided that for its 2021 survey it would capitalise on the MTS data collection and use the data that focused on the South Australian sites.
A total of 1,502 doctors in training in South Australia responded in 2021, an increase from 737 in 2019. Through all years the greatest subset of doctors in training has been specialist non-GP trainees (42% this year), followed by prevocational trainees (19% in 2019 and 25% this year). Support for trainees, hours of work and leave, workplace culture, and bullying and harassment remain key areas of interest, with additional attention this year on how COVID-19 is affecting training.
Many of the issues highlighted by this survey have been identified as areas of advocacy by the AMA(SA) DiT Committee. It is validating, if disappointing, to see the data reflect that these issues remain of major concern. As has been pointed out by spokespeople from the AMA and Colleges, these issues have a direct impact on doctors’ capacity to perform their roles and, therefore, on the health outcomes of our patients. Specific training groups, such as prevocational trainees, international medical graduates, and general practice trainees, have specific issues, as well as those reported more generally. Advocacy to stamp out bullying and harassment, and a focus on the impacts of COVID-19 on training, should remain priorities.
In 2021, less than half (44%) of prevocational and unaccredited registrars have training or development plans and only 54% report that they receive formal feedback. International Medical Graduates (IMGs) comprise a lower proportion since the travel restrictions were imposed in 2020 but still made up 10% of South Australian respondents. Fewer respondents were GP trainees (15% compared to 17% two years ago), which reflects reports that training numbers have decreased and concerns that in a few years there will not be enough GPs. These figures demonstrate the ongoing importance of advocacy for working and training conditions in prevocational and GP training and for IMGs, some of the AMA(SA) DiT Committee’s key priorities.
Position statements by the AMA and most training colleges increasingly recognise that fatigue among junior doctors, rostering with inadequate breaks, and excessive shift work lead to detrimental outcomes for patients. For example, the AMA recognises that bullying and harassment are patient safety and workplace safety issues, and provides comprehensive recommendations in the recently published Workplace Bullying, Discrimination and Harassment position statement. However, it seems there is still some way to go in translating the recognition among doctors’ advocates into employers providing improved working conditions. More than 80% of DiTs reported that their workplaces are proactively addressing concerns over patient care and safety, yet only 25% of witnesses and 33% of victims felt they could safely report bullying and harassment.
There are some positive notes for South Australia in comparison to other states, including that 90% of interns (first year doctors) reported that their education programs were helping them develop as doctors compared to 79% nationally. Access to study leave (65%) and research opportunities (55%) were similar to the national averages (65% and 57%).
All doctors are aware of the many effects of COVID-19 in medicine and across society. It also seems to have hindered the progress of many DiTs. This is likely to have implications for future service delivery and specialist availability for the general population. It should be noted that this data demonstrates experiences in 2021, a year when until December South Australia was relatively COVID-free. We anticipate these issues will only become more pronounced in the 2022 data. The MTS data has been key for making state and hospital wide comparisons to continue our advocacy improving doctor in training wellbeing.
The full report can be accessed from AMA(SA) here
“A safe working environment is critical to safe medical practice.”
That’s the view of Associate Professor Mitra Guha, Chair of the Royal Australasian College of Physicians’ (RACP) College Education Committee. She recognises how confidential, comparative data gathered through the MTS supports the RACP to improve training environments.
The RACP has been using data from the MTS, in conjunction with results of its own Physician Training Survey, to explore and address localised and systemic issues with trainee and educator safety and wellbeing.
Focusing locally, the RACP assesses survey data against pre-defined thresholds to identify training settings that may have notable trainee or educator safety or wellbeing concerns.
Taking a collaborative, quality improvement approach, the RACP works with leaders at these training settings to evaluate the evidence base, and then asks those leaders to identify actions taken to address the concerns. Training setting leaders have shown a strong commitment to listening to the concerns signalled through this feedback, further exploring issues and investing in actions to improve safety and wellbeing.
Systemically, reports from RACP trainees and educators indicate bullying, harassment, discrimination, and uncivil behaviours are significant issues within medicine.
In 2020, one in every five RACP trainees who responded to the MTS experienced these behaviours. The data shows not all events are being reported. Concerningly, those that are reported are not always addressed.
A further concern is the data shows that doctors are the main perpetrators of bullying, harassment, and discrimination.
In response, in November 2021, the RACP convened the Safe Training Environments Summit. Education and trainee leaders and invited guests agreed on a strategic approach to tackling bullying, harassment, and discrimination in physician training environments.
Summit participants explored the root causes of bullying, harassment, and discrimination and identified high-level strategies to address these. Dr Sally Langley, President of the Royal Australasian College of Surgeons, shared RACS’ experiences in dealing with these issues in surgical training programs. The Summit culminated in development of a leadership statement and prioritisation of the RACP’s key strategic areas for action. In coming months, the RACP will use these to form a strategic action plan.
The RACP will closely monitor future MTS results, continue to collaborate with training settings on localised issues and use survey findings to guide and evaluate its strategic action plan.
Leaders across Australia’s medical community have come together to build support and commitment to improving the culture of medicine.
The Medical Board of Australia’s Culture of Medicine Symposium, held in Melbourne on 27 May, shared evidence of poor culture, but focused on fostering a commitment to positive change.
The symposium aimed to build a common understanding of current problems and a shared commitment to positive change.
Opening the session, Medical Board of Australia Chair, Dr Anne Tonkin, said poor culture was associated with poor patient outcomes, which placed the issue firmly within the scope of regulators. Participants identified improved awareness and understanding of cultural safety, meaningful action on racism and collaborations to help effect change as a focus for future effort.
Dr Tonkin said cultural change was complicated and everyone across medicine had a role in improving the culture of medicine.
'No single agency or individual – acting alone - has all the levers needed to achieve positive change. But what we can’t do individually, we can do collectively,' she said.
'Many of the biggest challenges rest where accountabilities and responsibilities intersect, and real cultural change will come from agencies navigating jointly, not problem solving individually,' she said.
'We need to be open to caring about and respecting each other, as we care for and respect patients. We need to be open to not knowing all the answers but trusting that together we can build a culture we can be proud of,' Dr Tonkin said.
Across three years, results from the Medical Training Survey have shown that while medical training in Australia is generally in good shape, there are serious cultural problems in medicine, including bullying, harassment, racism and discrimination. Results of many other surveys across medicine and the wider healthcare sector reveal similar problems.
Symposium participants included representatives from the Australian Indigenous Doctors’ Association (AIDA), the AMA Council of Doctors in Training, medical students, specialist medical colleges, jurisdictions, employers, advocates, insurers, academics and clinicians.
Collaborations to foster a positive culture in medicine are at the heart of the Board’s Professional Performance Framework, which aims to support doctors to practise competently and ethically throughout their working lives.
'Everyone wants to foster a culture that is focused on patient safety and the Board is committed to working in partnership with the profession to reshape the culture of medicine and build a culture of respect,' Dr Tonkin said.
Townsville Hospital and Health Service in 2021 actively encouraged doctors in training to participate in the Medical Training Survey (MTS). Their increased participation has allowed the health service to partner with North Queensland Regional Training Hubs to develop reports for departments with large training programs. We plan to benchmark our local programs against the state and national results and track our success and areas for improvement over time.
Over time, we hope the MTS and our response to the results can become part of intern and college accreditation processes. We shared MTS results with our directors of training and heads of departments. It was very powerful to see clinical directors discussing the benefits of using MTS results to celebrate areas where we performed well and reflecting on our areas for improvement.
Results, where we stood out from the benchmark build a compelling case for change. Being a regional health service, we are acutely aware of the current medical workforce challenges particularly for rural Australia. It is sobering to see that nationally 18% of doctors in training are considering a future outside of medicine. We now have a window of opportunity to engage with doctors in training on the important issues identified in the MTS.
Through utilisation of the 2020 Medical Board of Australia’s (MBA) Medical Training Survey (MTS) results, the Australian and New Zealand College of Anaesthetists (ANZCA) Trainee Wellbeing Project Working Group have been able to progress recommendations that directly support the health and wellbeing of our trainees and fellows.
One issue identified by the 2020 MBA Medical Training Survey results was the need to increase awareness of return to work strategies and flexible work options. It was apparent that advocacy was needed for flexible work options in all regions. Thus, following publication of the survey results, various college units collaborated on having the recommendation addressed. With the support of the Education Executive Management Committee (EEMC), the ANZCA handbook for training was updated to outline trainees’ options for different training models. These options better support those with special circumstances, such as trainees who require interrupted training, trainees who need to undertake their training in a part-time capacity or those who undertake their training overseas. It is important to the college to listen to the feedback of the trainees and ensure that the recommendations of the Trainee Wellbeing Project Group were aimed at providing trainees with tangible and practical outcomes to support their wellbeing. The handbook goes on to advocate not just for various options of flexible training, but further detailing what trainee support is available.
The results of the 2020 ANZCA and MTS were reviewed and triangulated, with recommendations made to address issues and trends raised across both surveys. The ANZCA Trainee Committee, EEMC and the college’s executive leadership team are all instrumental in progressing and responding to the outcomes of this review. The trainee surveys have informed the progress of the recommendation by the Trainee Wellbeing Project Group to “Develop processes to collect data on: burnout, mental illness, training-related stressors, uptake of receiving feedback resources, experiences of receiving feedback, lifestyle factors (e.g. GP, substance use, sleep patterns, exercise, leisure time). The college is looking to progress a working group to consider the best format and frequency for data collection including validated tools like K10.”
A working group was formed in 2021 which progressed the college survey to be managed externally, thus ensuring complete anonymity. The same practice is undertaken for the ANZCA Trainee Survey. Through guaranteed confidentiality, trainees are more at ease in answering questions that they otherwise may feel uncomfortable doing so and in turn, allows the college to address important issues. In addition, the ANZCA complaints process is under review to allow for easier access for trainees and fellows to make complaints.
It is only through listening to trainee feedback and being open to making changes that improvements can be made. Utilising the Medical Board of Australia’s Medical Training Survey results, ANZCA developed an action plan and continues to monitor and evaluate the framework that addresses these results. The college remains committed to continuing this important engagement.
Specialist medical colleges are using MTS data to research the impact of COVID-19 on the development of Australia's future medical workforce.
The Council of Presidents of Medical Colleges (CPMC) saw first-hand the disruptions to medical training during 2020. It set up a research project using MTS data, to better understand the impacts on doctors in training and evaluate changes to training developed in response to COVID.
2020 MTS data revealed COVID had a mixed impact on training, creating uncertainty and reducing training opportunities, but also triggering innovation in training.
The CPMC research will use MTS results to inform policy recommendations to Australia's National Medical Workforce Strategy. Learn more.
Results of the 2020 MTS reflect the views of 57 per cent of doctors in training in Australia. Rich MTS feedback is informing the work of the Queensland Health Wellbeing Working Group (the Wellbeing Working Group).
During 2021, the Wellbeing Working Group will be focused on developing strategies to prioritise and promote the mental health and wellbeing of Queensland medical practitioners and students.
The Working Group have identified the MTS results as an important data source to assist in the development of strategies and will create tailored reports using the interactive data dashboard on the MedicalTrainingSurvey.gov.au website to source data pertinent to trainee insights on workplace environment and culture.
As response rates to other internal survey tools limit the insights available, including the relevance of particular issues across different groups of medical practitioners, the MTS data will be utilised to complement and address gaps in other relevant datasets by providing further insight into the experience of workplace environment and culture of QLD doctors in training.
Using the MTS online data-dashboard to filter aggregated national data and create tailored reports with current state and sometimes hospital specific feedback, the Working Group plan to analyse trainee feedback expressed in MTS data, to identify what trainees think is working well and what can be done better. Based on this and building on other data sources, the Group will develop and prioritise actions that will make a difference, consistent with the five pillars of coordinated action outlined in the Every Doctor, Every Setting National Framework.
As an example, one of the pillars in the national framework relates to improving training and work environments to reduce risk, with a particular target on safe and inclusive training and work environments where bullying, harassment and discrimination are not tolerated.
Click here for further information on the Every Doctor, Every Setting National Framework.
Australia’s health system is one of the best in the world. It provides quality, safe, and affordable health care and this contributes to Australians enjoying one of the longest life expectancies in the world.
Our community has a generally high opinion of the healthcare system and research suggests this has improved since 2008, with doctors ranking highly in the cohort of health care providers.
The public’s confidence has been built by generations of highly skilled and dedicated doctors providing service in local communities and specialist centres, but now more than ever it is under assault.
Covid -19 has heightened public attention on the medical community. Numerous high-profile cases of inappropriate behaviour, misdiagnosis, inadequate staffing, overburdened hospitals, and tragic health outcomes fuel growing concerns about the quality and effectiveness of doctors.
Mainstream and social media focus on failure, amplify these concerns. A case in point is most reporting of the 2020 Medical Training Survey results. Common mainstream media headlines and stories related how junior doctors were overworked, underpaid, harassed, and bullied. This is hardly a glowing endorsement of the medical training and development regime and is a legitimate problem that needs to be addressed. But it is equally true that 80% of respondents to the Medical Training Survey recommended their training program and their current workplace and rated the quality of clinical supervision and teaching sessions highly.
The Medical Training Survey is rich in information. Although in its infancy, it is being widely used to understand and improve various facets of the medical training system and workplace. These changes should reflect in future surveys creating a virtuous cycle of improvement.
The training received by doctors is a vital part of the accreditation system, which provides the community with a highly skilled, competent, and ethical workforce delivering safe, high quality patient care. Medical training is a critical component in maintaining and enhancing community confidence in the health system
While overwork, underpayment and bullying are unacceptable and need to be redressed, the Medical Training Survey primarily highlights the excellence of the current training system and must be a prime source for strengthening community confidence. Cut through in promoting the positive and improving aspects of the training survey in the mainstream media, is a critical success factor in that endeavour.
The STHC provides a comparison of the training experience between different specialty training pathways and identifies areas of excellent experience as well as areas for improvement.
Improving exam feedback, providing access to mental health services, improving pathways to address bullying, harassment and discrimination, providing access to study leave and supporting employment at the endo of training are areas where an ongoing commitment at all levels of training is needed to ensure Australia continues to produce highly qualified doctors.
The AMA hopes that the STHC will be of value to medical colleges, training institutions and other key stakeholders. Click here to read the AMAs STHC.
The Australian Medical Council (AMC) says the MTS has the potential to strengthen further the voice of trainees within its accreditation assessments and monitoring activities and help shape medical training.
Over time, the Medical Training Survey will enable the AMC to build a longitudinal view of how training programs are being experienced by trainees across Australia and whether College initiatives to improve training are having a positive impact from the trainees’ perspective
The Medical Training Survey will become an important data source in AMC accreditation processes, by bringing interns and trainees together with education providers and health services to review training against the AMC’s accreditation standards.
Published MTS results already enable education providers and health services to consider the experience of their trainees, relative to sector-wide results.
In 2020, the AMC has asked Colleges to reflect on 2019 MTS results and consider how, over time, they can be used in evaluation and quality improvement of training programs.
Read more about how the AMC will be using MTS results in accreditation to help secure high quality education in supportive training environments.