'The Four Pillars Program': Barriers to Implementation ...

‘The Four Pillars Program’: Barriers to Implementation of a New Prevocational Education Program Sarah Michael, Andrew Kemp, Yoon Ooi, Matt Ho St Vincent’s Hospital, Sydney Introduction

Image 1. The Four Pillars Program

Inadequacies in prevocational education and training in Australia are well-documented. Implementation of the Australian Curriculum Framework for Junior Doctors remains an issue due to multiple factors, including an over-reliance on voluntary contributions of teaching, lack of resources, poor collaboration between stakeholders, and junior doctor factors (1-4). Studies show that the types of teaching which junior doctors find most useful, including formal teaching from senior staff, high-fidelity simulation, and clinical skills training, tend to be the least frequently delivered (5). Finally, the links between prevocational and vocational training are not well-developed (2). Whilst the Unified Lecture Series has been designed for interns, following this there is little curriculum articulation until vocational training, meaning that junior doctors may feel unprepared for commencing work in a vocational position.

Surgical

Medical

Community

Critical Care

Precautions and Theatre etiquette Surgical instruments Suture and needle selection Knots workshop Local Anaesthetics Wounds Suturing workshop Drains and Tubes Diathermy

Type II respiratory failure Chest drains CT head Managing a stroke call Lumbar punctures Advanced arrhythmias End-of-life decision making Antibiotic stewardship Advanced Electrolytes

Psychosis The suicidal patient Ice use and complications from substance abuse Mums and Bubs Opioid Dependence Psychopharmacology Dermatology for GPs HIV and Hepatitis Managing substance withdrawal Sexual Health

Airways Transfusions Ultrasounds/Lines Ventilators Chest Trauma EMST Inotropes/ Chronotropes Head Trauma ALS and Pacing

Aim St Vincent’s Hospital in Sydney has attempted to address these issues in prevocational education by the development of the ‘Four Pillars Program’ (see image 1). This approach broadly assumes that at the level of PGY1-2, trainees will begin to select one of four training pathways - surgery, general medicine, critical care, or community medicine, and thus provides tailored education in these areas. In effect, the pillars aim to fill the black hole that previously existed for PGY2-5 prevocational trainees.

Critical Care Airways session

Critical Care – Learning chest drain insertion on lamb racks

Design From the perspective of education design, the pillars anchor at the Unified Lecture Series informed by the Australian Curriculum Framework, and taught during internship. They lead up to college-level training programs, providing curriculum articulation from medical school to advanced training. Each ‘pillar’ consists of both practical and interactive small-group tutorials and lectures, and, where relevant, clinical skills training and simulation sessions, and has been developed with consultation from both junior and senior doctors. Each of the pillars is an encapsulated series of 9-10 sessions which can be run during a term (6). The program was piloted over terms 1-4 in 2014.

Image 2. Barriers to implementation

Inter-organisational/State/Federal Lack of Lack of Hospital specific curricula information on for PGY2-5 Reliance on registrar vocational and fellow input resulting in Lack of available training continuity issues with term rooms programs and changeover how best to Difficulty in Inexperienced prepare Individual program administrative JMOs for accreditation JMOs Educators staff training Lack of Cancellations due Rural terms to clinical work, low medical Rostering/ Access to educators prioritisation, Shiftwork funding Competing No employed by departmental staff Workload Interests for recognised hospital shortages, or Interruptions from administrative Access to template for personal reasons wards time, including equipment PGY2-5 accreditation education Competing Interest in participating and mandatory education Access to Perceived usefulness of training programs SIM centre program requirements Clinical emergencies Large No outcome numbers of Lack of senior statements VMOs with less doctor involvement in for PGY2-5. teaching time planning Failure to share program details Reliance on donated between hospitals teaching time Lack of communication between training colleges and hospitals

Discussion Whist this initiative has been welcomed by junior doctors, its implementation has not been without challenges (see image 2). Issues have occurred at an individual, hospital and inter-organisational level, including a lack of resources, a lack of evidence and literature in this field; difficulty securing senior doctor involvement and buy-in; competing clinical and education interests, and junior doctor factors, such as workload and rostering. As the program continues to evolve we are looking at ways to address these barriers, including a hospital-wide approach to ensure protected teaching time; ongoing liaison with senior doctors and educators to ensure their support; utilisation of outside doctors, registrars and nursing staff to help provide teaching; inter-hospital collaboration; significant forward planning, and constant evaluation of the course to ensure it meets the needs of JMOs.

Conclusions Whilst the gaps in prevocational education are well-recognised, our experience in implementation of a program attempting to address these met with challenges at various levels. We are hopeful that with innovative approaches to teaching we will be able to overcome these barriers in the future. We support earlier calls encouraging greater prioritisation and recognition of the role of teaching in the prevocational years, including better resourcing and systemic support at hospital, state and federal levels.

References 1.

Paltridge D, ‘Prevocational medical training in Australia: where does it need to go?’, MJA, 2006; 184: 349-352.

2.

McGrath B et al, ‘Lack of integration of medical education in Australia: the need for change’, MJA, 2006; 184: 346-348.

3.

Gleason A et al, ‘Prevocational medical training and the Australian Curriculum Framework for Junior Doctors; a junior doctor perspective’, MJA, 2007; 186: 114-116.

4.

Neate S et al, ‘Barriers to continuing medical education in Australian prevocational doctors’, Australian Health Review, 2008; 32: 292-300.

5.

Dent A et al, ‘Learning opportunities for Australian prevocational hospital doctors: exposure, perceived quality and desired methods of learning’, MJA 2006; 184: 436-440.

6.

Kemp A, ‘Prevocational Medical Training: The Four Pillars Program’, Feb 2nd, 2014. Staff Brief.