Medical education in Australia

Medical education in Australia includes the educational activities involved in the initial and ongoing training of Medical Practitioners (medical doctors). In Australia, medical education begins in Medical School; upon graduation it is followed by a period of pre-vocational training including Internship and Residency; thereafter, enrolment into a specialist-vocational training program as a Registrar eventually leads to fellowship qualification and recognition as a fully qualified Specialist Medical Practitioner (such as that of a suitably qualified General Practitioner or Specialist Consultant). Medical education in Australia is facilitated by Medical Schools and the Medical Specialty Colleges, and is regulated by the Australian Medical Council (AMC) and Australian Health Practitioners Regulatory Agency (AHPRA) of which includes the Medical Board of Australia where medical practitioners are registered nationally.
The Australian medical education system is historically similar to that of the United Kingdom, but in recent decades, has received influences from the United States and Canada. In contrast to their North American counterparts, Internship and Residency in Australia are pre-vocational terms intended for general clinical rotations so that the junior doctor can gain a broader clinical experience in various medical specialties prior to embarking on a specialist-vocational training program as a Registrar. In the United States, there are no pre-vocational terms, whereby specialty selection during Internship ensures streamlined clinical rotations for that intended specialty pathway, and thereafter, enrolment and progression onto a Residency program towards achieving specialist board certification; thus, Residency in the United States is equivalent to a Registrarship in Australia. Board certified Attending Physicians in the United States are equivalent to specialty-fellowship certified General Practitioners or Specialist Consultants in Australia.
Most of the specialist fellowship qualifications and medical school degrees awarded to Australian-trained clinicians are internationally recognised. Reciprocally, Australia accepts most recognised university and specialty qualifications of international medical graduates from countries with well-established medical education programs and health systems; that is, pending verification of the person's identity (including visa and immigration requirements), qualifications, practice history and experience, English language competency, a probationary period of supervised practice, and any necessary examinations and assessments to abridge any gaps in knowledge to ensure clinicians are aligned to the current standard of medical practice in Australia as dictated by the relevant Medical Specialty College, Australian Medical Council and Medical Board of Australia.
The education and training requirements of a medical practitioner from starting medical school to completing specialist training typically takes between 9 years to 16 years (or more) assuming full-time study and work, and dependent on the specialty choice and satisfying in-training requirements. In Australia, it is most common for medical practitioners to follow either the General Practitioner or Specialist Consultant career and training pathways, with a small subset choosing not to attain fellowship qualification and continue their career as non-specialist Hospitalist clinicians. General Practice is recognised as a medical specialty with its own specialty college and specialty training program; it is akin to the scope of practice of Family Physicians in the United States or Canada. 
Medical School.
Entry into medical school and its successful completion allows the graduate to become recognised as a medical practitioner (doctor) and commence their post-graduate pre-vocational training. The aim of medical school is to teach basic medical knowledge and clinical skills to prepare the prospective junior doctor for safe and competent practice upon commencement of their internship. It remains one of the most highly competitive university programs to apply for.
Nomenclature.
Historically, Australian medical schools have followed the United Kingdom by conferring the degrees of Bachelor of Medicine and Bachelor of Surgery (MBBS) to its medical graduates, whilst reserving the degree of Doctor of Medicine (MD) to be issued to those who have completed higher research studies or given honorarily to those who have contributed significantly to the medical professional community (analogous to the PhD or honorary doctorates). While a significant proportion of Australian medical schools as of the early 1990s have shifted from undergraduate to graduate entry programs (that is, enrolling students who have already completed a bachelor's degree in another field of study), medical schools continued to nevertheless award the MBBS as its standard medical degree regardless if it was an undergraduate or graduate entry program. Some medical schools have moved to awarding MD (or a combination of a BSc and MD) instead of the MBBS to its medical graduates. However, given that the MBBS is categorised in the Australian Qualifications Framework (AQF) as a Level 7 Bachelor's level degree it had the benefit of not mandating its students to partake in a research project, whilst the MD is categorised a Level 9 Master's level degree it does require its students to formally produce a research project as part of their studies; that said, students in the MBBS program commonly did nevertheless still pursue research on an extra-curricular basis.
Regardless, both MBBS and MD awarded at any Australian medical school qualifies a person to be registered with the Medical Board as a medical practitioner and allow the graduate to be customarily addressed by their prefix title of 'Doctor (Dr.)'. It is also worthwhile to note that while the colloquialism of the term 'physician' in the United States is used to broadly refer to any type of medical practitioner, in Australia and the United Kingdom 'physician' typically refers to a medical practitioner who specialises in the field of internal medicine / general medicine or its sub-specialities; similarly, the 'surgeon' typically refers to a medical practitioner who specialists in a surgical specialty. In order to avoid confusion given the wide interpretation and availability of those who utilise the prefix of 'Doctor (Dr.)' in other professions, the Medical Board and relevant federal and state legislation has chosen to refer medical doctors formally as medical practitioners in Australia.
Undergraduate Entry.
Medical schools have traditionally in Australia followed the Commonwealth and United Kingdom by admitting students directly from secondary school (high school) matriculates. About half of the medical schools in Australia remain undergraduate in their admission. Applicants apply directly to the medical school and/or through the statewide facilitated university course placement program. Applicants are typically assessed by a combination of their:
Undergraduate medical programs are typically 5 to 6 years in length following the traditional two-semester academic year (the exception to this is Bond University which has a three-semester academic year which allows students to complete the course in 4.6 years). Notwithstanding that there are some universities, while accepting the student as an undergraduate, typically require they complete a first degree in science (or something else) in addition to the medical degree that is to be completed concurrently.
Graduate Entry.
About half of medical schools in Australia have followed the United States and moved to post-graduate entry. Applicants are varied from those of "pre-med" or health sciences related background and those from unrelated professions such as law or engineering. Applicants are typically assessed by a combination of their:
Graduate medical programs are typically 4 years in length. They do not follow a typical university academic year due to the volume of content and experience required to be learned.
Syllabus.
Most medical schools follow a similar education program, which includes essentially two phases:
Most learning is multi-modal and include traditional didactic learning through lectures, workshops, seminars, clinical simulation and tutorials, group-based tutorials such as Cased-Base-Learning (CBL) or Problem-Based-Learning (PBL), in addition to any hospital facilitated educational activities.
Research project(s) are mandatory in the Master's level MD programs and optional in the Bachelor's level MBBS programs. This is in addition to encouraging students to be able to critically appraise literature and practice Evidence Based Medicine.
Assessments commonly include a mixture of written (MCQ, EMQ, short and long answer) and clinical exams (OSCE) at the end of each term or unit. It is important to note that unlike our counterparts in the United States where there is a standardised exam (USMLE) across the country in order to become licensed to practise medicine, Australian medical school exit exams are set by the individual medical school and serve as the qualifying exam to be eligible for Medical Board registration. Successful completion of medical school allows the graduate to be registered provisionally with the Medical Board and proceed to applying for an internship. It is not until speciality training where there are standardised examinations held across the nation that is facilitated by respective medical speciality colleges.
Current Australian medical schools and their basic qualifying medical degrees are listed below:
Internship.
Internship is a period of mandatory supervised general clinical experience. It allows medical graduates to consolidate and apply clinical knowledge and skills while taking increasing responsibility for the provision of safe, high quality patient care. Diagnostic skills, communication skills, management skills, including therapeutic and procedural skills, and professionalism are developed under appropriate supervision. Internship also informs career choices for many graduates by providing experience in different medical specialities including general practice, and providing a grounding for subsequent vocational (specialist) training.
The Medical Board of Australia has established the "Intern Registration Standard". It defines the supervised intern (provisional registration year) training requirements that must be completed in order for graduates of Australian and New Zealand medical programs accredited by the Australian Medical Council and approved by the Medical Board of Australia to be eligible for general registration.
Graduates of these programs of study are required to hold provisional registration and to satisfactorily complete 12 months of supervised practice as an intern before being eligible for general registration. Whereby, general registration indicates that the practitioner has the skills, knowledge and experience to work as a safe entry level medical practitioner able to practise within the limits of their training.
Interns are required to perform satisfactorily under supervision in the following terms:
There are usually four or five terms in an internship (between 10 and 12 weeks duration). Interns are required to complete three core terms in medicine, surgery and emergency care and other (non-core) rotations make up the balance of the intern year providing opportunities to explore additional areas of medicine and surgery, anaesthesia, psychiatry, paediatrics and less acute care such as rehabilitation medicine, palliative care, geriatrics and general practice.
Internships are positions facilitated and funded by both State Governments and the Commonwealth (federal) Government. In 2016, there were 3314 state-funded intern positions and 100 Commonwealth funded intern positions. With the increasing number of medical graduates, there have been concerns about the number of available internships.
Applications for internships are typically coordinated by the relevant State Government's Health Department through an annual recruitment campaign. Applicants have the opportunity to preference the district and/or hospital(s) they wish to be employed at, and are selected based on a combination of a ballot-based and merit-based system. The Australian Medical Student Association provides a yearly "Internship Guide" to help guide medical graduates in their application process, as well as providing general information about the different State and Territory Health systems and clinical opportunities available at the various hospitals.
Residency.
Residency, for most doctors in Australia, is typically a further one or two years following internship spent working in the hospital (or occasionally, in community health settings) to gain more clinical experience in a range of settings with increased levels of responsibility. In contrast to medical education following the United States system, internship and residency in Australia are considered pre-vocational terms where doctors have yet to formally commence their training in a specific speciality. While some specialist medical colleges accept entrants after successful completion of internship or postgraduate year 1 (PGY-1), most prefer applicants to have completed at least a further 2 to 3 years (or more) of pre-vocational training at the level of a resident (PGY-2 to PGY-3 or more) in order to have gained sufficient additional clinical experience prior to applying for a specialist training program. Clinical rotations and terms are at the preference of the resident (and dependent on the availability of the health service); there are no mandatory terms to fulfill; for example, if the resident has aspirations to pursue enrolment in surgical speciality training, they would preference and request more rotations in the various surgical specialties (for instance, Neurosurgery, Cardiothoracic, or Urology), versus if the resident had interests to pursue emergency medicine, he or she would probably benefit from further rotations in the various critical care specialties (that is, Intensive Care Medicine, Emergency Medicine, or Anaesthetics).
During residency, these clinicians are known by a variety of terms, including but not limited to:
Residents typically have general registration with the Medical Board of Australia; that is, having successfully completed internship in Australia. Whilst the Medical Board no longer requires performance reports to be submitted directly to them, it mandates and delegates the responsibility to the relevant hospital administration, post-graduate medical councils and speciality colleges, to ensure the continual support, education and teaching of their residents (and registrars) as well as ensuring routine performance reviews and term reports from senior clinicians supervising their practice.
Applications for residency is similar to that of internship, and is coordinated by the relevant State government through an annual recruitment campaign. Applicants have the opportunity to preference the district and/or hospital(s) they wish to be employed at, and are selected on a merit-based system which typically includes a review of the applicant's resume, interview, and referee reports.
Registrarship / Speciality Training Programs.
Registrars.
Registrars are doctors formally enrolled and accredited into a speciality (also known as 'vocational') training program; hence, they are also known as "trainee specialists". After completing internship and one or more additional years as a resident and meeting the pre-requisites for the relevant speciality college, doctors can apply for admission to a recognised medical speciality training program. Registrarship or vocational specialty training is akin to an apprenticeship or clerkship in other professions. It is a period of on-the-job training and assessments in order to qualify for fellowship of one of the recognised specialist medical colleges, which allows a doctor to practice medicine independently and unsupervised in that relevant speciality field, and with this access to an unrestricted Medicare provider number and Medical Board specialist registration.
Selection into a speciality training programs are based upon merit and are highly competitive. Nowadays, most colleges require applicants to have previous clinical supervisors submit referee reports, and fulfil a number of criteria in their "curriculum vitae" which typically involve scoring the candidate in four domains:
Applicants with satisfactory "CV" are invited to partake in interviews or assessments that typically assess adequate medical knowledge to commence speciality training and explore psycho-socially if the candidate if suitable for the speciality.
Registrars pay an annual enrolment fee to be part of the speciality college (in addition to fees for exams and courses). In order to qualify for election to fellowship and specialist recognition, most specialist colleges have clinical, practical and exit exams, in conjunction with other assessments to assess the full range of skills and behaviours required as a doctor, such as communication and team work. Specialist training programs and examinations are administered by the individual colleges and vary between three and seven full-time years to complete, depending upon the speciality you choose. Part-time training is available to most specialities, and dual-speciality-training is optional and streamlined for some specialities. Vocational training for most medical specialities is undertaken in a public teaching hospital, however it increasingly includes rotations in private hospitals, regional, rural and community health settings. The exception is general practice, where doctors undertake most of their training in designated private general practices in a community setting.
Registrars are nonetheless employed and remunerated by the hospital at which they work for; and thus, are still required to submit an application for a position through the recruitment campaigns coordinated by the relevant State government's ministry of health. That said, some colleges help allocate employment and allocation to various training sites and hospitals to streamline the traineeship and employment obligations, whereas some colleges leave this entirely to the discretion of the trainee.
Registrars are typically classified into :
Registrars are comparable to Residents in the United States medical system; that is, at this stage of their medical career, both are undergoing specialty training. As aforementioned, Residents in the Australian medical system are doctors who have completed internship and undergoing additional years of general clinical rotations to gain further experience, prior to enrolling into a specialty training program. In the United States, choice of specialty is decided upon commencing Internship, such that clinical rotations and specialty training requirements are streamlined early on and flows straight on to Residency. There is no requirement in the United States for junior doctors to complete "pre-vocational/pre-specialist" training or experience general clinical rotations prior to specialty training enrolment; which is in contrast to Australian and other Commonwealth medical systems that choose to keep this traditional format in view that it ensures junior doctors receive holistic training and generalist exposure in various specialties of medicine before choosing a specialty to pursue.
Unaccredited Registrars.
"Unaccredited" registrars are doctors who are fulfilling the higher duties and role of a specialist registrar at a hospital, but are not formally enrolled in an accredited training program. They typically come from the cadre of senior residents with adequately more experience and aspirations to pursue that specific specialty as a career, but have yet to meet the pre-requisites to formally enrol into the specialist training program and become an accredited specialist trainee; where typically time spent working and training as an unaccredited registrar does not usually count towards formal specialty training time. Unaccredited registrars help fulfil shortages in hospital services where otherwise an accredited registrar is unable to be recruited; thus, they are sometimes also known as "service" registrars.
Doctors who choose to take up the role of a unaccredited registrar are typically those:
Medical Specialist Colleges.
In Australia, the Australian Medical Council has recognised 16 medical speciality colleges responsible for the continued education, training, and accreditation standards of their respective specialities:
Hospitalists / Non-Vocational & Non-Specialist Doctors.
In Australia, hospitalists are career hospital doctors; they are experienced generalist medical practitioners whose principal focus is the provision of clinical care to patients in hospitals; they are typically beyond the internship-residency phase of their career, but have decidedly chosen as a conscious career choice not to partake in vocational-specialist training to acquire fellowship specialist qualification. Whilst not specialists, these clinicians are nonetheless senior in their years of medical practice, and depending on their scope of practice and experience, they typically work with a reasonable degree of independence and autonomy under the auspices of their specialist colleagues and supervisors. Hospitalists form a demographically small but important workforce of doctors in hospitals across Australia where on-site specialist (or registrar) coverage is otherwise unavailable.
The commonest pathway in medicine, is to complete medical school, then internship and residency, before finally completing a specialty training program as a registrar thereby becoming a specialist medical practitioner. Hospitalists typically come from clinicians who have completed their internship-residency, and usually some further formal or informal rotations as a registrar, but have decided not to, or have yet not, complete their vocational specialty training. The reasons for why hospitalists choose their career track are varied, some of which include:
These clinicians are known by a variety of terms, including but not limited to:
Hospitalists are typically employed in a variety of public and private hospital settings on a contractual or salaried basis. Traditionally, career medical officers or hospitalists are employed as permanent full-time or part-time staff, but more commonly in recent times, due to a significant workforce of clinicians been in-flux with their specialty training and insufficient staffing of middle-grade clinicians at hospitals, there has been an increase supply and demand for hospitalists on a "locum tenens" or casual basis. Dependent on their place of employment and duties, the responsibilities and remuneration of non-specialist hospitalists are usually comparable to somewhere between registrars and consultants. Despite the common trend for clinicians to specialise nowadays, non-specialist hospitalist clinicians have an important role in fulfilling shortages in the medical workforce, especially when specialist (or registrar) coverage and accessibility is unavailable, where there is an area-of-need, and after-hours or on-site medical care is required. These clinicians and employed across Australia in a variety of clinical environments which include Medical & Surgical Wards, Mental Health Units, Intensive Care Units and Emergency Departments. Nonetheless, these clinicians work closely and continually consult with the relevant attending specialists on-call; that is, final responsibility and care for the patient ultimately still rests with the attending specialist.
General Practice is formally a speciality of its own with formal vocational specialist training. That is, those wishing to practice as a non-vocationally registered General Practitioner (Non-VR GP) without specialist registration can only do so in designated areas-of-need (such as that of rural townships) and at the compromise of only been able to invoice for limited Medicare rebates. The exception to this are those who were 'grandfathered' as already working as GPs for at least 5 years prior to 1996. Non-specialist doctors are issued a restricted Medicare provider number that allows them to initiate referrals and request pathology and radiology investigations, but not access full Medicare billings.
The Australian Medical Association (AMA), Australasian Society of Career Medical Officers (ASCMO) and Australian Salaried Medical Officers Federation (AMSOF) are organisations that represent this group of medical practitioners. Despite been non-vocational and non-specialist clinicians, they are still required to meet continuing professional development requirements and frequently attend courses facilitated by these organisations and the hospitals to keep their practice and skillsets up-to-date alongside their vocationally-trained specialist colleagues.
Consultant Specialists & General Practitioners.
Upon completion of the prescribed specialty training program by the relevant medical specialty college, doctors are awarded a fellowship of that college and eligible to register and be recognised as a specialist with the Medical Board; paying annual fees to both the Medical Board and Specialty College for their specialist registration. These clinicians are considered to have satisfied all the necessary education and training requirements to become qualified for that specialty. Those with specialist registration are allowed to practice independently and unsupervised in their area of expertise, which in effect allows them to pursue private practice. Specialist clinicians are eligible for an unrestricted Medicare provider number that allows clinicians to bill rebates from Medicare for services delivered to patients, privileges for hospital admissions and private health fund billings, where most patients in Australia are a mixture of publicly covered Medicare and privately insured through a health fund. Whilst most specialist clinicians take the opportunity to pursue private practice, many of them (with the exception of a majority of GPs) continue to work at least part-time as salaried employees in the state public hospitals. There is also an opportunity for specialists partake in hospital administration to take-up committee or managerial positions, such as director of their department or the hospital or health service, as well as being actively involved in the education and supervised training of their junior colleagues.
Specialists are typically now recognised by their specialty profession name; for example, Radiologist, Pathologist, Haematologist, Nephrologist, Neurologist, et cetera. Physician broadly refers to those who specialise in any of the internal medicine sub-specialities. Surgeon broadly refers to those who specialise in any of the surgical sub-specialities. Doctors which have completed their specialist training are known by a variety of terminology, including but not limited to:
As of 1995, General Practice in Australia has been formally recognised as specialists by the Medical Board with its own specialist vocational training pathway; its specialised role in health care is that of providing primary medical care to the community and comparable to that of specialist family physicians as in the United States and Canada; that is to say, a properly trained and qualified GP should be able to independently diagnose and treat a wide variety and range of illnesses in the primary care setting prior to referral to their specialist colleagues. That having been said, the term 'specialists' more colloquially and traditionally refers to clinicians qualified in a specialised field of medicine beyond the scope of General Practice. Medicare also makes this delineation for the purposes of appropriately allocating referrals, rebates and billings amongst 'Non-VR' GPs versus 'VR' GPs versus 'Specialist' Consultants. That is, those wishing to practice as a non-vocationally registered General Practitioner (Non-VR GP) without specialist registration can only do so in designated areas-of-need (such as that of rural townships) and at the compromise of only been able to invoice for limited Medicare rebates. The exception to this are those who were grandfathered as already working as GPs prior to 1996. Non-specialist doctors are issued a restricted Medicare provider number that allows them to initiate referrals and request pathology and radiology investigations, but not access full Medicare billings. Medicare requires that patients attend their GP as their primary point-of-care, and in order to access Specialist care, the GP has to initiate and provide a referral.
Fellowship qualified specialists are required as part of their specialist registration to partake in activities throughout the year ensuring their continued professional development (CPD) which is monitored and facilitated by their respective specialty medical college.
Additionally, while there is no requirement to do so, some clinicians at this stage of their career may consider further education (that is, if they have already not done so):
Continuing Professional Development (CPD).
Continuing professional development (CPD) ensures clinicians remain up-to-date and evidence-based in their medical practice as mandated and audited by the Medical Board of Australia:
Education of junior doctors (that is, Interns to Residents to Registrars) is typically arranged on a regular basis by the hospital at which these clinicians work at and are facilitated by the senior staff specialist clinicians, as well as a proportion of self-directed learning in their own time. The forms of education can include but not limited to:
Education of fellowship qualified General Practitioners and Specialist Consultants, is typically facilitated by the relevant specialty medical college; with each college having its own CPD program. Similarly, Hospitalists and Registrars financially enrolled in the College as non-fellow or trainee members may also partake in the CPD program and educational activities, some of which are highly recommended or mandatory. Most specialty colleges use a points-based system to keep track of the clinician's CPD obligations for each year, with each specific activity attracting a certain number of points (for instance, attending a conference or workshop may be worth 3 CPD points, whereas reading a journal article and completing the online quiz may be worth 1 CPD point). There are certain education modules that are mandatory for specialists and their trainee-registrars, and others which are optionally recommended to be completed at the preference of the clinician.
Mandatory education activities typically require the clinician to participate in activities that ensures ongoing up-to-date competency and receive feedback on core skills and clinical knowledge related to their scope of practice. These typically include:
In addition to the above hospital-based education already mentioned, additional forms of self-directed education include such activities as:
Recency of Practice.
To meet the standard, medical practitioners must practise within their scope of practice at any time for a minimum total of:
Full-time equivalent is 38 hours per week. The maximum number of hours that can be counted per week is 38 hours. Medical practitioners who work part-time must complete the same minimum number of hours of practice – this can be completed part-time.