Reforming professional programs to achieve higher learning outcomes : transition to an MD for primary medical training in Australia

Introduction: Professional education programs are at the leading edge of endeavour for university graduates to be more work ready. In medical education, there is an international trend toward aligning the levels of qualifications attained and employing quality standards to assure a doctor trained in one country can practice safely in another. Universities have also been called upon to embed research training in primary medical programs with a broader view to instilling inquiry as a cornerstone of practice in pursuit of a better health system and healthier populations. Medical schools need to remain relevant in order to train doctors who meet the evolving needs of the community. This manifests in continual incremental curriculum renewal. Attaining larger-scale innovative change is less well understood. The purpose of this study was to shed light on the process of change from a Bachelor Degree to a Masters Degree (Extended) in Australia, conferring the award of Doctor of Medicine (MD). This transition, while peculiar to Australia, provided an opportunity to illuminate factors that influence change and impact curriculum development more generally in primary medical education. Within the constraints of accreditation and standards of the Australian Medical Council (AMC) and the Australian Qualifications Framework pertaining to medical education in Australia, change in the medical programs studied was subject to similar regulatory bodies and quality assurance processes as medical schools globally. Understanding was sought of the intent of the higher learning outcomes of the Masters degree in professional contexts, and how these could be achieved to highlight novel and innovative approaches that might support medical student learning. A more in-depth analysis of MD research projects in an acute healthcare setting was undertaken to explore the impact of the clinical context, rather than an academic one, on students' research-based learning. Methods: This thesis chose a comprehensive case study research (CSR) approach to a single health system and community/dual programs that took very different pathways to a similar (in principle) outcome, focusing on research training to contribute to continuous quality improvement of safe and high-quality health care. There were two embedded units of analysis ‚Äö- transition to a graduate-entry 8-semester MD, and transition to a school-leaver entry 14-semester MD. Results: A rich set of subject data was collected, comprising organisational procedure and transition documentation, national regulations, knowledge elicited from 34 participant interviews, and field notes and observations from five site visits over a 14-month period. Analysis: Three objects (frames of analysis) were undertaken to scrutinise the subject (case) data: 1. the MD transition process in the two medical schools, utilising a process-tracing method; 2. the level of understanding required in a Masters Degree (Extended) for primary medical education in Australia and achieving higher order learning outcomes through project work in different settings, utilising content analysis; and 3. research-based learning in an acute healthcare setting in Australia, utilising hermeneutic phenomenology. Discussion: This study of transition to a higher-level degree in medical education provides insight into underlying process, conditions and change mechanisms. Different theoretical lenses highlighted key constructs of interest and has served to embed new understanding in conceptual frameworks for further research. New knowledge has been proposed, specifically for advancing the quality of CSR in medical education, for engineering innovative change in a professional higher education degree, and for promoting higher-order learning outcomes to better prepare doctors for lifelong learning and aspiration for continual improvement in the health of patients and populations. Achieving change in medical programs has not been well understood, and there is some trepidation to embark on change that may not align with existing Australian Medical Council accreditation agenda. Curricula may be a source of differentiation when schools mobilise the collective intelligence of staff, organisational infrastructure and community partnerships. This study has identified key mechanisms and a model for engineering innovative change in a professional medical education program. Academic drift may elongate or make medical education more expensive with no added value for governments or the health system and may further disadvantage rural students and those with less financial support. While some higher learning outcomes may be achieved through activities other than research, there are specific requirements for knowledge and skills in research and their application to professional medical practice. Analysis of the requirements of the Australian Qualifications Framework Level 9 (Extended) degree and the Australian Medical Council standards and competencies pertaining to research knowledge and skills determined: ‚Äö the highest levels of understanding required (extended abstract) pertain to functional knowledge: critically analysing information, reflecting on and applying theory. Graduates are expected to have 'expert' knowledge and abilities in this area based on 'research, experience or occupation'; ‚Äö a high level of functional knowledge is required to plan and execute a project; and ‚Äö a fairly high, but lower, level of declarative knowledge (relational) is required pertaining to scientific methods, ethical and privacy principles, and these are heavily grounded in application to the profession. Existing research competency frameworks are not easily transferrable as they are academically focussed and do not adequately incorporate the essence of quality improvement and valuable formal and informal learning that is integral to developing research expertise in the real world of health service delivery. Further, the availability of information through pervasive technology is shifting the intellectual role of doctors as all-knowing, to assume the professional identity of knowledge integrator, offering finely tuned judgement and decision-making. To achieve the leadership expected of the profession, knowledge and skills in information literacy require greater emphasis at all levels of medical training in both Bachelor and Masters level programs. The steps in evidence-based healthcare are proposed as a frame of reference to assist doctors to learn and organise the skills required for critical inquiry relevant in clinical practice and continuous quality improvement. Broad and in-depth research knowledge and skills are a specialised domain and may be complex to action in healthcare settings. Clinicians preferred a co-supervision model of MD student research, where a university academic actively supervised students providing an appropriate level of oversight and support tailored to the ability of the student and clinical co-supervisor. If research knowledge and skills are taught and enacted poorly in the clinical setting there is a risk that poor research outcomes will deter further learning and research experience and detract from research being embedded as a core component of well-functioning health care systems. Given the differences in the way research is considered, to cultivate the willingness to work together towards an agreed purpose and generate cooperative enterprise between academic and healthcare organisations, a sustainable and effective model requires institutional design and leadership. This study has highlighted the importance of formal research collaboration or partnerships between academic institutions and healthcare organisations, where there is genuine interest in co-production of knowledge, delivering value to the healthcare organisation and relevance for the community, as well as meeting the institutional imperatives of the university.