Education more than governance
“Education” comes from Latin “educates”, with meanings related to bringing up, rearing, bringing out or leading forth (Doublas Harper, 2017).
Despite the core purpose of education offering a directionality of knowledge acquisition and development, how this is achieved in a contemporary and rapidly evolving social and technological landscape is less well defined. Several inter-related and generic factors are driving change in higher education, including technology, monetary, market forces, social and political change, and international events. As a result, changes have been observed in the HE sector in relation to funding, competition, workload, priorities, and accountability. These forces and the resulting trends are explored by Marshall, Henry and Ramburth (2013), Commonwealth of Australia (2009), and Gallagher (2010).
I have chosen to reflect predominantly on accountability issues in relation to specialist medical education.
While undergraduate medical training is, like other university courses, accountable to the public purse and through frameworks such as TEQSA and higher education standards framework, medical specialist training and colleges have different accountabilities and do not fit naturally within defined HE frameworks.
Specialist medical education occurs after completion of the primary medical degree and is delivered by “Colleges”, resulting in ‘fellowship’ of a particular training scheme, which entitles the graduate to practice as a specialist in a particular field.
Despite this training occurs over six plus years, and incorporates rigorous examinations, assessments and research requirements, the ‘fellowship’ qualification does not fit within the TEQSA framework and the resulting qualifications are not recognised along this continuum. Instead, they are regulated by the Australian Medical Council. They are further held accountable indirectly to the public and the medical fraternity, based on the quality of medical care delivered.
Some colleges are incorporating qualifications from the AQF framework as a component of their specialist training, which further muddies the waters of their classification. For example, HETI (Health Education Training institute) delivers the Master of Psychiatric Medicine which is one requirement for completion of fellowship (specialisation) in psychiatry. There could be scope for development of qualifications by HETI, perhaps in conjunction with the colleges, to deliver recognisable education programs as part of medical speciality training.
The question remains: should specialist medical training conform to other HE frameworks of accountability?
The argument against change (and managerialism)
Komsaroff, Kerridge, Issacs and Brooks’ 2015 article in the Medical Journal of Australia explored the concept of managerialism which they argue has taken over the health and education sectors and specifically the Royal Australasian College of Physicians (RACP).
They describe managerialism as a ‘scourge’, with “destructive” consequences. They describe it as a process where the focus on an organisation moves to the operation of an enterprise with “generalisation of the standards and practices of management” and a shift to privatisation and cost cutting, with standardised organisational structures, with the main regulatory principle being the market.
They indicate that through this process, “other criteria such as loyalty trust, care and a commitment to critical reflection have become displaced and devalued” and that these things “are viewed as quaint anachronisms with less importance and meaning than formal procedures or standards that can be readily linked to key performance indicators, budget end points, efficiency markers and externally imposed targets”.
They identify that this shift to managerialism has been seen in:
- Health care with “a shift in power from clinicians to managers” with priorities changing from “from a commitment to patient care to a primary concern with budgetary efficiency”
- University sector – where activities are “assessed in relation to the prosperity of the institution as a business enterprise rather than as a social one”, where education “is seen as a commodity like any other, with priority given to vocational skills rather than intellectual values”
- The RACP with a shift since approximately 2010 from physician member led activities and direction to ‘corporatisation”, with moves for the council to be replaced by a board, centralisation of activities, and reduction of democratic member input.
Aligning the accountability framework for specialist medical education with that of HE could be seen as an example of managerialism, fitting the institution into a ‘one size fits all” model being driven by market forces.
Where to from here? More questions than answers……
While I agree that it is important to not lose sight of the underlying philosophical purpose of higher education in general and specialist medical education in particular, the need for efficiency and accountability remains and also the rate of change on many fronts. The key question is how can a balance be struck between remaining true to ideologies, yet not allowing this ideological dedication paralyse evolution and progress within the context of international trends.
In addition to finding greater clarity with regards to accountability, other pressing challenges facing medical education include:
- How can graduate capabilities be meaningfully ensured in specialist medical training? This includes a shift towards Competency Based Medical Education (CBME) in both post graduate and undergraduate work
- Technology – how is it best for technology and simulation be incorporated into medical education? Is this shifting focus as relevant to medical education as it is to other fields? What features of medical education make
More questions than answers for now, but through the journey of this course, I hope to be able to answer them or at least make some inroads into finding greater clarity.
I found this first topic really difficult being such a “big picture” one…….and have written about half a dozen starts to it, and procrastinated greatly on completing it! I am more a trees than a forest kind of gal! Many subjects I have enrolled in (quite reasonably) kick off with a “big picture” topic like this one did, and I typically find it hard to reflect on at the start, being almost overwhelmed with the many areas introduced at a surface level, without yet having the knowledge about where and how these themes will all come together, which is revealed throughout the course…..and yet it is important to have a big picture “fly over” at the start.
Commonwealth of Australia (2009) Transforming Australia’s Higher Education System, Commonwealth Government, Canberra.
Gallagher, M. (2010) Drivers of Policy Change: The accountability for quality agenda in higher education, The Group of Eight, Canberra
Douglas Harper (2017). Educate (v). Online Etymology Dictionary. Retrieved from: http://www.etymonline.com/index.php?term=educate.
Komesaroff, P. A., Kerridge, I. H., Isaacs, D., & Brooks, P. M. (2015). The scourge of managerialism and the Royal Australasian College of Physicians. Med J Aust, 202(10), 519-521.
Marshall, S., Henry, R., & Ramburuth, P. (Eds.). (2013). Improving assessment in higher education: A whole of institution approach. UNSW Press.