General medicine

Welcome, my name is Spencer Toombes. I'm a general physician at Toowoomba Hospital, and I'll be the presenter for tonight. I'm very pleased that we've also got Dr. Mel Dietz, who's a gen med advance trainee at Cairns at present, here to answer some of your questions, but also to talk from an advanced trainee perspective and from a rural and regional training perspective. Just to advise you all, that tonight's talk is being recorded and will be shared later for those people who don't make it. And although numbers are relatively small, we will pause as we go along to take opportunities for questions. You should be welcome to ask verbally or to pop them in the chat.

Alrighty, so tonight we're going to talk about general medicine Advanced Training, and these are the four things that we're hoping we'll achieve this evening. I'm going to give you a brief introduction to what general medicine Advanced Training looks like in Queensland and what it is to be a general physician and how you prepare to be one. I'll talk about the college's training requirements and how the network, which is a Queensland Health construct, helps you to navigate those training requirements.

We'll talk briefly about the application and selection process so that if you are applying for training this year, you'll be in a position to do that when the RMO campaign opens. And then as we tick along, we'll give you the opportunity to ask questions. If you want to throw stuff into the live chat as we go along, you're welcome to do that. I probably can't see the live chat with my presentation open, but we'll certainly check it intermittently to do our best to deal with your questions.

General physicians, according to the Internal Medicine Society of Australia and New Zealand, we are highly trained specialists. We provide non-surgical healthcare, sort of defining what we don't do rather than what we do. But we care for difficult, serious, unusual medical problems, and we continue to see patients until the problems are resolved or stabilized and can hand their care over to their General Practitioners.

If you read through the curriculum, general and acute care medicine training from the college, we're apparently experts. We're diagnosticians. We provide integrated care. We solve problems. We advocate for patients. We are very good at communicating and negotiating, innovating and leading, and we're also a lot of the teaching and mentoring falls to us as well. While those are very much aspirational goals for every general physician, there is a core of truth to this. It's part of the job of general physicians in hospitals and in healthcare systems in Queensland.

There is a spectrum of practice. You will find general physicians doing all sorts of different jobs in regional hospitals. You'll find some really interesting jobs. For example, Cape York is serviced by flying physicians, so predominantly Outreach medicine, some sub-specialists, but many general physicians from Cairns will do flying clinics all over the Cape and up to Thursday Island, all over the state. Not very many of them, but here and there, you will find solo physicians who live in regional towns and occasionally in remote communities providing local care and Outreach care to the communities around them.

Here in Toowoomba, which I appreciate is not very regional because we're only a two-hour drive away from the beach or a half-hour drive away from the fancy shops in Brisbane, we have general physicians looking after core medical inpatients. They run our medical assessment planning unit, but we also have general physicians on our endoscopy roster, including after hours, and they provide a straight perfusion roster. I've crossed COVID positions off because now apparently all of us are covered physicians. We don't have a specific unit for them here anymore. But when COVID position was a thing, most of them were general physicians. Locally, we provide obstetric medicine, paraoptic medicine, rheumatology clinics, some respiratory clinics, and antimicrobial stewardship.

Elsewhere in the state, I'm aware of dual-trained general physicians providing dermatology and some dual-trained and just with an interest providing infectious disease bronchoscopy and supervising chemotherapy in cooperation with oncology services. In the metropolitan hospitals you'll find general physicians in AMUs and MAPUs doing specific preoperative management, running residential Outreach or Hospital in the home, doing hospital admission prevention programs, or complex patient multi-system disease clinics. And then, with niche expertise or dual training, you'll find them doing clinical pharmacology and running deprescribing clinics, involved in epidemiology and high-level government decision making, and you'll find experts in health information systems and change management who are general physicians. So, with that spectrum of a complex and diverse set of skills, you have to ask, how does the College of Physicians ensure that when they hand someone an FRACP in general medicine, that they are up for these jobs and how do you train someone for these jobs?

From Queensland Health's perspective, we have to ask where they're going to train and ultimately where they're going to work. In order to try to solve some of these problems or simplify some of these questions, we have the Advanced Training Network for you to apply to. So, who are the key players? Well, these are the four key players, and of course, we put the trainee in the centre because they are at the core of our training process. But each trainee needs an employer, so you need a job, and the majority of those jobs are provided by Queensland Health. But clearly, if you're in Brisbane and you work for the Mater Hospital or for Greenslopes, then you can find yourself outside of Queensland Health and still in the system.

And then you have the college. The college is responsible for accrediting each of those training employers and accrediting the jobs that they do and the terms that they provide. And then also attached, we have the network. So the network's role is to facilitate the rotation of trainees through different jobs, through different roles in order to meet accreditation or the requirements of the terms set up by the college and the standards for training set up by the college.

So, let's talk briefly about what the college's requirements are for advanced training. So, while there is a lot of talk at the moment about moving to a competency-based curriculum rather than a time-based curriculum, at the moment, it's time-based. If you're going to be an advanced trainee, you need to complete a minimum of three years of training, and that training is divided ideally up into six-month terms. From a pedantic point of view, the college will accept a four-month term as a core term. So, you could plausibly do three terms a year. And if you are doing it part-time, then three months full-time equivalent part-time is considered as one whole term. The college used to have flexible training down to 0.2 FTE, and they still go down to 0.2 as flexible training now. But if you think that through, at 0.2, you need to do essentially 12 months to just sneak into three months of FTE. Even then, maybe a little bit further of the three years of events regarded as core training, which is to say a minimum of four core terms. Two of those terms, 12 months, are expected to be in general medicine or general medicine-like terms. Core general medicine is a general medical service, inpatients, outpatients, continuity of care. General medicine-like terms are terms where you might be looking after a medical assessment planning unit or a perioperative unit or a hospital in the home, or a small number of other things. On the college's website, for the additional year of core training, you need to get some subspecialty exposure. So, non-general medicine, and those two subspecialties need to be different from each other. The idea here is that you're achieving breadth as well as depth of knowledge across the spectrum of medical care.

Now, the one year of non-core training, I hasten to point this out; non-core is not the same as unimportant or irrelevant. When I was wearing a college hat and assessing people's applications, it would horrify me that people would be doing very boring or very non-attributive to their training jobs and claiming that as non-core time. Because the goal is to use every one of those three years of Advanced Training to enhance your experience and make you a better physician.

So, the non-core year could be used to get your six months of acute medicine, although there are jobs, for example, such as acute medical assessment planning units, where you can do both the core general medicine and the acute term simultaneously. The one year of non-core is sometimes used as 12 months for dual training specialty, and we'll talk about dual training in a moment. You could add an extra six months of one of your core terms, so that you get a particular subspecialty flavour, something that you're interested in and want to become good at. You might use it as a year acquiring a procedural skill, such as bedside ultrasound, endoscopy, or you could plausibly use it for two more subspecialty terms to really increase your breadth of exposure.

There are some other considerations for your training. In the course of three years, the college would like you and the network would like to facilitate you to train a minimum of two hospitals. It's a good idea to see how different people do different things because pretty much everywhere you go, all Queensland Health hospitals are going to have very different personalities. You can find very different approaches to rostering, problem-solving, leadership, and plausibly different approaches to medical care. Getting that experience of breadth is key.

Nightshift is a bug bear for the college. Clearly, there are particularly smaller hospitals where general medicine Advanced trainees are expected to contribute to nights, so there is an allowance from the college's point of view for a couple of weeks of nights per term, mostly to help out with the roster. And there are some hospitals, like the Royal Brisbane and the Gold Coast, where they have specific hospital at night terms, where a general medicine Advanced trainee might be rostered into a night shift, not as a basic trainee granted inpatients, but as someone taking the triage, assigning tasks, supervising junior registrars. In certain limited circumstances, the college will accredit that as training, but you need to negotiate that with the individual hospitals as you go along. Certainly, ordinary scutwork night shift is not counted as Advanced Training by the college.

ATs, in general, are still committed to the PREP program, so physician readiness for expert practice. This means doing a learning needs analysis per year, a case-based discussion per year, and a professional quality is reflection per year. The summative assessments take the place of your supervisor reports, which have to be completed at least every six months, and the Advanced Training research project, which is a publishable piece of research of high quality that you need to produce one in the course of your three years of Advanced Training.

Dual training is a sort of special case. For most of the subspecialties, you can do two years of subspecialty and two years of general medicine, overlapping the non-core year for both of those subspecialties with the medicine. In order to complete accreditation in two subspecialties in four years, to my knowledge, the two subspecialties that you can't do that in at the moment are Cardiology and Nephrology, which require three full core years of Advanced Training. If you want to dual train in either of those specialties, it'll take you five years, rather than the four years.

With that list of skills, especially ready to tick off, I don't think you buy those skills. What sort of terms, what sort of duration will it take, and where are you going to acquire them? Where are those terms available? That might require a bit of research to talk with the information we have on the website.

Now, I think this is the point where I bow out and get Mel's impression of that from the perspective of recently doing it as an Advanced trainee. So, thanks, Mel. You're up next. Thanks, Spencer.

So, my name's Mel. I'm one of the final year Advanced trainees in general medicine in Cairns. I think, talking a little bit about what Spencer has already mentioned, I guess my training background is that I spent my first year of Advanced Training in Mackay and then have done the last two years in Cairns. I've been very fortunate that I've had very varied training. So, I had the opportunity to do a bit of chief medical registrar role while in Mackay, predominantly doing gen med while I was there. While being in Cairns, I've done infectious diseases. I did the Cape Outreach job that Dr. Toombes is talking about, and I was fortunate enough to actually see some of your notes, Spencer, when I was up in Thursday Island, which is a very interesting job for anyone. I'll just spruke it. It's really a different term that you won't experience anywhere else, flying out to the First Nations communities, and doing general medicine is very exciting and interesting. I'm currently doing the palliative care diploma and then will finish doing a neuro-stroke term. So, you can make your general medicine training whatever you want it to be, and your non-core is where you can really, I guess, be a bit more flexible.

Finding things that are going to pique your interest and also help you in your career path. I know a few of my colleagues have done things like there's a hypertension job at the Princess Alexandra Hospital where you can do a little bit of UQ teaching with medical students while doing hypertension. There are some trainees that are doing point-of-care ultrasound sub-specialisations as part of their general training. So there are so many things that you can do within general medicine that's not just getting an extra BPT role where you kind of slide into a sub-specialty as you would have as a BPT. You can use your general medicine training to do something a little bit different. So again, as Spencer said, when you're trying to plan your general medicine training, try and consider where you want to be and what you want to be doing so that you can gain the skills that you need to take into consultancy. Because your advanced training is meant to prepare you for being a consultant, and it gets a little bit daunting when you're in your final year and you realise that not that this is all you're going to get, but kind of you realise that this is where your formal training ends and your last opportunities to kind of do those different sub-specialties. And yes, you can always go back, but definitely take advantage of the time you have as an advanced trainee. Understand your training requirements. As Spencer has gone through already, understanding that you need your acute time and your sub-specialty time, making sure that that's locked in early. Don't leave your acute term until your last 12 months and be struggling to find an acute term because that can make things very tricky for you because training goes very fast. You really want to make sure slides, you really want to make sure that your training is maximised.

Prepare your training for becoming a consultant. So take into account where you want to work and what skills you want to have is really important. The importance of networking. I probably didn't realise this until I was an advanced trainee just how important the networking is as part of your training and getting a consultant job. A consultant said to me at the end of last year, your consultant job application starts as soon as you are an intern. People remember you and they remember how you work. So it's important that you are always widening your network to meet new people, especially if you're interested in working as a consultant in a particular place. You are meeting these people early. Going to conferences is a really good way. And I'm just going to spruke the Gen Med conference while I'm talking about that, since it's our Gen Med, the sub-specialty, and I've forgotten the word, our groups of society. Society is weird, sorry. It's our society, and we're fortunate that we're actually having it in Cairns this year, so it's in Queensland, it's in September. It's a really good opportunity to meet general physicians from around Australia, the state, and also from New Zealand. The trainee day, which is on Wednesday, we're actually having a session on ways that you can find interesting training opportunities, running through how to maximise your training and other trainee issues. So, I would recommend that you come along to that, and the program should be up soon. Also, I recommend finding a mentor when you're trying to plan your training. It can be really hard if you don't necessarily know the requirements or what opportunities are out there. So finding somebody to help you plan your training is really important. Also, enjoy your training, so do things that you enjoy and maximize your opportunities.

I presume Spencer, you can talk about GMATS a little bit later or... Yeah, we've got a couple of slides on that. Great. So, my training has been so put a little bit up about why you should consider regional training and that it's actually quite important, one for your own skill development as well as your CV and getting a consultant job. That's where a lot of the jobs are. And I think that's where general medicine is actually its most interesting, where there's not access to necessarily as many sub-specialists right at the door. And it's great for general medicine. So that's all I sort of wanted to talk about. And yeah, feel free to put any questions in the chat or ask at the end.

Thanks, Mel. We actually have a questions slide in there, just to see if anyone's going to pop up some questions at this point. Often, they don't because you've been so thorough. Yeah, it's interesting that Queensland is nearly 50% of the population is outside the metro area. We're a widely dispersed population, and that's why there is so much work for general medicine and so much interesting stuff to see outside of the southeast corner. There are lots of great opportunities and some amazing things to see and do, not to mention the reef and the rainforest and all that stuff. Alright, I'm watching the chat window. Nothing's popped up. We might press on. So, thanks, Mel, for providing that perspective and filling us in on the joys. I guess the other thing to say is that at the end of advanced training, you're not going to feel necessarily that you're ready to be a consultant. And it's just as there was a huge hump has moved from being a resident to being a basic training registrar and it's a bit of a hump moving from basic training to Advanced Training.

There's another series of lifts as you become a consultant, and I will recall feeling for the first probably three or four years as a consultant feeling that I was a senior registrar pretending to be a consultant. And then, as you fake it for long enough, you eventually realise, no, actually, this is what consultants do, and you keep faking it.

Now, let's talk about the network. The purpose of the network is, again, it's a Queensland Health construct. It's about providing access to jobs. But our main goal is to provide a centralised, mostly transparent, criteria-based allocation process for people who desire to commence advanced training in general medicine. We have between 50 and 60 new positions per year, depending on where people are going with their jobs. We assess, interview, and allocate trainees across the state.

Training program preferences are step 10. You need to put the facility as College pathway or network determined. Tell us whether you want to work full-time or part-time. The position you want is registrar, the specialty is medicine, the subspecialty is Gen Med. You need to preference hospitals that you would be prepared to work at.

There's also an opportunity for dual trainees. We're happy to consider dual training applicants. If you're hedging your bets and you're putting your primary specialty first and general medicine second, we can't guarantee you an interview. We will interview everyone who preferences us first.

After the primary merit ranking, you'll need to nominate a pair of referees who can comment on your skills and experience. Make sure to seek permission from your referees before you put them down.

For the application process, you'll need to apply via the RMO campaign. Open on June 5th and close on July 3rd. Interviewing will be afterward. You'll also need to preference up to six hospitals.

When assessing applications, we assess CVs, short statements, and career intentions against specific criteria. After that, a rank order is generated and then applied to available positions. Successful candidates are allocated to 12 months at their preferred training hospital.

In summary, helpful tips include thinking about what kind of physician you want to be, planning your training to achieve that outcome, communicating your intentions with mentors and hospital directors, crafting your CV and short statement to match selection criteria, and considering the advantages of regional training and careers.

Feel free to ask any questions.

If you need any further assistance, please let me know.