The Role of Pre-Vocational Medical Education

After four to six years of study, graduates are usually full of medical facts and knowledge, and eager to enter the medical workforce. After a few years most will enter a vocational training program which will determine their medical career until they retire.

The two to three years between graduation and vocational training are known as pre-vocational years. In the past these were largely the "forgotten years" with no real professional development during this time. However over the past 10 to 15 years there has been increasing recognition of the importance of these years, and each state has set up a Postgraduate Medical Council (or equivalent) to oversee training during those years.

I have interviewed many interns over the past seven years. Nearly all comment that their intern year was a bit of a shock and harder (usually much harder) than expected. Their difficulty was not due to a lack of medical knowledge but rather one of the following reasons:

1. Working full time and long hours

Many students have never worked before (or at least not full time), and are not prepared for the mental and physical demands of full time work. They quickly find that arriving late, going home early, or skipping a day when tired (as they may have done as a student), is unacceptable in the workplace. Even post-graduate students, who have often worked in different professions before medicine (often at senior levels), find the bottom rung of the medical workforce quite demanding.

2. Responsibility and accountability

Even though interns are closely supervised, and nearly all clinical decisions of importance are directed by a registrar or consultant, the intern is the signatory to what is done, and is often the first port of call if things go wrong. Many interns tell me that they lie awake at night worrying about patients they have treated that day.

3. Organisational culture

Australian teaching hospitals tend to have a hierarchical culture where employees have ranks and roles, and there are formal and informal processes for getting things done. Medical students are largely protected from the hospital culture (they have the university culture to worry about), and it is not until they are employed as a small cog in a big wheel that they start to understand it.

I think the most important aspect of their learning is the role modelling provided by their supervisors (registrars and consultants) regarding:

• work ethic
• how to treat other staff and patients with respect
• how to be approachable and constructive
• how to apply knowledge and skills to everyday work situations. 

It is also important that the hospital as a whole respects and values its junior workforce. They are in effect our front-line troops and the hospital would quickly grind to a stop without them. Non-medical issues really do matter, such as being given annual leave and study leave, being treated fairly with rosters and term allocations, and having adequate rest and recreation facilities. Pre-vocational doctors also have an important role to play in developing many hospital policies and procedures.

If at the end of their pre-vocational years we have junior doctors who feel valued and respected at work, and who value and respect their colleagues and patients, then we have done our job.

David Oldham, a MDA National Member, is the Director of Post Graduate Medical Education at Fremantle Hospital and Winner of the Clinical Educator of the Year Award for 2011 of the Australasian Confederation of Postgraduate Medical Education Councils.