New Fellowship Program: Contemporary education governance: From mandatory rotations to assured clinical immersion

In previous columns I have described the emerging Fellowship curriculum prototype being developed by the New Fellowship Program Taskforce.

At its centre is the simple vision, endorsed by the Board, that Fellowship should be designed intentionally to develop independent specialist psychiatrists with defined capabilities, able to work in partnership with patients, families, communities and the health system. A design logic sets out the commitments, principles, constraints and trade-offs that guide every decision.

The curriculum architecture describes a coherent educational system that integrates clinical learning, supervision, structured learning, assessment and progression all towards the purpose of ensuring that the capabilities that define specialist psychiatric practice are delivered.

This column turns to one of the most contested questions in Fellowship design, namely what should the Fellowship Program govern in relation to clinical learning? This has been and remains a subject of heated debate and we are grateful for the numerous contributions in this regard.

Clinical experience is the foundation of specialist training

No curriculum can produce a psychiatrist without sustained participation in meaningful clinical work.

It is through assessing, working with and caring for patients and families, making decisions under supervision, working within multidisciplinary teams, managing uncertainty, and reflecting on practice that psychiatrists develop the judgement expected of independent specialist practice. Structured learning, supervision and assessment are all essential. But they support clinical learning and cannot replace it.

So, the question we want to explore now is not whether clinical experience matters, but rather how a Fellowship Program should assure that every trainee receives the breadth and quality of clinical learning required for independent specialist practice and the vision of Fellowship.

Traditionally, we have governed where trainees work

Fellowship has assured breadth by requiring trainees to complete a series of set mandatory rotations. This has provided structure and reassurance. Mandatory rotations protect trainees from overly narrow service demands and help ensure exposure to important areas of psychiatric practice. However, they also embody a critical assumption that the best way to assure learning is to prescribe where trainees work.

The Taskforce has increasingly questioned whether this assumption remains true in today’s clinical settings and whether it will stand up as a governance model in the context of future pressures and service changes. Psychiatry has become broader, more diverse and more integrated than when the current training models were designed. If every important domain of contemporary psychiatric practice were translated into its own mandatory rotation, Fellowship would become increasingly rigid, difficult to deliver across Australia and Aotearoa New Zealand, and leave little flexibility for individual learning pathways or advanced interests. Moreover, it would still not necessarily assure learning.

Completing a rotation does not guarantee meaningful clinical participation. Equally, completing a workplace assessment or entrusted professional activity does not demonstrate the depth and breadth of experience required to support independent practice. The challenge for us as a Taskforce is to determine whether we can achieve the Fellowship outcomes in more flexible, nuanced and less rigid ways.

Rotations are not educational outcomes

Perhaps the most important distinction emerging from our work is that rotations do not guarantee learning. 

Rotations are organisational units that reflect the way health services are structured, and they are dynamic. A consultation-liaison rotation, for example, rarely teaches consultation-liaison psychiatry alone. It provides experience of being invited into the clinical practice setting of other specialties. And it provides sustained exposure to some combination of medical-psychiatric complexity, addiction, eating disorders, capacity assessment, systems consultation, acute care and multidisciplinary collaboration. Similarly, addiction learning may occur within specialist addiction services, or it may be found in emergency psychiatry, consultation-liaison psychiatry, community psychiatry, youth services or forensic settings. One rotation may therefore contribute to several important domains of learning. Likewise, one domain of psychiatric practice may develop across several different clinical settings. The relationship between rotations and learning is therefore not one-to-one.

From mandatory rotations to Assured Clinical Immersion

The Taskforce has therefore begun thinking differently about clinical learning. Rather than asking which rotations should be mandatory, we are exploring what forms of clinical immersion should every psychiatrist experience before Fellowship? 

This has led us to the concept of Assured Clinical Immersion (ACI). An Assured Clinical Immersion is not a single patient encounter, a completed EPA or attendance at a clinic. Neither should it be compared to the approach being used in the present curriculum for aged and addiction psychiatry, for example, where competency is indicated by the completion of three EPAs in Stage 2 of training. It is rather a sufficiently sustained period of participation (the amount of which is importantly yet to be determined) in authentic clinical work that enables repeated exposure, progressive responsibility, supervision, feedback and reflection within a given domain of psychiatric practice. The emphasis is on immersion and participation, rather than attendance or simply time served though the latter cannot be discounted. In sum, it is not set and forget or tick and flick, but meaningful learning as designed educationally rather than by location.

What should be assured?

Every Fellow should experience meaningful clinical immersion across the breadth of psychiatric practice.

This breadth has several dimensions: the settings in which psychiatrists practise, including hospital, community and ambulatory care; where in the course of illness they are placed to intervene, from emergency and crisis care through continuing care, rehabilitation and compulsory care; the specialised areas of practice in which they work, including adult, child and adolescent / youth, later-life, addiction, perinatal, eating disorders, intellectual disability and neurodevelopmental psychiatry, and medical-psychiatric complexity; the clinical approaches they employ, including medical, pharmacotherapeutic and psychotherapeutic care; and the specialist roles they fulfil through direct care, consultation, liaison, collaborative and shared care, and leadership within multidisciplinary and interagency systems.

Importantly, these are educational requirements, not necessarily separate rotations. Some immersions may occur principally within one clinical environment. Others may develop across several intentionally designed learning experiences. The Fellowship Program should define the educational requirements and the standards by which they are assured. Either state or regional training networks, working with accredited services should determine how those requirements are delivered within their local context.

What remains mandatory?

This does not mean that mandatory rotations disappear. Rather, they become an educational strategy rather than the organising principle of Fellowship.

A dedicated mandatory rotation is justified when immersion depends upon participation within a distinctive clinical ecology that cannot be credibly reproduced elsewhere. The required capabilities must be essential for every psychiatrist, difficult to develop reliably elsewhere, deliverable equitably across jurisdictions, and educationally important enough to justify restricting flexibility elsewhere in training.

The Taskforce believes rotations in child psychiatry provide a unique developmental, family, educational and statutory context. That is not say that they are of greater value but rather that the required learning is restricted to these settings. Whether other settings meet the same threshold remains an important question that continues to be explored.

A different model of governance

This way of thinking also changes the role of the Fellowship Program itself. The Fellowship Program should define the capabilities required of every Fellow, the Assured Clinical Immersions needed to develop those capabilities and the standards by which capability is assessed and progression decisions made. Accredited training programs within jurisdictions – possibly partnerships between state- or nationally- based training programs and services – should then determine how those immersions are delivered through their available clinical learning environments.

This is a crucial distinction that ensures local flexibility is built in and mitigates against system shock. The Fellowship Program should not govern where trainees work but it sets the standards and framework to achieve the new vision. It should govern whether they have had sufficient, high-quality clinical immersion across the domains of practice required for independent specialist psychiatry. That shift preserves educational standards while allowing flexibility in how those standards are achieved.

Looking ahead

Breadth remains fundamental to Fellowship. The emerging curriculum seeks to protect that breadth not by prescribing an ever-growing list of mandatory rotations, but by assuring meaningful clinical immersion across the domains that define contemporary psychiatric practice.

If we achieve this, every Fellow will complete training having developed the same capabilities, experienced the clinical worlds essential to specialist psychiatric practice, and been judged against the same high standards, even if their individual pathways through training are not identical.

The New Fellowship Program prototype consultation closes on Thursday 20 August. Please provide any feedback to newfellowshipprogram@ranzcp.org or through the consultation hub.

Thank you as always for your interest and your passion in this work.