We need you to be able to do this operation: continuity and contradiction in the training of ophthalmologists

Competency based training was introduced widely into Australian medical education during the 1990s, encouraged by the Australian Medical Council which accredits post-graduate training programmes. In 1997 the Australian and New Zealand College of Ophthalmology (the College) responded by introducing competency based training as its training form. It held the promise of allowing training to be more accountable to the community; of improved management of increasing levels of chronic (rather than acute) disease management resulting from the ageing of the population; and better accommodation of the increasing number of women in all areas of the workforce of medical specialties. Traditional time-based training is inflexible and this affects women more than men due to their different roles in child bearing. A question to be explored was whether competency based training, as an outcomes-based form of vocational education rather than a time-based form, might prove to be more flexible for trainees. Examination of the relevant theories of curriculum was needed to understand how the training of ophthalmologists might respond to changes in the external environment. The driver for the study was to understand how ophthalmologists are trained, and whether theories of vocational education and training could inform that understanding. The concept of expansive potential, arising from contradictions felt by teachers and practitioners, was located in the vocational education and training literature; it proved to have explanatory value. The curriculum change in the College was initiated in 1997 at a meeting of an invited group of ophthalmologists involved in postgraduate training. The researcher was a member of that group and was prompted to think deeply about how ophthalmologists are trained. This thesis is a result of that thinking. The research question for the study is ‘How are ophthalmologists trained?’ It was answered through an exploration of what was happening in curriculum, both according to the official view and to the reports of the lived experiences of curriculum by teachers and trainees. The study methodology was qualitative. It consisted of an empirical case study drawing on thematic analysis using the lens of feminist epistemology. The data were textual, including the College’s documents on training, transcripts of the curriculum review meeting that considered the introduction of competency based training, and transcripts of 29 subsequent individual interviews with trainers and trainees. The findings fill gaps in the literature about how this group of practitioners is trained, and examine from the perspective of the participants whether changes in training ought to occur and whether curriculum change might be possible. The study findings were that ophthalmologists in Australia and New Zealand are trained using a mixture of two vocational educational forms, competency based training and apprenticeship. Despite the official position of the College, apprenticeship dominates as a form of training and largely subsumes competency based training. An emerging curriculum form, complexity based training, lies nascent in curriculum talk and may provide a bridge to the future. The study also found that training is androcentric and continues to focus on acute disease. Androcentrism is supported by the requirement of the apprenticeship form that the apprentice model themselves on the knowledge and attitudes of the master. Although there is some evidence that change is possible, competency based training fails in its social reconstructive attempts because it has not replaced the apprenticeship-based curriculum. There is evidence in the data that the management of chronic disease is not regarded as central to the work of ophthalmologists, and there is no effective response to androcentrism. A ‘culture of no culture’ prevails which provides stability to the curriculum and silences critique of work practices. However, contradictions felt by practitioners that were identified in the data in relation to gender and the importance of chronicity of disease both indicate a potential for change to occur. The data include contradictory dialogues about whether training and accreditation are to be understood as primarily work focussed, or primarily worker focussed. The data suggest that work is the curriculum. To change curriculum thus requires most attention to practice, the work itself. Attention to education primarily may be misdirected. This matter is currently ill defined in the policies of the College and the Australian Medical Council. Such a lack of clear definition affects both the training body’s capacity to deliver good training, and the accrediting body’s capacity to lead much-needed change.