Complexity is not merely a feature of Australian healthcare but one of its defining characteristics.1 Nowhere is this more evident than in general and acute care medicine (GACM). Whether formulating a unifying diagnosis to undifferentiated clinical presentations, managing multiple comorbidities and psychosocial issues or navigating fragmented services to ensure appropriate care, complexity and uncertainty are central to our practice.2 GACM physicians are also pragmatic healthcare leaders who often contribute to whole-of-health system approaches through managing access pressures and bed capacity, coordinating care across services and solving the operational problems that emerge when systems collide.3 This work is often unglamorous and unseen, but is essential to the day-to-day functioning of the entire health system. Developing the new Royal Australasian College of Physicians curriculum in GACM afforded an opportunity to deeply reflect on our unique identity and value (Box 1).4, 5 This reflection revealed a cultural blind spot evident in how we train, recognise and value our colleagues; general medicine's operational and complex systems leadership expertise deserves better recognition and acknowledgement and is required for sustainable leadership.6 Adapted from: The Royal Australasian College of Physicians.7 Medical graduates begin as interns assessing individual patients. Although medical school curricula may include systems thinking,8 junior doctors face an inevitable emphasis on the individual patient, which is entirely appropriate at this stage of training. Basic Physician Training expands on this foundation, teaching breadth and complexity at the individual patient level. Advanced trainees (ATs) in GACM need to shift their perspective. Complexity refers to the interaction of multiple medical, functional, psychological, social and health- system factors that make care decisions interdependent and require integrated, rather than disease-specific, care.2 Without an understanding of dense and often confusing healthcare and social systems, trainees cannot positively impact outcomes.9 We as medical educators thus have a responsibility to evoke curiosity in ATs, develop their system analytical skills and empower them to become agents of system change to serve our patients better. Trainees must develop systems literacy: how to leverage quality and service improvement, patient access and flow, hospital avoidance programmes and community-based services.10 Enabling trainees to develop the advocacy and leadership skills necessary to manage complexity allows them not merely to ‘think about systems’ but act effectively within them. The GACM curriculum details 19 learning goals (Table 1) across three phases: specialty foundation, specialty consolidation and transition to fellowship.4, 5 Assessment occurs through learning captures (self-directed learning) and observation captures (observed activities). Supervisors can combine adult learning principles (Box 2)11 and the new curriculum framework to identify ways to teach complexity.12 The following case study demonstrates this approach, and could be used to inform many Entrustable Professional Activities (as listed in the ‘Do’ section of Table 1), depending on the interest and needs of the trainee. The supervisor and AT could choose to focus on an individual learning goal, or many. Be These are competencies that form a professional practice framework Do These Entrustable Professional Activities (EPAs) outline the essential work tasks trainees need to be able to perform in the workplace Know These Knowledge Guides define what trainees need to know to achieve fellowship and form a basis for knowledge acquisition These provide detailed guidance to trainees on the important topics and concepts trainees need to understand to become experts in GACM Trainees are not expected to be experts in all areas or have experience related to all items in these guides Note: This case study is a fictionalised composite created for educational purposes to illustrate systems-level complexity and teaching approaches in GACM. Mr J is a 38-year-old man admitted to the acute medical unit with severe abdominal pain, vomiting and hypokalaemia. This is his fifth admission in 18 months with similar presentations. His history includes poorly controlled type 2 diabetes, cannabis hyperemesis syndrome and recurrent episodes of acute kidney injury secondary to dehydration. He lives in unstable housing and has no regular general practitioner (GP). By day 3 of his admission, the junior medical team has stabilised his electrolytes and Mr J is medically ready for discharge. The bed manager has flagged the bed as needed; there are patients waiting in the emergency department and the ward is at capacity. However, the AT recognises a pattern: previous admissions ended with referrals to community services, endocrinology and mental health support, but none has been actioned. Mr J returns to the same circumstances, without diabetes education, structured support or a medical home. The cycle repeats within weeks. The AT leads discharge planning amid explicit pressure to discharge. On the surface, this appears straightforward, but a conflict exists; bed capacity weighs against recognition that expedited discharge has culminated in early readmissions. Affirm the acute medical management. Invite an examination of chronic patterns. Consider social determinants of health. Identify system failures and suggest solutions. Develop realistic plans with the patient. Advocate for system improvement. GACM physicians manage the operational and systems complexity that is closely intertwined with the clinical care of our patients. Leadership in complexity is a defining element of GACM as a specialty, and we have an obligation to teach these vital skills to our trainees.3 ATs who achieve mastery in navigating complexity, improving systems and healthcare quality and providing operational leadership will have a firm identity, purpose and influence. These are not secondary skills acquired incidentally but core competencies to be deliberately taught and assessed. Research on sustainable healthcare leadership demonstrates that deliberately recognising these capabilities in clinicians is essential.6 The case discussion illustrates the need for GACM physicians to be systems experts. The acute management of Mr J's electrolytes, while important, is merely the tip of the iceberg for this patient. Excellence in patient-centred care requires determination of why he returns, where and when the system fails and how to lead the change that prevents future admissions.13 The case touches on multiple aspects of the GACM specialty overview and learning goals, clinical complexity, systems thinking, quality improvement patient access and flow, leadership and advocacy. and uncertainty management. It considers both acute and longitudinal care, transitions of care and health equity. It illustrates how adult-learning principles can be utilised to teach and assess ATs using learning captures and observation captures.11 Role modelling, explicit signposting and deliberate teaching will ensure that the next generation recognises what GACM offers and ensures the invisible labour of managing complexity becomes visible and valued. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.
Rane et al. (Mon,) studied this question.