Rural Clinical Research Articles

Medical students’ reported barriers to training at a Rural Clinical School

To understand and address students' concerns about attending one of the new Commonwealth-funded Rural Clinical Schools. Analysis of students' reported reasons for clinical school selection from 2003 to 2004. The School of Medicine and the Rural Clinical School, University of Melbourne. Data were obtained from de-identified preference documents submitted by the medical student cohort assigned to the University of Melbourne clinical schools to begin in July, 2004. Thirteen categories of student concerns (social) were identified from written student preference documents. Evaluation of the students' concerns about social dislocation if they were assigned to a rural clinical school has provided important information about perceived barriers to rural training. These issues must be systematically addressed at the school, university and community level.

Development of 'rural week' for medical students: impact and quality report

The Rural Undergraduate Support and Coordination program funds medical schools to provide all medical students some time in rural Australia throughout their course. The University of Adelaide has developed a rural week program for both first and second year students to fulfill part of this objective. First year students' rural week is an introduction to a range of rural health issues, Indigenous culture and rural lifestyle issues. Second year students choose either a clinical rural week with a general practitioner or a week of Indigenous cultural learning with the Adnyamathanha people in the Flinders ranges, South Australia. Evaluation data were collected from students, practitioners and university staff during rural weeks in 2003 and 2004 using quantitative and qualitative methods. First year students increased their knowledge of and interest in rural medicine and enjoyed their (limited) clinical interaction with patients. Second year students appreciated the clinical experience and valued the welcome they received from doctors and practice staff. Those who chose Indigenous cultural programs appreciated the opportunity to interact with and learn from Indigenous people. General practitioners valued contributing to student knowledge and skills and the opportunity to promote rural practice. Volunteer community members were very enthusiastic about meeting the students and their generosity had a significant impact on the students' ideas about rural lifestyle. University academic and administrative staff found rural week very intensive work but experience and thorough preparation now ensures that few problems occur. Rural weeks are now an established part of the first year and second year curriculum at the University of Adelaide Medical School. The ability to provide small groups of students with an intense introduction to rural practice and/or Indigenous culture results in a positive change in opinion about this aspect of medical education. Students now have first-hand experience to positively influence their choice of rural education or Indigenous health options in the medical course. Problems do occur with students being away from the traditional classroom, and protocols have been put in place for behaviour of all parties. Despite the rural weeks program being very demanding on staff energy, financial resources, general practices and rural communities, we feel that this program is valuable and sustainable. Further experience will determine if rural weeks function effectively as a recruitment strategy for the long rural placements offered by the Rural Clinical School.

Do benefits accrue from longer rotations for students in Rural Clinical Schools?

The Australian Government has provided funding for Rural Clinical Schools (RCS) to provide substantial rural clinical experience to medical students. The strategy aims to acculturate students into rural living with the intended long-term outcome of increasing the availability and viability of rural health services. When evaluators from two of the Rural Clinical Schools discussed findings and insights relating to rural rotations from their in-depth evaluation studies of their respective schools they found a range of similarities. This article is a collaboration that articulates parallel findings from evaluations over 2 years, using three different approaches to students' placements across the two RCS: (1) students based long term in one centre (with only a few days away at a time); (2) students based long term in one centre with short-term rotations of 3-6 weeks away from home base; and (3) week rotations without a home base. The two RCS, as part of their initial establishment, put comprehensive internal evaluation processes in place, including the employment of dedicated evaluators extant from the teaching and assessment of the rural medical curriculum. Data were collected and analysed according to standard education evaluation procedures. Home-base preference: most students preferred having a home base in one centre and having as little time as possible away from that centre, while recognising that sometimes the requirement to go and learn elsewhere was useful. The reasons for this were three-fold: academic, clinical and social. Academic benefits: students enjoyed the excellence of teaching and learning opportunities in their rural sites and did not want their discipline of learning interrupted by what they perceived as unnecessary change. Students with a home base used their learning opportunities qualitatively differently from those students who had 6 week rotations. Their learning became self-directed and students sought opportunities to extend and consolidate areas of need. Clinical benefits: contributions to the clinical team: students in their clinical years want to feel useful and to be allowed to become contributors to the medical care, even as they are learning. A longer rotation allows them to become known to their teachers who are then able to easily assess the type of contribution that is appropriate for their students to undertake. Students then become full participating members of the healthcare team, rather than observing learners. Social benefits: all students with a home base actively participated in a wide range of community activities outside their role as medical students. Those students undertaking short rotations without a home base seldom connected in the same way to any rural community. Evaluation from these two RCS has shown that short rotations are likely to be less optimal than longer rotations for meeting the broader goals of the RCS to build future workforce capacity. Our results suggest that one opportunity to acculturate students into the rural lifestyle is lost when students' placements are insufficiently long for them to put down roots in their community, and to understand how to 'live' there more broadly. Good rural experiences and teaching and learning opportunities are not sufficient in themselves. Students' emotional attachment to rural living comes from experience related to time and the connection to local people that comes as a result of time spent in the community. Students on short rotations do not make that local connection.

Community-based or tertiary-based medical education: so what is the question?

This edition of Medical Teacher brings to our attention another insightful article from the Flinders University Rural Clinical School, led by Professor Paul Worley (Worley et al., 2004), enquiring as to what students actually do on their clinical rotations. Beginning with the premise that there is little published material exploring the learning activities undertaken by students in different learning environments, Worley and colleagues conducted a study that was able to compare three groups of students. These students were exposed to the same curricula material in three different environments, namely an urban teaching hospital, a remote secondary referral hospital and a rural community-based programme. Although Worley et al. admit to the small numbers of students within the study, and the generalisability of their results, the community students reported greater and more valuable patient contact, more effective time spent in clinical settings and an increased time being supervised by experienced clinicians, compared to the secondary and tertiary based students. The secondary hospital based students reported more time spent in lectures and tutorials than the tertiary or community-based students and the time spent in their clinical settings was valued less than the time spent learning at home. The impact is that this is yet another paper that demonstrates the value of communities as a credible alternative to the traditional teaching hospital. However it does raise other questions regarding medical education and community learning.“If we want things to stay as they are, things will have to change”Guiseppe di Lampedusa (1957)

'What makes it really good, makes it really bad.'
 An exploration of early student experience in the first cohort of the Rural Clinical School in the University of Western Australia

The Australian Commonwealth Department of Health and Ageing has implemented the Government's Regional Health Strategy. This strategy provides funding to universities for the establishment of Rural Clinical Schools (RCS) on a national basis. The strategy aims to secure a rural education and training network to increase the availability and viability of rural health services in the long term. The University of Western Australia set up the RCS in 2002 with the objective of setting up a full 5th year medical course in remote communities (RRAMA [Rural Remote and Metropolitan Area Classification] 4-7) for the 2003 academic year. There were 21 students in five areas: Kalgoorlie/Esperance (9 students), Broome (4 students), Port Hedland (3 students) and Geraldton (5 students). These students covered the 5th year curriculum with internal assessment and final examinations, in the same manner as city students. Only the delivery was different, according to geographical location. Structured questionnaires using open-ended questions were distributed to students on two occasions. At the sixth month, semi-structured interviews were held with each student. The interviews were transcribed and a thematic analysis of the data was undertaken. Constant comparison of data was undertaken, themes identified and relationships among the themes clarified. In general, students were very happy with the teaching and learning opportunities they had during the first half of the year. However the initial themes of curriculum content, curriculum delivery, and assessment, were eclipsed by an overarching theme of anxiety and its management. The issue of student anxiety was addressed during the analysis. A number of factors were identified which ameliorated student anxiety or contributed to increased anxiety. From this evaluation a number of contributory factors to such student anxiety were identified. The investigators became more cognisant of the impact of group dynamics and of the need to structure the 'unstructured' environment of rural and remote medicine. In this way, students focus on only a few learning tasks at a time. They complete each topic with at least one other student so they can share the experience. The key role of each site coordinator also became apparent. The site coordinator should know the curriculum thoroughly and transmit this information to other teachers and preceptors at their site. It was also found desirable that the RCS was clear as to which assessment processes were flexible and which were 'fixed'. The medical school must clarify which curriculum content is essential, which is desirable and which is additional. Issues of workload must be monitored, and good work practices must be encouraged and supported. It was found that the high level of commitment to learning lead to the potential for burnout, generating the student comment: 'What makes the RCS really, really good makes it really bad...' Setting up an innovative program is always a major task, but setting up five different offices with four centers of learning separated by thousands of kilometers has not been undertaken, apparently, anywhere else in the world. It has been a 'fast uphill journey' that has been subject to evolving change as the RCS has adapted to conditions not expected from an academic point of view. Key contributory factors to student anxiety were identified and organizational strategies were implemented immediately, where possible, to reduce such anxiety. These insights were also used in the preparation for, and implementation of, the 2004 curriculum.

Parallel Rural Community Curriculum: is it a transferable model?

The chronic shortage of doctors in rural Australia has been well documented. Enabling medical students to undertake positive rural experiences during their undergraduate course is a well-supported long-term strategy to provide a sustainable solution to this problem. The Parallel Rural Community Curriculum (PRCC) was developed by Flinders University, South Australia, in 1997 to enable senior medical students to undertake an entire clinical year based in rural general practice in the Riverland region of South Australia. The academic success of this program has been widely acknowledged. Many institutions are planning to use this model as a basis for their own curriculum reform. However, questions have been asked as to how well this program would translate into another region. Due to the success of the Riverland program, Flinders University decided to commence a second PRCC program in 2002, this time in the Greater Green Triangle (GGT) region of South Australia and Victoria, Australia. This new program was developed collaboratively by the GGT University Department of Rural Health and the Flinders University Rural Clinical School. The mean student rank improved by an average of 17 places out of a class of 90 students. Partnership development took time. General practitioners (GPs) initially showed significant anxiety particularly in regard to their teaching capacity, time commitment of students and the infrastructure demands on their practices. Specialists' engagement was a challenge, requiring a significant change to their teaching paradigms. Horizontal and vertical integration of teaching was complex and required ongoing effort to maximize efficiency. The community had high expectations of the workforce outcome and these needed to be tempered with realistic expectations about the length of time required to train doctors, and an understanding of workforce mobility. The initial evaluation of the GGT PRCC suggests that the Riverland PRCC is translatable. Successes, including student performance, GP acceptance and community ownership have been replicated in the GGT community-based medical education program. A key to the success has been the recognition of the crucial role of partnerships in an environment where, for clinicians, clinical service provision and other personal needs take precedence over teaching roles and responsibilities.

INCREASING RURAL ACTIVITY AND CURRICULUM CONTENT IN THE ADELAIDE UNIVERSITY MEDICAL SCHOOL

ABSTRACT: This study aimed to document the level of rural activity and curriculum content in the Adelaide University Medical School. A questionnaire was distributed to all heads of departments within the Medical School and additional information was obtained from reports and discussions with key personnel. There has been an increase in the proportion of students with a rural background enrolled from 9% in 1994 to 22% in 2000. There has also been an increase in the number of weeks available for rural placements from 12 (mostly optional) to 29 weeks (some mandatory), and an increase in the number of departments offering rural placements. There has also been improved academic support to rural practitioners and many departments directly provide services in rural communities. A new combined University Department of Rural Health (UDRH)/Rural Clinical School associated with the Adelaide University Medical School aims to provide at least half of all clinical training to 25% of all medical students of Australian origin.

Increasing rural activity and curriculum content in the Adelaide University Medical School.

This study aimed to document the level of rural activity and curriculum content in the Adelaide University Medical School. A questionnaire was distributed to all heads of departments within the Medical School and additional information was obtained from reports and discussions with key personnel. There has been an increase in the proportion of students with a rural background enrolled from 9% in 1994 to 22% in 2000. There has also been an increase in the number of weeks available for rural placements from 12 (mostly optional) to 29 weeks (some mandatory), and an increase in the number of departments offering rural placements. There has also been improved academic support to rural practitioners and many departments directly provide services in rural communities. A new combined University Department of Rural Health (UDRH)/Rural Clinical School associated with the Adelaide University Medical School aims to provide at least half of all clinical training to 25% of all medical students of Australian origin.

Teaching culturally competent care: nursing students experience rural Appalachia.

This article describes two courses, Health in Rural Appalachia and Clinical Practice in Appalachia, developed by one of the authors to increase students' cultural competence as professional nurses. Characteristics of the Appalachian culture are described as well as the need for cultural awareness and sensitivity in those providing health care. Both the three-credit seminar course and the one-credit clinical course are described. Students' comments, from journals and other assignments, are interspersed throughout to illustrate various aspects of the cultural heritage they experienced as they worked with nurses and patients in eastern Kentucky.

Pastoral mobility, sedentarization and accessibility of health services in the northeast Badia of Jordan

The World Health Organisation (WHO) has attempted to achieve ‘Health for All by the Year 2000’. However, this aim has been limited in its success and significant levels of poor health remain. The WHO concede this and have revised their slogan: ‘Health for All in the Twenty-First Century’. One of the central problems has been social and geographical inequity of development and, importantly, that health services are inaccessible to large segments of the population in many developing countries. To this end, the Jordanian government has attempted to improve accessibility in rural communities by providing an extensive network of basic rural health clinics. However, a significant factor impeding this goal has been that much of the population is dispersed and that many practise pastoral nomadism. This paper reviews the extent to which rural clinical services have been made accessible to the nomadic and sedentarizing population of the northeast Jordan Badia.

Rural Nursing

SANDRA STUART-BURCHARDT. RN. MSN, is the director of the Rural Clinical Nurse Placement Center, California State U., Chico.

Teaching Family Medicine in Rural Clinical Clerkships

Clinical clerkships that lasted for a term of six weeks in rural areas were used for instruction of undergraduate students in family medicine at the University of Washington School of Medicine. Once the objectives for such clerkships had been determined, teaching contracts between the University and rural practitioners were made whereby these practitioners assumed full responsibility for teaching the clerks. Although some problems, such as how to avoid "overstudy" of clerkship participants while documenting results, remain unsolved, it was found that the practitioner, in his realistic clinical setting, can make unique contributions to the education of both medical students and residents. (<i>JAMA</i>228:1408-1410, 1974)