Family Medicine Education Research Articles

Using Photovoice to Explore Family Medicine Residents' Burnout Experiences and Resiliency Strategies.

Physician burnout is well described in the literature. In response, experts are now shifting to try to understand physician resiliency. We sought to better understand burnout and resiliency from the perspective of family medicine residents through the qualitative analysis of photographs and discussion. We used Photovoice, a qualitative research method, to understand how residents describe and cope with burnout. Faculty assigned residents at a Midwest family medicine residency program to take photographs and provide captions that reflected personal experiences of burnout and resilience. Residents viewed the collective photographs and discussed their impact during three audio-recorded small-group sessions. Researchers qualitatively analyzed the captions and recordings using a hermeneutic phenomenology approach, and analyzed the visual content of the photographs using a standardized rubric. We identified six themes for the resident description of burnout: basic needs deficiency, physical exhaustion, self-neglect, personal depletion, being overwhelmed, and feeling like an outsider. Six themes were also identified for cultivating resilience: self-care, nurturing relationships, seeking the comforts of home, escaping to refuel, self-reflection, and identifying strengths from adversities. Resilience pictures were more likely to have been taken in a natural setting; burnout photographs were duller in color. Family medicine residents experience burnout in specific, unique ways, and are able to identify common sources of resilience. Family medicine educators can use the Photovoice methodology to help residents capture their personal experiences of burnout, share their experiences with peers, and discover sources of resilience.

Social, Individual, and Environmental Characteristics of Family Medicine Resident Burnout: A CERA Study.

Burnout impacts medical students, residents, and practicing physicians. Existing research oversimplifies characteristics associated with burnout. Our study examined relationships between burnout, depressive symptoms, and evidence-based risk factors. Our study questions were part of a larger survey conducted by the Council of Academic Family Medicine Educational Research Alliance (CERA), from May 9-23, 2020. Three emails were used to recruit a national sample of family medicine residents (n=283; questions completed via Survey Monkey). We determined descriptive statistics (frequency, means) for demographic and work environment characteristics, UCLA Loneliness Scale items, health behaviors, burnout (emotional exhaustion, depersonalization), and depressive symptoms. Multivariate data analysis included developing three logistic regression (LR) equations (emotional exhaustion, depersonalization, depressive symptoms) based on four blocks of potential risk factors (demographics, work environment characteristics, UCLA Loneliness items, and health behaviors). Rates of psychological distress included 33.1% emotional exhaustion, 31.1% depersonalization, and 53.0% depressive symptoms. We determined stepwise forward-entry LR models for emotional exhaustion (feel isolated OR=6.89, low quality of wellness program OR=5.91, and low companionship OR=4.82); depersonalization (feel isolated OR=5.59, low quality of wellness program OR=15.11, graduate US osteopathic medical school OR=0.329, and African American OR=7.55); and depressive symptoms (feel isolated OR=5.31, inadequate time for restful sleep OR=0.383, and no dependent children OR=2.14). Current findings document substantial social disconnection, substandard residency wellness programs, inadequate time for exercise, sleep, and other forms of self-care in addition to substantial levels of emotional exhaustion, depersonalization, and depressive symptoms. We explore implications for the design of future burnout prevention efforts and research.

Simulation-Based Medical Education in Family Medicine Residencies: A CERA Study.

To better understand the current use of simulation and barriers to its use in family medicine resident education, we surveyed US family medicine residency (FMR) program directors (PDs) about opinions and use of simulation-based medical education (SBME) in their programs. A number of specialties have incorporated or required simulation-based educational techniques in residency education over the past 10 years, but little is known about the current use of SBME in family medicine graduate medical education. We also evaluated associations between program characteristics and the use of SBME in FMR education. Questions were included on the 2019 Council of Academic Family Medicine Education Research Alliance (CERA) survey of US FMR PDs. The survey included questions regarding current use of SBME along with questions to identify barriers to its use in family medicine programs. Thirty-nine percent (n=250) of PDs completed the survey; 84.5% reported using simulation. PDs reporting they did not use simulation were less likely to view simulation as valuable for education or assessment. Unexpectedly, residency program size was not associated with simulation use or access to a dedicated location for SBME. Use of SBME in family medicine resident education has increased since 2011. PDs value simulation for education and remediation, and most programs have introduced some degree of simulation despite barriers. The results of this study can inform resources to support the continued integration of SBME into family medicine resident education.

A Novel Blended Learning Module in Family Medicine: An Interventional Study at the Faculty of Medicine, Suez Canal University, Ismailia, Egypt

Blended learning (BL) has been reported as an effective method for teaching family medicine to undergraduates in high-income countries; however, studies of its effectiveness are limited in low- and middle-income countries. This study aimed to assess the effectiveness of an innovative BL module in family medicine including knowledge, skills and attitudes (KSA), and e-learning experiences. The grades of the fourth-year medical students at the Faculty of Medicine, Suez Canal University were correlated with the above items. A pre–post interventional study was conducted on a convenience sample of 117 fourth-year students in the educational year 2017–2018. Their KSA were assessed using valid and reliable questionnaires before and after the intervention was implemented. The intervention combined the traditional training in primary healthcare settings with the newly designed asynchronous e-learning module on the Moodle platform. The prepared website consisted of e-sections and an e-forum which was validated by expert staff. A questionnaire about students’ e-learning experiences was used to assess students’ satisfaction. The students’ final fourth-year marks for the family medicine module were correlated with their KSA and e-learning satisfaction. The overall means of students’ KSA were statistically significantly improved post-implementation. The posttest students’ skills were positively correlated with their marks in family medicine (rs = 0.308, p = 0.001). Students valued the e-resources and their relevance to the face-to-face activities. They were satisfied with their e-learning experiences (54.7%). Their e-learning satisfaction was positively correlated with the improvement in their knowledge (rs = 0.20, p = 0.031). BL had positive effects on students’ KSA and their satisfaction with the family medicine module. Combined asynchronous and synchronous e-learning in the COVID-19 era was applied in this study.

Changes in the Shortage and Quality of Family Medicine Clinical Training Sites.

This study examined changes over time in the shortage and quality of clinical training sites for students. The surveys provided baseline and milestone measurements for the Society of Teachers of Family Medicine's (STFM) Preceptor Expansion Initiative. Data were gathered in 2016 and again in 2020, through the Council of Academic Family Medicine's (CAFM) Educational Research Alliance (CERA) survey of family medicine clerkship directors. Clerkship directors answered questions concerning number of students requiring placement, number of precepting sites used, frequency of negative comments about family medicine as a specialty, and about opportunities for students to experience comprehensive care, patient-centered care, and document in electronic health records. The number of students who annually required placement at family medicine preceptor sites increased slightly from 2016 to 2020, but the number of sites utilized per family medicine department did not. There were no changes in the percentage of sites having Patient-Centered Medical Home or similar recognition or providing comprehensive care with or without obstetrics. However, more students were allowed to enter data and write patient encounter notes in 2020 than in 2016. Clerkship directors continue to struggle to find high-quality family medicine training sites for students. STFM's Preceptor Expansion Initiative has made strides to help students become active, productive members of care teams, to reduce the administrative burden of teaching, and to promote the precepting of multiple students at once.1 These efforts to incentivize precepting are ongoing, but won't be enough to compensate for the rapid growth in the number of students and the increasing demands on physicians for high-volume patient care.

Teaching Family Medicine and General Practice.

The teaching of family medicine and general practice should aim to develop an appreciation of the unique nature and role of the specialty. Teachers should relate patient cases to the principles of family medicine. These principles include (1) compassionate care; (2) a generalist/holistic approach focusing on the whole person, family, and community; (3) continuity of relationship, i.e., building a patient-physician bond of trust; (4) reflective mindfulness; and (5) lifelong learning. The curriculum, instructional strategy, and assessment should be carefully aligned. Core competencies include patient-centered communication, physical examination skills, clinical procedures, palliative care, humanities in medicine, holistic care, shared decision-making, family therapy, home and community visits, chronic disease care, problem-based documentation, team-based care, data-driven improvement, information mastery, ethics and professionalism, and work-life balance. Family medicine/general practice is defined as the medical specialty that manages common and long-term illnesses, focusing on overall health and well-being. Hence, clerkship schedules should maximize clinical exposure and opportunities for self-reflection. A learner-centered approach should begin with a self-identified inventory of learning needs based on the curriculum; next, these needs should be chosen as topics for student presentations. Teaching methods should include mini-workshops: a combination of didactic lectures and small-group exercises. Individual face-to-face formative feedback should occur at midcourse and culminate in a group reflection on the learning experience. Clinical supervision should gradually decrease as each resident demonstrates safe patient care. Procedure skills training should be closely supervised, formally documented, and constitute about one-fourth of learning sessions.

Assessing the frequency with which primary care providers address sleep of infants and young children.

Sleep problems during early development are common and associated with negative health outcomes. Earlier recognition of poor sleep health permits earlier intervention and improved outcomes. This retrospective cohort study aimed to identify the frequency with which primary care providers assessed sleep health when completing the Rourke Baby Record for infants and young children during routine well-baby visits from 2002 to 2019. Using 1180 electronic medical records from an academic family medicine teaching clinic, we identified the frequency with which primary care providers assessed sleep health at three time intervals in child development: 1week to 1month; 2months to 6months; and 9months to 12-13months. Sleep variables were night waking, healthy sleep habits, and safe sleep. The frequency of having any aspect of sleep addressed was 85.4%, 90.2% and 66.7% at the three respective time intervals. There were no differences in the frequency with which sleep was assessed based on birthweight or sex. Children born during 2002-2015 were approximately half as likely to be assessed for sleep compared with those born during 2016-2019 at the second and third time intervals. In the first and second time intervals, children who were not exclusively breastfed had their sleep assessed significantly less than children who were exclusively breastfed. To our knowledge this is the first study to explore the area of sleep discussions and breastfeeding status in primary care during routine well-baby visits. These results are clinically relevant for clinicians and parents, due to the known associations between sleep issues and sudden infant death syndrome, childhood injuries, and emotional dysregulation.

Nurses' Contributions in Rural Family Medicine Education: A Mixed-Method Approach.

Family medicine residents frequently collaborate with nurses regarding clinical decisions and treatments, which contributes to their education. In rural areas, these residents experience a wider scope of practice by collaborating with nurses. However, nurses’ contributions to rural family medicine education have not been clarified. This study measured the contributions of 88 rural community hospital nurses to family medicine education using a quantitative questionnaire and interviews. The interviews were recorded, transcribed verbatim, and analyzed using the grounded theory approach. Nurses’ average clinical experience was 20.16 years. Nurses’ contributions to the roles of teacher and provider of emotional support were statistically lower among participants working in acute care wards than those working in chronic care wards (p = 0.024 and 0.047, respectively). The qualitative analysis indicated that rural nurses’ contributions to family medicine education focused on professionalism, interprofessional collaboration, and respect for nurses’ working culture and competence. Additionally, nurses struggled to educate medical residents amid their busy routine; this education should be supported by other professionals. Rural family medicine education should incorporate clinical nurses as educators for professionalism and interprofessional collaboration and as facilitators of residents’ transition to new workplaces. Subsequently, other professionals should be more actively involved in improving education quality.

Implementation of Transgender/Gender Nonbinary Care in a Family Medicine Teaching Practice.

Numerous studies have shown that transgender or gender nonbinary (TGNB) individuals encounter significantly more health care barriers, including overall lack of access to gender-affirming care providers. This study describes 2 assessments of transgender care services at a large family medicine teaching practice. Staff and providers were invited to attend an optional, practice-wide, hourlong free training session on gender-affirming care offered on 3 different dates in 2019. A structured protocol was used to collect observational data from which key takeaways from the training sessions were developed. Separately, a retrospective chart review of patients with a gender dysphoria diagnosis was completed. Charts were reviewed for adherence to regional and international organization recommendations for comprehensive transgender care. Three main takeaways from the training sessions included lack of knowledge or familiarity with gender terminology and expression, fear of offending patients, and employee hesitation to change behaviors when interacting with patients. On chart review, the most common interventions identified were need to schedule a follow-up visit (61.5%), need for health maintenance screenings (osteoporosis screening, 50%; Papanicolaou smear, 56.3%; mammogram, 66.7%), need for mental health screening (41.5%), need for laboratory monitoring of testosterone therapy (20%), and corrected gender markers/names listed in the appropriate place in the patient chart (16.9%). This study highlighted hesitation to provide and lack of familiarity with transgender care among practice staff. Although some aspects of comprehensive transgender care are well implemented, maintaining follow-up, completing health maintenance and mental health screenings, and appropriate laboratory monitoring are areas for improvement.

COVID-19 Exposure Risk, Burnout, and Shifts in Family Medicine Faculty's Efforts: A National Survey.

In response to the COVID-19 pandemic, academic family physicians had to change their clinical, teaching, research, and administrative efforts, while simultaneously balancing their home environment demands. It is unclear how the changes in effort affected physicians' personal well-being, particularly burnout. This study sought to identify changes in faculty's clinical, teaching, research, and administrative efforts during the COVID-19 pandemic and how effort shifts were associated with burnout. We also examined associations with important demographics and burnout. We took data from the 2020 Council of Academic Family Medicine's Educational Research Alliance survey of family medicine educators and practicing physicians during November 2020 through December 2020. We analyzed self-report measures of demographics, effort (clinical, teaching, research, and administrative) before and during the pandemic, COVID-19 exposure level, and rates of burnout (emotional exhaustion and depersonalization) using logistic regressions. Most participants reported no change in efforts. If changes were reported, clinical (21.6%) and administrative (24.8%) efforts tended to increase from before to during the pandemic, while teaching tended to decrease (27.7%). Increases in teaching and clinical efforts were associated with higher rates of emotional exhaustion. Higher depersonalization was associated with increased clinical efforts. Being older and working in a rural setting was associated with lower burnout, while being female was associated with higher burnout. Shifts in effort across academic family physicians' multiple roles were associated with emotional exhaustion and, to a lesser degree, depersonalization. The high rates of burnout demand additional attention from directors and administrators, especially among female physicians.

Faculty and Resident Contraceptive Opt Outs and Training Site Restrictions: A CERA Study.

Contraception is a core component of family medicine residency curriculum. Institutional environments can influence residents' access to contraceptive training and thus their ability to meet the reproductive health needs of their patients. Contraceptive training questions were included in the 2020 Council of Academic Family Medicine Educational Research Alliance (CERA) survey of family medicine residency program directors. The survey asked how many faculty and residents opt out of providing contraceptive methods for moral or religious reasons, and whether training sites have institutional restrictions on contraception. We performed descriptive statistics and regression to identify program characteristics associated with having a resident or faculty opt out of providing contraceptive care. Of 626 program directors, 249 responded to the survey, and 237 answered the contraceptive questions. Percentages of program directors reporting any residents or faculty who opted out of contraceptive services are as follows: pill/patch/ring (residents 27%; faculty 17%), emergency contraception (residents 40%, faculty 33%), or intrauterine devices/implants (resident 29%; faculty 23%). Programs in the South (OR 2.78; 1.19-6.49) and those with Catholic affiliation (OR 2.35; 1.23-4.91) had higher adjusted odds of at least one opt-out faculty but were not associated with having opt-out residents. Eleven percent of programs had at least one training site with institutional restrictions on contraception. To ensure that residents have access to adequate contraceptive training, residencies should proactively seek faculty and training environments that meet residents' needs, and should make limitations on services clear to potential residents and patients.

Racial Justice Curricula in Family Medicine Residency Programs: A CERA Survey of Program Directors.

Structural racism is a cause of health disparities. Graduate medical education is tasked with training physicians who understand and address disparities. Addressing health disparities includes education on racism, such as racial justice curricula (RJC). We surveyed program directors (PDs) about the prevalence and characteristics of RJC in family medicine residency programs (FMRPs). RJC questions were included in the 2020 Council of Academic Family Medicine Educational Research (CERA) survey of FMRP PDs. We calculated univariate and bivariate statistics to describe respondent characteristics and attitudes, program characteristics, curriculum characteristics, and barriers to implementation. Of 624 PDs, 312 (50%) responded and 283/312 (90.7%) completed RJC questions. Less than one-third of FMRPs reported RJC, of which 98.9% focused on implicit/unconscious bias. Program characteristics associated with RJC included location, percent underrepresented minorities in medicine (URMM) residents and faculty, and percent patients identifying as Black, Latino/a, and Native American. FMRPs with RJC were more likely to have PDs who reported favorable attitudes toward including RJC and believed it is important for family physicians to understand structural racism. The greatest barrier to implementation of RJC was lack of faculty training. In this national survey, most FMRPs reported no RJC. Most respondent PDs endorsed that it is important for family physicians to understand structural racism and that RJC should be included in residency. Lack of faculty training was the greatest barrier to implementation. Research is needed to evaluate existing RJC and explore strategies for overcoming barriers to implemention.

Medical Teachers Appraisal. New challenge for European Family Medicine Teachers

A professional appraisal can be defined as the process whereby an appraiser examines and evaluates an appraisee’s work by comparing it with pre-set standards [1]. This process is generally designed to encourage the professional to reflect on his or her work and to provide evidence that the required standards are being achieved

Physician Attitudes and Self-reported Practices Toward Prostate Cancer Screening in Black and White Men.

Updated 2018 prostate cancer screening guidelines recommend informed decision-making discussions, which should include education on prostate cancer's disproportionate impact on Black men. It is unknown whether academic family physicians follow these guidelines. Family physicians were surveyed as part of the 2020 Council of Academic Family Medicine Educational Research Alliance (CERA) survey. We used χ2 to compare physicians' knowledge and screening practices stratified by physician age, gender, and percentage of Black patients in patient panel. We calculated logistic regressions predicting shared decision-making conversations, barriers to shared decision-making, inclusion of race in prostate cancer screening approach, and prostate-specific antigen (PSA) testing adjusted for physician age, gender, and percentage of Black patients. Physicians reported engaging in shared decision-making for prostate cancer screening in half of eligible men. Only 29.2% of physicians reported routinely informing Black men of their increased prostate cancer risk. In logistic regressions, physician gender (female) and fewer Black patients in panel (<25%) were associated with lower frequency of shared decision-making with Black patients. Physician age (<40 years) was associated with not discussing race during screening discussions (OR 2.24, 95% CI 1.55-3.23). Most academic family physicians do not appropriately inform Black men of increased prostate cancer risk, with younger physicians less likely to discuss race than older physicians. Female physicians, and physicians who see fewer Black patients, are less likely to have shared decision-making conversations with Black patients. This suggests educational efforts for these groups are needed to address health disparities in prostate cancer.

HIV Preexposure Prophylaxis Training in Family Medicine Residencies: A National Survey.

Preexposure prophylaxis (PrEP) reduces HIV transmission among high-risk individuals. Yet, the HIV epidemic continues to expand among marginalized populations and America's Southeastern states. Various barriers remain to PrEP uptake, namely provider knowledge and education. We sought to investigate residency training, competency, and prescribing of PrEP among population size. Additionally, we asked program directors to identify barriers to PrEP. We surveyed family medicine program directors as part of the Council of Academic Family Medicine Educational Research Alliance survey from January 2018 through February 2018. Our survey questions had a 52.9% (276/522) response rate. No programs in rural communities less than 30,000 population (0/27) reported significant PrEP training for their residents; those in nonrural communities of at least 30,000 reported this training more frequently (41/246, 16.7%). Compared to Fischer expected values, the finding was statistically significant (P=.019); using a 75,000 population demarcation lowered significance (P=.192). We found programs that identify significant PrEP training also cite more PrEP prescribing within their practice (OR 7.27, P<.001). Programs with significant training also report their residents graduate with greater PrEP competency (OR 18.33, P<.001). The largest barriers identified were faculty expertise, not having enough high-risk patients, inadequate screening, and resident knowledge/training. We identified natural associations between increased training in PrEP and perceived PrEP competencies. We identified a lack of significant PrEP training and associated PrEP competencies in rural residency programs. Barriers identified in this study can help inform curricular needs to improve primary care workforce capacity to lower HIV risk.

Structured Individual Mentoring as Part of Continuing Education in Family Medicine in Bavaria - a Multicenter Evaluation

Since 2019, the competence center for specialist training in family medicine Bavaria (KWAB) offers an individual mentoring program to accompany specialist training in family medicine. The mentors are confidants for matters of specialist training, private practice, career development and compatibility of work and family life. The training takes place after registration via an online portal. The evaluation was conducted 24 months after the start of KWAB mentoring (06/30/2021-08/01/2021). All active participants were interviewed via online survey. In each case, separate questionnaires were developed, which inquire on the one hand about the content-related aspects of the mentoring, such as topics discussed, and on the other hand about the individual mentoring relationship, such as the interpersonal relationship. The mentees received 39 questions (34 closed, 5 open) and the mentors received 26 questions (21 closed, 5 open), which were subsequently analyzed using descriptive statistics. N = 30 mentors and N = 72 mentees were invited to participate in the evaluation (25 (83 %) mentors and 32 (44 %) mentees participated). More than half of the participants met each other at least twice. The main methods of communication were telephone, face-to-face meetings, and email contacts. The individual time commitment in each case was judged to be appropriate. According to the mentors, the mentees showed interest in the content of the program and demonstrated availability and commitment. All respondents indicated a high level of satisfaction with one-on-one mentoring and would recommend it to others. Mentors and mentees in family medicine residency reported a great benefit from the one-on-one mentoring offered and a will to continue their mentoring relationships even after the project period.

Continuity in the academic family medicine teaching environment: Exploring the potential of the CFPC's Patient's Medical Home.

Continuity is at the heart of family medicine, and its benefits are many: increased efficiency, improved health outcomes, enhanced trust, and increased satisfaction for both patient and physician.[1][1]-[8][2] Continuity is also a pillar of the Patient’s Medical Home (PMH) model developed by the

Family Medicine Resident Perceptions on Racial Justice Training in Residency: A CERA Study.

Structural racism is a root cause of health disparities. While family medicine residency programs recognize the importance of addressing race in medicine, it is unclear how many programs have established racial justice training (RJT). This study examines residents' views on the current state of RJT in their respective programs. This survey was part of the Council of Academic Family Medicine Educational Research Alliance (CERA) 2021 national survey of family medicine residents. Questions addressed RJT, resident reported barriers to implementing such training, and recommendations for change. Of the family medicine residents who responded (n=266), the majority of individuals (91.5%) and their residency programs (65.0%) stated that addressing racism in medicine is an educational priority. Residents reported a minority of their programs (17.3%) have a longitudinal curriculum. Residents who received RJT in residency are more likely to be in communities of color (P=.03). The top requests included recruiting faculty and residents of color, and establishing community-based partnerships. Few residencies have been able to implement RJT to the extent that residents' desire. Lack of curricular time and faculty training were commonly cited barriers. Strategies to address these barriers and implement RJT across residencies are needed to combat structural racism.

Fundamental Teaching Activities in Family Medicine Framework: Analysis of Awareness and Utilization.

In 2015, the College of Family Physicians of Canada, in performing their commitment to supporting its members in their educational roles, created the Family Medicine Framework (FTA). It was designed to assist family medicine educators with an understanding of the core activities of educators: precepting, coaching, and teaching within or beyond clinical settings. Given that an examination of member awareness of FTA has not been previously undertaken, our primary objective was to conduct an evaluation on its utility and application. In partnership with College of Family Physicians of Canada Faculty Development Education Committee members, we used a practical participatory evaluation approach to conduct a two-phase mixed-methods evaluation of the FTA. We distributed an electronic survey in French and English languages to Canadian faculty development, program, and site directors in family medicine. We then conducted follow-up interviews with self-selected participants. Of the target populations, 12/15 (80%) faculty development directors (FDDs), 12/18 (66.7%) program directors, and 34/174 (19.5%) site directors completed the electronic survey. Subsequently, 6 FDDs, 3 program directors, and 3 site directors completed an interview (n = 12). Findings indicate that awareness of the FTA was highest among FDDs. Facilitators who encourage teachers to use the FTA and barriers for low uptake were also identified. This evaluation illuminated that varied levels of awareness of the FTA may contribute to the low uptake among education leaders. We also suggest future research to address possible barriers that hinder effective applications of the FTA in faculty development initiatives.

Effect of Residents-as-Teachers in Rural Community-Based Medical Education on the Learning of Medical Students and Residents: A Thematic Analysis.

Residents-as-teachers (RaT) is a theoretical framework emphasizing the significance of the similar learning background of teachers and learners. In Japan, community-based medical education (CBME) is a practical approach to teaching family medicine. This study aimed to investigate the impact and challenges of RaT on the learning of medical students and residents in CBME at a rural community hospital in Japan. Over the course of a year, the researchers conducted one-on-one interviews with three residents and ten medical students participating in family medicine training at the hospital. The interviews were recorded and transcribed verbatim. Grounded theory was used in the data analysis to clarify the findings. Three key themes emerged from the research: lack of educational experience with RaT, effectiveness of RaT, and challenges of RaT. Although participants were prejudiced against RaT, they felt its implementation could facilitate the establishment of beneficial relationships between learners and teachers. They were also able to participate in medical teams effectively. The findings suggest that the increased participation of senior doctors in RaT could strengthen its learning effects. RaT in rural CBME should be applied in various contexts, and its effectiveness should be further investigated both qualitatively and quantitatively.