Outcomes of Australian rural clinical schools: a decade of success building the rural medical workforce through the education and training continuum.

INTRODUCTION: The establishment of the rural clinical schools funded through the Commonwealth Department of Health and Ageing (now Department of Health) Rural Clinical Training and Support program over a decade ago has been a significant policy initiative in Australian rural health. This article explores the impacts of this policy initiative and presents the wide range of educational innovations contextualised to each rural community they serve. METHODS: This article reviews the achievements of the Australian rural clinical and regional medical schools (RCS/RMS) through semi-structured interviews with the program directors or other key informants. The questions and responses were analysed according to the funding parameters to ascertain the numbers of students, types of student placements and range of activities undertaken by each university program. RESULTS: Sixteen university medical schools have established 18 rural programs, creating an extensive national network of RCS and RMS in every state and territory. The findings reveal extensive positive impacts on rural and regional communities, curriculum innovation in medical education programs and community engagement activities. Teaching facilities, information technology, video-conferencing and student accommodation have brought new infrastructure to small rural towns. Rural clinicians are thriving on new opportunities for education and research. Clinicians continue to deliver clinical services and some have taken on formal academic positions, reducing professional isolation, improving the quality of care and their job satisfaction. This strategy has created many new clinical academics in rural areas, which has retained and expanded the clinical workforce. A total of 1224 students are provided with high-quality learning experiences for long-term clinical placements. These placements consist of a year or more in primary care, community and hospital settings across hundreds of rural and remote areas. Many programs offer longitudinal integrated clerkships; others offer block rotations in general practice and specialist clinics. Nine universities established programs prior to 2004, and these well-established programs are finding graduates who are returning to rural practice. Universities are required to have 25% of the students from a rural background. University admission policies have changed to encourage more applications from rural students. This aspect of the policy implements the extensive research evidence that rural-origin students are more likely to become rural practitioners. Additional capacity for research in RCS has influenced the rural health agenda in fields including epidemiology, population health, Aboriginal health, aged care, mental health and suicide prevention, farming families and climate change. There are strong research partnerships with rural workforce agencies, research centres for early career researchers and PhD students. CONCLUSIONS: The RCS policy initiative has vastly increased opportunities for medical students to have long-term clinical placements in rural health services. Over a decade since the policy has been implemented, graduates are being attracted to rural practice because they have positive learning experiences, good infrastructure and support within rural areas. The study shows the RCS initiative sets the stage for a sustainable future Australian rural medical workforce now requiring the development of a seamless rural clinical training pipeline linking undergraduate and postgraduate medical education.

Secondary prevention for acute coronary syndrome in rural South Australia: are drugs best? What about the rest?

INTRODUCTION: Acute coronary syndrome (ACS) is a major cause of morbidity and mortality worldwide. Current Australian clinical guidelines recommend all patients with ACS receive comprehensive secondary prevention services to address this burden. Optimal patient outcomes rely on the timely and effective implementation of proven therapies and for secondary prevention to be successful, pharmacological interventions must be combined with cardiovascular disease (CVD) risk factor identification and management. The ability to implement clinical guidelines is also reliant on available resources, yet many rural populations in Australia do not have access to structured secondary prevention services, and the level of support available to them in the form of unstructured services is unclear. Our aim was to examine the scope of secondary prevention in a 'significantly restricted' rural region of South Australia that does not have access to structured secondary prevention services. METHODS: A retrospective analysis of medical records was undertaken to identify documented evidence of assessment and intervention for medical, lifestyle and behavioural CVD risk factors in hospital and at follow up in general practice (GP) clinics. Eligible participants were patients admitted to hospital in the Riverland Region of South Australia with myocardial infarction over a 12 month period. Of 77 eligible participants, permission was received to access the medical records of 55 patients in the hospital setting, and 34 of these 55 patients in GP clinic follow up. RESULTS: Most patients received baseline assessment for previous AMI (98%), history of hypertension (82%), history of diabetes (78%), and smoking status (76%). Most poorly documented was history of dyslipidaemia (53%) and obesity/ overweight (2%). Prescribing rates for recommended ACS medications at the time of hospital discharge were aspirin (90%), beta blockers (55%), ACE inhibitors (42%), lipid lowering medication (66%) and clopidogrel (64%). Overall prescribing rates in the 12 month study period rose to 80% or higher for all recommended medications. There was no evidence of interventions for smoking and obesity/ overweight in the hospital setting and 45% of smokers in the GP clinic setting received quit advice. Measurement of biomedical risk factors (blood lipid analysis and blood glucose levels) was suboptimal, and there was no evidence of a written action plan for chest pain for any participants. CONCLUSIONS: Unstructured services provided some of the recommended elements of secondary prevention. However, deficits in care exist that have the potential to negatively impact patient outcomes in this already disadvantaged population. Future research needs to focus on the extent to which this and other rural and remote health care services are working within current clinical guidelines for the management of ACS, and subsequent patient outcomes. Urgent consideration must also be given to the introduction and evaluation of a more structured and consistent approach in this and other rural and remote regions of Australia. The development of rehabilitation and prevention services that build on existing strengths and resources have the potential to widen access, enhance current services and ensure care is based on best practice guidelines. This in turn may reduce the burden of CVD and improve the overall health and quality of life for patients in rural and remote Australia.