Is small beautiful? Student performance and perceptions of their experience at larger and smaller sites in rural and remote longitudinal integrated clerkships in the Rural Clinical School of Western Australia.

INTRODUCTION: The Rural Clinical School of Western Australia (RCSWA) provides 25% of Western Australia's medical students in their first full clinical year with a longitudinal integrated clerkship in rural and remote areas. They live and work in 10 different sites in groups of 3 to 10 members. This study aimed to discover if students at the smaller sites were disadvantaged by the reduced number of student colleagues, and also by a smaller population catchment area potentially providing a smaller number of clinical presentations. METHOD: Data were collected from 2003 until 2007 from a variety of sources including annual comparisons of end of year results, annual mid-year interviews of all students and staff, and the Dundee Ready Education Environment Measure (DREEM) Survey. RESULTS: There was no difference in end of year results between smaller sites and larger sites and both had slightly higher marks (and statistically significantly better) than their metropolitan colleagues. Mid-year interviews were shown to correlate significantly with the findings from the DREEM questionnaire in terms of student perceptions. Students at small sites were more satisfied with their educational experience than those at the larger sites. CONCLUSION: With good infrastructure, clarity about learning objectives and a structured academic approach to the complexities of the first full clinical year's curriculum, students need not be disadvantaged by being sent in small numbers to small and/or remote sites for their clinical education. This was established both academically in terms of end of year marks, and also by their subjective experiences.

'It's really, really good, but it could be a lot better': qualitative evaluation of a rural clinical school, four years on.

INTRODUCTION: In their first clinical year 25% of Western Australia's medical students undertake a clinical longitudinal integrated clerkship in rural and remote Western Australia. Annual evaluations are undertaken. METHOD: All students, academic and administrative staff employed by the university were interviewed. Qualitative analysis of interview data was taken, fed back to the coordinators and modifications for the next annual cycle were then discussed and decided upon. RESULTS: The predominant themes were elation at the excellence of much of their rural experience and frustration at some individual sites because of issues which were not being resolved. Students were overwhelmingly positive in their interpretation of problems seeing them as systems issue to be improved. Staff at some sites, however, had a strong tendency to blame the student and not respond to the actual problem. All students passed their end of year examinations. DISCUSSION: Most academic evaluation of courses has focussed on comparative academic results with less, if any, attention paid to the qualitative experience of students. Not all clinical clerkship experiences are positive and it is useful to identify what works and what does not work in any medical school. Staff defensiveness is a well-recognised response to challenges and an evaluation system which encourages staff development is an essential component to any school's ongoing improvement.

A comparison between findings from the DREEM questionnaire and that from qualitative interviews.

BACKGROUND: The Rural Clinical School of Western Australia educates one quarter of all Western Australian medical students in their first clinical year in rural settings. As part of a comprehensive evaluation programme students give feedback regularly. AIM: To identify if the Dundee Ready Education Environment Measurement (DREEM) data could be used qualitatively and descriptively to determine specific problems from the data alone despite the small numbers at some sites. METHOD: The DREEM questionnaire was administered on the same day as qualitative interviews were undertaken. The qualitative interviews were analysed thematically first and then compared with findings from DREEM. RESULTS: Each major (student related) evaluation issue identified by the qualitative interviews was also identified by the DREEM questionnaire analysis. DISCUSSION: When the DREEM study was undertaken in the Rural Clinical School of Western Australia there was no real expectation that it would provide sufficient information to identify issues picked up in the extensive and time consuming qualitative study. About half of the work undertaken by the qualitative evaluation, that of the experiences of the students at the site, was picked up by the DREEM questionnaire in a much shorter time frame and at less cost of staff time and resources. CONCLUSION: The DREEM questionnaire can be used qualitatively to assess very specific issues relating to each of the subscales. These findings extend the use of DREEM from quantitative and statistically significant research to qualitative meaning-filled interpretations. The issues then need to be addressed sensitively.

Reported reasons of medical students for choosing a clinical longitudinal integrated clerkship in an Australian rural clinical school.

INTRODUCTION: With the expectation that students educated in a rural setting will be likely to return to practise in a rural area after graduation, the Rural Clinical School of Western Australia (RCSWA) focuses on long-term placements in rural areas during students' clinical training. OBJECTIVE: to identify why students chose to come to RCSWA. SETTING: each of the 10 rural and remote sites in the RCSWA office. METHODS: All students in 2006 and 2007 attending the RCSWA who were available for the mid-year evaluation interviews participated (n = 98). A qualitative thematic analysis of individual interviews was undertaken and emerging themes were compared, with the 2006 data used as a basis to consider the data from 2007. RESULTS: Three major reasons for coming to RCSWA were identified, with most students giving more than one reason. Over 80% of the students reported that they expected to receive broader and better clinical and academic learning opportunities in the rural setting. Three-quarters of the students chose the RCS in order to have the chance to have a year experiencing rural life. One-third of the students came for personal development and increased life experience. The reasons for coming were often multidimensional. Students also articulated reasons for not coming which they considered prior to accepting the position in the RCSWA. In addition, they gave examples of why their decision to come had been a good one, in terms of opportunities for clinical learning and their other identified reasons. CONCLUSION: Students reported they perceived an academic year spent in a rural area to be so overwhelmingly positive that they were prepared to give up everything the city has to offer and go to a different, often challenging environment in order to participate.

A student view of the difference between general practice and rural and remote medicine.

INTRODUCTION: Shortages in the Australian medical workforce have been a concern for the rural sector and government alike for many years. The Commonwealth Department of Health and Aged Care has implemented the Government's Regional Health Strategy to secure a rural education and training network which, it is hoped, will increase the availability and viability of rural health services in the long term. The University of Western Australia's Rural Clinical School was established in 2002 and has delivered a one-year clinical course to a total of 81 students at eight rural and remote sites throughout Western Australia. AIM: To identify student perceptions of rural general practice and whether they perceived any differences from city general practice. METHODS: All available students in 2005 participated in a mid-year semi-structured interview with an evaluator. This article reports the findings relating to the question: 'In your experience so far, do you think there is a specialty that could be called rural and remote medicine that is different to general practice?' Analysis focussed on aggregating responses to the question so that the greatest variety of differences that students perceived could be identified. A thematic analysis was undertaken. RESULTS: Thirty of 33 (91%) 2005 students were interviewed. All but one student believed that rural practice was different to the general practice they observed in the metropolitan region. All but two students thought that rural and remote medicine was a specialty on its own and needed its own training program that was different from city general practice. Five themes were identified from the data to justify the suggestion that the way medicine is practised is different: the importance of a broader and deeper clinical knowledge; the necessity to develop a different way of thinking and organising knowledge; a more socially oriented, patient-centred model of care; community expectations of social roles; and the personal cost of being a rural doctor. DISCUSSION: This study provides us with a student view of rural medicine as a discipline distinct from general practice, and one that requires its own training program. Our students recognised the level of expertise of rural practitioners in managing complexity in rural medicine with its lack of resources, its internal diversity of peoples in its communities, the differences of rural living and the tyranny of distance. They also recognise the importance of training additional to the city level of general practice skills, in order to satisfactorily meet healthcare needs in the rural setting.

Making it pay and helping us stay: the viability of a rural general practice in New Zealand.

AIM: To provide a description of the invoices created for services delivered in a private general practice in a rural area of New Zealand with a view to assessing the value of the services to the community and the rewards to the private business. METHOD: Analysis of computer-based invoices and description of the working arrangements of the practice. RESULTS: A 24-hour, 365-day service was delivered to a local community at a cost of 129 dollars per patient per year, exclusive of the cost of drugs, laboratory, and other investigations and hospital referrals. The rewards for the professionals were mixed, with adequate reimbursement for 8 am-5 pm, 5-day care but those for the out-of-hours and maternity parts of the business were poor, with hourly rates far below New Zealand's minimum wage. CONCLUSION: The recent cosmetic changes to New Zealand Primary Health Care have failed to resolve the challenge of delivering personal medical care to rural communities. Investment in the small business of general practice has the potential to solve the rural health crisis.

Tuning medical education for rural-ready practice: designing and resourcing optimally.

In an effort to bring doctors back to the bush the Australian government has resourced a number of rural clinical schools (RCS). At the RCS in the University of Western Australia students were allocated in small groups to rural sites for the entire fifth year of a six-year course, sitting the same final examinations as city students. Key factors guiding the successful outcome were the resourcing and implementation of the infrastructure and teaching and learning pedagogy. In designing support, the disconnection of students from their city colleagues was anticipated as an issue, as was the pedagogical indoctrination of the teachers. The curriculum implementation was adapted in this light. The role of the Web in teaching and learning, and their status as 'student colleagues' and independent learners were pivotal aspects. As students settled at their site, their confidence grew and their anxiety over urban disconnection dissipated. By benchmarking themselves using Web-based formative assessments and in formative 'objective structured clinical examinations' staged for them by the RCS, the students received ongoing feedback on their progress. This model of embedding students in rural centres for an extended period with rural practitioners as teachers was successfully implemented at multiple sites geographically vastly separate.

Chronic fatigue syndrome. The patient centred clinical method--a guide for the perplexed.

BACKGROUND: Chronic fatigue states are common in general practice and over the past 20 years there has been considerable worldwide consensus developed on the criteria for chronic fatigue syndrome (CFS) also commonly known as myalgic encephalomyelitis (ME). Chronic fatigue syndrome is an illness characterised by the new onset of disabling fatigue, accompanied by cognitive, musculoskeletal and sleep symptoms. There are no specific diagnostic tests or biological markers and the diagnosis is made by ruling out other causes of fatigue. The pathophysiology of CFS is still unclear. OBJECTIVE: This article discusses the application of the patient centred clinical method to the diagnosis and treatment of CFS. DISCUSSION: There is no new breakthrough in the diagnosis or management of CFS in spite of much research and controversy. There is considerable evidence that the best place to manage CFS is in primary care under the care of the patient's own general practitioner, but it has been suggested that doctors feel unable to deal with the problem. The patient centred clinical method offers a constructive guide to management. The author considers that the best hope for sufferers is self management guided by a supportive and helpful health professional, preferably the patient's own GP.