Influence of a rural Longitudinal Integrated Clerkship on medical graduates' geographic and specialty decisions: a constructivist grounded theory study.

BACKGROUND: Like many countries, Australia is suffering from a longstanding and persistent medical workforce maldistribution with fewer doctors per capita in rural locations and a trend towards sub-specialisation. Longitudinal Integrated Clerkships (LIC), a medical education model, are more likely than other clerkship models to produce graduates who work rurally, in communities of increasing remoteness and in primary care. While this quantitative data is essential, there has been a dearth of program-specific evidence explaining this phenomenon. METHODS: To address this knowledge gap, a constructivist qualitative grounded theory approach was employed to identify how the Deakin University comprehensive rural LIC influences graduates' (2011-2020) career decisions in terms of both medical specialty and geographic practice location. RESULTS: Thirty-nine graduates participated in qualitative interviews. The Rural LIC Career Decision Making Framework was developed, postulating that an alignment of personal and program factors under the central concept of 'choosing to participate' can influence graduates' geographic and specialist career decisions, both individually and symbiotically. Once embedded in the clerkship, participation was augmented by the concepts of learning design affordance and learning in place, providing the participants with longitudinal opportunities to experience and compare medical disciplines in an integrated manner. CONCLUSIONS: The developed framework presents contextual elements of the program that were deemed influential on graduates' subsequent career decisions. The alignment of these elements with the program's mission statement has the capacity to enhance the program's rural workforce goals. Regardless of graduates' willingness to participate in the program, a transformation occurred. Transformation occurs through reflection, either challenging or confirming the graduate's pre-conceived ideas about career decisions and in turn influencing professional identity formation.

A case study of a novel longitudinal rural internship program.

INTRODUCTION: Rural medical training along all components of the medical training continuum has been shown to enhance rural workforce outcomes. However, due to the maldistribution of the Australian medical workforce, health services of increased rurality are limited in their ability to fulfil the supervision requirements for all levels of trainees, especially junior doctor training. Although longitudinal program design and pedagogy has flourished in medical school education through the Longitudinal Integrated Clerkship model, this has not yet been widely translated to prevocational training. This study describes how a longitudinal program design was conceptualised and implemented within a rural health service to create a novel internship program. METHODS: A descriptive case study methodology was employed to describe and evaluate the longitudinal integrated internship program. Relevant program documents such as rosters and accreditation submissions were reviewed to aid in describing the program. Interviews with participants involved in the program were conducted during the middle (May) and end (November) points of the program's first year (2021) to investigate perspectives and experiences of the internship model. RESULTS: Each week, interns were rostered for 1 day in the hospital's emergency department and 3 days in general surgery or general medicine, swapping disciplines after 6 months. In this way, interns completed core rotations longitudinally, meeting accreditation and supervision requirements. Additionally, 1 day per week was spent parallel consulting in general practice. Participants described program enablers as the organisational vision and staff buy-in, as well as the longitudinal attachments to disciplines. Barriers identified were the tenuous nature of the medical workforce and long-term sustainability of the program. Benefits of the program included value-adding and preparedness for practice, particularly in a rural context. CONCLUSION: Intern programs that meet the accreditation, supervision and learning requirements can be successfully delivered at rural health services through longitudinal models of medical education. As the intern year is a key component of the rural generalist training pathway, development of similar innovative models provides the opportunity for rural communities to grow their own future medical workforce.

Rural longitudinal integrated clerkships and medical workforce outcomes: A scoping review.

INTRODUCTION: Internationally the medical workforce is suffering from a persistent geographic and specialist maldistribution. Longitudinal models of rural medical education such as longitudinal integrated clerkships (LIC) have been one of the strategies employed to redress this issue. AIM: To map and synthesise the evidence on the medical workforce outcomes of rural LIC graduates, identifying gaps in the literature to inform future research. METHODS: This review followed Arksey and O'Malley's methodological steps. Databases searched included Medline, CINAHL Complete (EBSCOhost), Scopus, Embase (Elsevier), and ISI Web of Science. RESULTS: A total of 9045 non-duplicate articles were located, 112 underwent a full review, with 25 articles meeting the inclusion criteria. Studies were commonly cohort-based (84%), with data collected by database tracking and data linkage (52%). Five themes were identified to summarise the studies: (i) Overall geographic workforce outcomes (ii) influence of non-LIC medical training, (iii) remaining in region and level of rurality, (iv) medical speciality choice and rurality, and (v) selection and preferences. CONCLUSION: Synthesis of the evidence related to workforce outcomes of rural LIC graduates provides directions for future rural medical workforce planning and research. While rural LIC graduates were found to be more likely to work rurally and in primary care specialities compared to graduates from other training pathways there is evidence to suggest this can be enhanced by strategically aligning selection and training factors.

Referral and triage patterns of a new rural paediatric outpatient service in south-western Victoria, Australia.

INTRODUCTION: There is limited available information describing referral and triage patterns for rural paediatric outpatient clinics to guide health service planning and delivery. To address this, referrals for all new patients who attended an appointment during the initial year of a new rural paediatric outpatient service in Portland, Victoria, Australia were examined. METHODS: This was a retrospective review of referrals with initial consultations between 29 October 2018 and 28 October 2019. RESULTS: A total of 149 referrals for new patients were received, equating to a referral rate of 31.6 referrals per 1000 children for the service's Local Government Area (LGA). A total of 65.1% of new patients had not previously engaged with a paediatric service. Overall, 66.6% of referrals were triaged as having a behavioural or developmental problem. The median time from referral letter to initial appointment was 63 days, with referrals that were triaged as behavioural or developmental having an average wait time of 86 days until initial appointment. CONCLUSION: The establishment of this new rural paediatric service showed a latent need within the service's LGA, as demonstrated by higher referral rates compared to previously published studies and a majority patient population who had not previously accessed paediatric services. The greatest area of need identified by referral analysis was for behavioural and developmental problems.

If you build it who will come? Case mix data of a new rural paediatric outpatient clinic.

INTRODUCTION: There is limited current evidence describing the case mix data of rural paediatric outpatient clinics. Collection and analysis of this data is essential for health service planning, facilitating the identification of areas of need within specific communities to support contextualised delivery of paediatric health care. OBJECTIVE: To describe the case mix of patients seen during the initial 12 months of a rural paediatric service, providing evidence to inform rural health service planning. DESIGN: A retrospective cohort study. RESULTS: There were 149 initial consultations during the study period. Behavioural/developmental problems were found in 71.8% of patients and physical problems were present in 64.4% of patients. This resulted in 38.9% of patients having a combination of problem types. 42.9% of patients were referred to or already accessing allied health services, while 20% were accessing specialised paediatric support services such as the National Disability Insurance Scheme and child protection services. Investigations were ordered for 45% of patients, with medications prescribed in 43% of cases. Only 5.4% of patients were discharged after their initial appointment. There were significant differences in problems identified on the referral compared to at the initial appointment demonstrating the value of this service to a rural community. CONCLUSION: The case mix data illustrates a rural paediatric cohort with a complex and chronic burden of disease especially in terms of behavioural and developmental problems. These findings add to the literature on rural paediatric patient care and demonstrate the value of an embedded paediatric service in a medium sized rural town.

Impact of the COVID-19 pandemic on student experiences during rural placements in Australia: findings from a national multi-centre survey.

BACKGROUND: The aim of this national study was to explore the learning experiences of Australia's medical students who trained rurally during the COVID-19 pandemic in 2020. METHODS: A cross-sectional, national multi-centre survey was conducted in 2020, through the Federation of Rural Australian Medical Educators (FRAME). Participants were medical students who had completed an extended Rural Clinical School (RCS) training placement (≥ 12 months). A bespoke set of COVID-19 impact questions were incorporated into the annual FRAME survey, to capture COVID-19-related student experiences in 2020. Pre-pandemic (2019 FRAME survey data) comparisons were also explored. RESULTS: FRAME survey data were obtained from 464 students in 2020 (51.7% response rate), compared with available data from 668 students in 2019 (75.6% response rate). Most students expressed concern regarding the pandemic's impact on the quality of their learning (80%) or missed clinical learning (58%); however, students reported being well-supported by the various learning and support strategies implemented by the RCSs across Australia. Notably, comparisons to pre-pandemic (2019) participants of the general RCS experience found higher levels of student support (strongly agree 58.9% vs 42.4%, p < 0.001) and wellbeing (strongly agree 49.6% vs 42.4%, p = 0.008) amongst the 2020 participants. Students with more than one year of RCS experience compared to one RCS year felt better supported with clinical skills learning opportunities (p = 0.015) and less affected by COVID-19 in their exam performance (p = 0.009). CONCLUSIONS: This study has provided evidence of both the level of concern relating to learning quality as well as the positive impact of the various learning and support strategies implemented by the RCSs during the pandemic in 2020. RCSs should further evaluate the strategies implemented to identify those that are worth sustaining into the post-pandemic period.

Rural longitudinal integrated clerkships and medical workforce outcomes: a scoping review protocol.

INTRODUCTION: The shortage of doctors in rural locations is an international problem, contributing to limited access to healthcare and a health disparity between rural and metropolitan populations. To encourage additional doctors to work in rural locations, more doctors than ever are being trained in rural settings. One rural clerkship model that is gaining recognition for fostering rural careers is the Longitudinal Integrated Clerkship. Longitudinal Integrated Clerkship programmes vary in terms of settings and durations, but at their core have the fundamental commonality of continuity, with students learning the curriculum in an integrated manner. The scoping review will synthesise the literature pertaining to medical workforce outcomes of rural Longitudinal Integrated Clerkship programmes, to uncover areas that require further research and establish elements of medical education programme design that positively influence rural workforce outcomes. METHODS AND ANALYSIS: The review will follow Arksey and O'Malley's six step scoping review framework. MEDLINE, CINAHL complete (EBSCOhost), Scopus, Embase (Elsevier) and ISI Web of Science databases will be searched along with Google, Google Scholar, ProQuest and WHO library database. Single design studies examining the geographic work locations and/or medical specialty of rural Longitudinal Integrated Clerkship graduates will be included. Data from quantitative and mixed-methods studies will be included. Only studies written in English will be included. There will be no date range restriction imposed on the reviewed studies. Two reviewers will independently screen and critically appraise the articles to determine if they meet the inclusion criteria. Data from eligible studies will be extracted for synthesis. ETHICS AND DISSEMINATION: Scoping reviews do not require ethics approval. Results will be submitted to a peer-reviewed journal and may be presented at relevant conferences. The findings will also be shared within the Longitudinal Integrated Clerkship community of medical educators.

Levocarnitine supplementation for management of hypertriglyceridemia in patients receiving parenteral nutrition.

BACKGROUND: Levocarnitine deficiency has been observed in patients receiving parenteral nutrition (PN) and can cause or worsen hypertriglyceridemia. The objective was to characterize use of levocarnitine supplementation in PN and evaluate its effect on triglyceride levels in hospitalized adults. METHODS: This retrospective, single-center study included patients with triglyceride levels ≥175 mg/dl while receiving PN who had a subsequent reduction in lipid injectable emulsion dose. A piecewise linear regression was used to evaluate trends in triglyceride levels before and after the intervention, defined as initiation of levocarnitine in PN for the levocarnitine group, or reduction in lipid injectable emulsion alone for the control group. RESULTS: Two hundred sixty-one patients who received PN had an elevated triglyceride level and lipid injectable emulsion dose reduction, of which 97 (37.2%) received levocarnitine in PN. The median (IQR) levocarnitine dose added to PN was 8.0 (5.7-9.9) mg/kg. Triglyceride levels at 30 days post-intervention did not differ between groups (125 vs 176 mg/dl, P = .345). The addition of levocarnitine to PN was associated with a significantly greater rate of reduction in triglyceride levels pre-intervention to post-intervention compared with a reduction in lipid injectable emulsion alone (-11 vs -3 mg/dl per day; 95% CI, -15 to -2; P = .012). CONCLUSION: In hospitalized adults with hypertriglyceridemia who had a lipid injectable emulsion dose reduction, the addition of levocarnitine in PN was not associated with a difference in triglyceride levels at 30 days; however, a greater rate of improvement in pre-intervention to post-intervention triglyceride levels was observed.

Graduate rural work outcomes of the first 8 years of a medical school: What can we learn about student selection and clinical school training pathways?

OBJECTIVE: To determine the student characteristics and clinical school training pathways that are associated with postgraduate rural practice. DESIGN: A cross-sectional observational study. SETTING: Deakin University's School of Medicine, encompassing 3 rural and 2 metropolitan clinical schools, including a rural longitudinal integrated clerkship (LIC) year. PARTICIPANTS: A total of 948 School of Medicine medical graduates (2011-2018) who had an Australian Health Practitioners Regulation Agency registered work location in Australia (September 2019). MAIN OUTCOME MEASURE(S): Graduates' work locations were linked with admission and clinical school training data and analysed for significant associations. RESULTS: Graduates completing a rural LIC year and a regional rural clinical school year were 7 times more likely to be working rurally than metropolitan trainees. A small number of rural background (RB) students completed a rural LIC and rural clinical school year, 66.7% of whom were practising rurally. Further associations with rural practice were attending a rural clinical school for 2 years or a rural LIC for 1 year, student having a RB, rurally bonded course placement and being an international student. CONCLUSION: The significant influence of a rural LIC year on graduate rural work location is noteworthy, especially when undertaken by students from a RB in combination with a second regional rural clinical school year. These findings support the strategic alignment of rural student selection with rural clinical school training pathways to achieve the greatest impact on rural graduate workforce outcomes.

The impact of clerkship model and clinical setting on medical student's participation in the clinical workplace: A comparison of rural LIC and rural block rotation experience.

PURPOSE: To compare the participation of rural Longitudinal Integrated Clerkship (LIC) and rural Block Rotation (BR) students in surgical clinical activities. METHODS: Third-year medical students from Deakin University's Rural Clinical Schools were invited to record their participation during clinical encounters with ten common surgical conditions, using a descriptive five-point progressive entrustment scale. Participation levels of LIC and BR students were compared for differences, according to clinical task and context. RESULTS: LIC students recorded greater active participation across all clinical tasks.Highest levels of active participation occurred in General Practice, a setting only LIC students were exposed to at this course stage. BR students recorded the majority of their surgical encounters in the hospital inpatient setting, where their involvement was predominantly observational. Both groups recorded high levels of participation in the Emergency Department. CONCLUSIONS: Active participation in clinical encounters with surgical patients was enhanced by participation in a LIC program and cannot be attributed to the rural context alone. Student participation is influenced by clinical context, presenting the opportunity to reconsider the design of clerkships to include models that facilitate active student participation. Further research is required to investigate the learner, supervisor and contextual factors influencing entrustment decisions within clerkships.

Medical Students Can Learn Surgery Effectively in a Rural Longitudinal Integrated Clerkship.

BACKGROUND: At Deakin University School of Medicine, compulsory formal teaching in Surgery occurs in year 3. This may occur as part of a rural longitudinal integrated clerkship (LIC), or in a traditional teaching hospital block rotation (BR). The purpose of this study was to compare these groups' exposure to surgical common conditions and their academic outcomes. METHODS: Part I: This was a survey of students' encounters with patients with common surgical conditions between 2016 and 2018. Self-reported data were collected describing the nature of the encounters and their clinical settings. Part II: All third year Surgery MCQ and OSCE results from 2011 to 2017 were analyzed. Students were deidentified and grouped according to whether they were in the LIC or BR programme. RESULTS: Part I: Thirty-eight third year students (20 LIC, 18 BR) submitted data for a total of 188 clinical encounters. Both groups encountered all nominated common surgical conditions, but the settings in which this occurred were different. BR students saw most patients as hospital inpatients whereas LIC student encounters were distributed across multiple clinical sites. Part II: A total of 942 (121 [26%] LIC and 821 [74%] BR) students' assessment results were analyzed. The groups performed similarly in the MCQ (p = 0.21) and OSCE (p = 0.16) examinations. CONCLUSIONS: Students who were taught surgery in a LIC program performed similarly to on their final exams to their peers in traditional clerkships, with self-reported student data indicating both groups encountered a similar range of conditions.

'It could have been a lot worse': the psychological effects of farm-related serious injury in Victoria.

INTRODUCTION: The psychological response to injury is an important factor in recovery, and the development of psychological problems can result in a delay or inability to return to pre-injury function, including return to work. Farming is widely acknowledged as a stressful occupation, with non-injured farmers already at an increased risk of developing significant psychological problems, including high levels of stress and depression, and increased rates of suicide. This study aimed to investigate the psychological effects of serious farm-related injury on farmers, and how this influences their recovery. METHODS: This was a qualitative study of 31 farmers in the state of Victoria, Australia, who sustained major trauma between 2007 and 2013. Participants were identified using the Victorian State Trauma Registry and underwent an in-depth, semi-structured telephone interview. Recruitment continued until data saturation was achieved, and thematic analysis was used to identify important themes from the data. RESULTS: For many farmers, the traumatic circumstances and ongoing impact of their injury are life-changing. In this study, the psychological effects of sustaining a major farm-related injury varied between participants; however, four major interconnected themes were identified: importance of a pragmatic outlook; grief, helplessness and loss of independence; traumatic thoughts post-injury; and the importance of the support network and community. The findings of this study highlight both a reluctance for psychological assistance as well as the importance of psychological resilience and support networks to recovery. CONCLUSION: Overall, a positive outlook was found to be the primary enabler in the farmers' recovery. It is recommended that injured farmers should be provided with additional psychological support and advice to aid in their recovery. Additionally, psychological support services should be extended to include both the family network and the broader farming community, as these were found to experience significant short- and long-term stress following farmers' injury.

The role of vertically integrated learning in a rural longitudinal integrated clerkship.

BACKGROUND: Deakin's Rural Community Clinical School (RCCS) is a Longitudinal Integrated Clerkship (LIC) program in Western Victoria. Students undertake a year-long placement in a rural General Practice, many of which also host General Practice Registrars. There is a lack of evidence addressing the role and impact of Vertically Integrated Learning (VI) in practices hosting both LIC medical students and General Practice Registrars. The objective of the study was to establish how VI is perceived in the LIC context and the impact that it has on both learners and practices, in order to consider how to potentiate the role it can play in facilitating learning. METHODS: Semi-structured, in-depth, qualitative interviews were undertaken, with 15 participants located in RCCS General Practices. Emergent themes were identified by thematic analysis. RESULTS: Five main interconnected themes were identified; (i) understanding and structure, (ii) planning and evaluation, (iii) benefits, (iv) facilitators, and (v) barriers. CONCLUSION: VI in a rural LIC is not clearly understood, even by participants. VI structure and methodology varied considerably between practices. Benefits included satisfying and efficient sharing of knowledge between learners at different levels. VI was facilitated by the supportive and collegiate environment identified as being present in a rural LIC context. Resources for VI are needed to guide content and expectations across the continuum of medical training and evaluate its role. The financial impact of VI in a rural LIC warrants further exploration.

What Happens to the Farm? Australian Farmers' Experiences after a Serious Farm Injury.

OBJECTIVES: To investigate the experiences of farmers on returning to farming following a serious farm-related injury. METHODS: Patients who had sustained major trauma on a farm in Victoria, Australia, were identified using the Victorian State Trauma Registry (VSTR). In depth, semistructured phone interviews were conducted with 31 participants. Interview data were subjected to thematic analysis to identify important recurring themes. Interviews continued until data saturation was achieved. RESULTS: Interviewees included self-employed full-time farmers, part-time farmers with a supplementary income, and agricultural employees. Analysis of participant responses connected to returning to farming after a serious farm-related injury identified five major interconnected themes: (i) effect on farm work, (ii) farming future, (iii) safety advocacy, (iv) changes to farming practices, and (v) financial ramifications. CONCLUSION: Farmers who have sustained a serious farm-related injury are an important resource; their experiences and perspectives could assist in the development of educational and transitional support services from recovery back to working at a preinjury level, while ensuring farming production is sustainable during this period. Furthermore, farm safety programs can be enhanced by the engagement of farmers, such as participants in this study as advocates for improved farm safety practices.

Lifestyle risk factors and corresponding levels of clinical advice and counselling in general practice.

BACKGROUND: The objective of this study was to examine prevalence rates of lifestyle risk factors in the Western Victorian Primary Health Network (WV PHN) general practice patient population and the corresponding levels of clinical advice and counselling. METHODS: Analysed data from the Bettering the Evaluation and Care of Health (BEACH) program from April 2011 to March 2015 were examined, providing a comparison of three geographical areas of general practice patients: WV PHN, Victoria and Australia. RESULTS: Rates of clinical advice and counselling for diet and exercise provided by general practitioners (GPs) in the WV PHN network were significantly lower than Victorian and Australian rates, despite the region's higher obesity rates. Smoking rates were higher in the WV PHN compared with Australia, but there was no difference in the levels of smoking cessation advice disseminated. Across all regions, one in four patients drank alcohol at hazardous levels. DISCUSSION: GPs in rural practice require further support, encouragement and resources to provide diet and exercise advice to their patients more frequently.