Twelve tips for establishing a new medical school.

Many new medical programs have been established during the last 20 years, and this trend seems set to continue as the health care needs of the world's populations become more complex and demand increases for more physicians to provide the necessary health care. In this paper, we address how best to establish a new medical school, based on our experiences in new ventures in several countries. Success requires a combination of boldness of vision, support from many stakeholder groups, adequate financial and human resources, educational expertise, confidence, patience, and persistence.

Positive impacts on rural and regional workforce from the first seven cohorts of James Cook University medical graduates.

INTRODUCTION: The regionally-based James Cook University (JCU) School of Medicine aims to meet its mission to address the health needs of the region by combining selection and curriculum strategies shown to increase rural career recruitment outcomes. The School has graduated 536 students in its first seven cohorts from 2005 to 2011. This paper presents the early career practice locations and the specialty training undertaken by these cohorts, and describes the association between later practice location with both hometown at application and internship location. METHODS: Hometown at application' data for JCU Bachelor of Medicine, Bachelor of Surgery (MBBS) graduates was retrieved from administrative databases held by the university, while postgraduate location and career data were obtained either from personal contact via email, telephone, Facebook or electronically from the Australian Health Practitioner Regulation Authority website. Practice location was described across Australian Standard Geographical Classification Remoteness Area (RA) categories. RESULTS: Data for the primary practice location of 536 JCU MBBS graduates across postgraduate years (PGY) 1 to 7 is 99% complete. A total of 65% of JCU graduates undertook their internship in non-metropolitan locations including 20% in RA 2 and 44% in RA 3-5, a pattern of practice different to that of other Australian clinicians. For the internship year, 'non-metropolitan-origin' JCU MBBS graduates predominantly worked in RA 2-5 locations, while 'metropolitan origin' graduates were more likely to work in major cities. However, by PGY 7, the distribution of 'rural' and 'metropolitan' origin JCU graduates across RA categories was similar. The RA category of internship location - either 'metropolitan (RA 1) or 'non-metropolitan' (RA 2-5) - was associated with the location of subsequent practice across PGY 2-7. CONCLUSION: This comprehensive data set provides the first real evidence from one of Australia's new medical schools on actual postgraduate practice location, as compared to 'intent to practice'. The geographic profile by RA of JCU graduates' hometown and patterns of postgraduate practice is different to that of other Australian medical students and doctors. This early evidence supports the JCU model of distributed non-metropolitan medical education, and suggests more regionally-located internship and specialty training places would further increase the medical workforce in northern and/or rural Australia. The workforce impact of the seven cohorts of graduates in this study is starting to be felt in rural and regional Australia, and, if these trends continue, will result in significant workforce improvements over the next decade. These results support further investment in regional and rural medical education.

Are medical student results affected by allocation to different sites in a dispersed rural medical school?

INTRODUCTION: As medical education becomes more decentralised, and greater use is made of rural clinical schools and other dispersed sites, attention is being paid to the quality of the learning experiences across these sites. This article explores this issue by analysing the performance data of 4 cohorts of students in a dispersed clinical school model across 4 sites. The study is set in a newly established medical school in a regional area with a model of dispersed education, using data from the second to fifth cohorts to graduate from this school. METHODS: Summative assessment results of 4 graduating cohorts were examined over the final 2 years of the course. Two analyses were conducted: an analysis of variance of mean scores in both years across the 4 sites; and an analysis of the effect of moving to different clinical schools on the students' rank order of performance by use of the Kruskal-Wallis test. RESULTS: Analysis revealed no significant difference in the mean scores of the students studying at each site, and no significant differences overall in the median ranking across the years. Some small changes in the relative ranking of students were noticed, and workplace-based assessment scores in the final year were higher than the examination-based scores in the previous year. CONCLUSIONS: The choice of clinical school site for the final 2 years of an undergraduate rural medical school appears to have no effect on mean assessment scores and only a minor effect on the rank order of student scores. Workplace-based assessment produces higher scores but also has little effect on student rank order. Further studies are necessary to replicate these findings in other settings and demonstrate that student learning experiences in rural sites, while popular with students, translate into required learning outcomes, as measured by summative assessments.

Rural internships for final year students: clinical experience, education and workforce.

INTRODUCTION: The James Cook University School of Medicine is the only complete medical school in northern Australia, and it has a mission to prepare graduates to meet the unique needs of the region with a particular emphasis on rural, remote, Indigenous and tropical health. Eight-week 'rural internships' have been undertaken by all sixth-year medical students at James Cook University since 2005. Each student had previously completed at least 12 weeks of structured rural placements in years 2 and 4, as well as other core teaching in rural health including the year 2 subject, 'Rural, Remote, Indigenous and Tropical Health'. Students worked in rural hospitals across northern Australia developing and practising clinical skills under the supervision of senior staff. Students undertook full-time inpatient and outpatient responsibilities under supervision, being rostered for after-hours work with appropriate support. Assessment involved a learning portfolio, including multi-source feedback from peers, supervisors and patients, and a population health project and a telephone referral exercise. METHODS: This article describes the development, implementation and assessment of the first years of the program, from 2005 to 2007. Evaluation included student questionnaires, site visits and interviews, and follow-up teleconferences with preceptors. RESULTS: The rural internship provides senior medical students with valuable experience by active participation in the healthcare team. Students reported a rich and varied clinical experience. Students accept limited supervised responsibility and further their ability and confidence to undertake the role of the intern. Importantly, they proved not to be a burden to the system. This rotation therefore appears to meet educational needs without compromising the local workforce (and indeed may add to it). Students felt welcomed by their communities and enjoyed the social and cultural aspects of their attachment, as well as the clinical aspects and the opportunity to further their understanding of rural communities, rural health care and the healthcare team. Preparation of the students, the preceptors and the communities emerged as a key element of success. CONCLUSION: This model extends and enhances the traditional apprenticeship model by its rural focus and distributed nature, and involvement of the entire student cohort. In addition, the contribution to patient care by senior students and junior doctors enables a consultant-registrar-resident model, in which experienced rural doctors function as consultants providing advice, support and tuition rather than predominantly face-to-face patient care. This approach also provides a means to address an emerging paradox: rural preceptors and communities want to teach students, appreciating the long-term workforce implications, but are increasingly constrained by resources, particularly time. Similar innovative approaches should be explored in other settings.

Developing the accredited postgraduate assessment program for Fellowship of the Australian College of Rural and Remote Medicine.

INTRODUCTION: Accreditation of the Australian College of Rural and Remote Medicine (ACRRM) as a standards and training provider, by the Australian Medical Council (AMC) in 2007, is the first time in the world that a peak professional organisation for rural and remote medical education has been formally recognised. As a consequence, the Australian Government provided rural and remote medicine with formal recognition under Medicare as a generalist discipline. This accreditation was based on the ability of ACRRM to meet the AMC's guidelines for its training and assessment program. METHODS: The methodology was a six-step process that included: developing an assessment blueprint and a classification scheme; identifying an assessment model; choosing innovative summative and formative assessment methods that met the needs of rural and remote located medical practitioner candidates; 21 rural doctors and academics developing the assessment items as part of a week-long writing workshop; investigating the feasibility of purchasing assessment items; and 48 rural candidates piloting three of the assessment items to ensure they would meet the guidelines for national accreditation. RESULTS: The project resulted in an innovative formative and summative assessment program that occurs throughout 4 years of vocational training, using innovative, reliable, valid and acceptable methods with educational impact. The piloting process occurred for 3 of the 6 assessment tools. Structured Assessment Using Multiple Patient Scenarios (StAMPS) is a new assessment method developed as part of this project. The StAMPS pilot found that it was reliable, with a generalisability coefficient of >0.76 and was a valid, acceptable and feasible assessment tool with desired educational impact. The multiple choice question (MCQ) examination pilot found that the applied clinical nature of the questions and their wide range of scenarios proved a very acceptable examination to the profession. The web based in-training assessment examination pilot revealed that it would serve well as a formative process until ACRRM can further develop their MCQ database. CONCLUSIONS: The ACRRM assessment program breaks new ground for assessing rural and remote doctors in Australia, and provides new evidence regarding how a comprehensive and contemporary assessment system can work within a postgraduate medical setting.

Videoconferencing: practical advice on implementation.

Videoconferencing provides a useful tool for improving information flow, with clinical, educational and administrative uses being particularly relevant to rural and remote Australia. This paper describes the range of possible uses for computer-based videoconferencing and describes the authors' experience in delivering rural medical education in North Queensland via videoconference. Principles that ensure successful videoconferencing are outlined and are applicable to a variety of formats and uses. They include the need to keep it simple, the importance of thorough preparation, and ensuring that education drives technology, rather than the converse.

Phosphoglycerate-kinase-glyceraldehyde-3-phosphate-dehydrogenase interaction. Molecular mass studies.

When rabbit muscle phosphoglycerate kinase (PGK; a 48-kDa monomeric protein) and glyceraldehyde-3-phosphate dehydrogenase (GraPDH; a 145-kDa homotetrameric protein) are present together in solution in the proportion of 1 mol PGK/1 mol GraPDH monomer (total protein 0.2-1.0 mg/ml), an 80--82-kDa protein species is observed by gel-penetration (dilution factor) method and by the conventional procedure of elution from a gel column. Individually, PGK and GraPDH do not exhibit any self association or dissociation in the concentration range employed. Electrophoresis of the 80-82-kDa peak eluted from the gel column shows a single protein band with mobility intermediate between those of GraPDH and PGK. In titration experiments by the gel-penetration method, plots of dilution factor of PGK (or GraPDH) activity versus GraPDH (or PGK) concentration shows two linear portions intersecting at approximately 1 mol GraPDH monomer/1 mol PGK. From the molecular-mass values and the titration experiments, it has been suggested that, in solution, these enzymes form a complex consisting of 1 molecule of PGK and one monomeric subunit of GraPDH (expected molecular mass 84 kDa). Its dissociation constant has been estimated to be equal to or less than 13 nM. The complex is dissociated in the presence of KCl or NADH, with approximately half dissociation at 0.1 M salt or 0.25 mM NADH. At 0.1 M KCl, the complex is completely dissociated by adding ATP, NADH or 3-phosphoglycerate. AMP, ADP, NAD+, glyceraldehyde-3-phosphate, phosphate ions and fructose-1,6-bisphosphate reverse the effect of KCl.

Why I like rural practice.

Not all rural doctors have had a lifelong ambition to enter rural practice. For some the decision comes after a positive experience even quite late in their professional development. This paper is written by a rural doctor with little experience of rural life until he was posted to a small one-doctor community under the Queensland Government's State Fellowship scheme. Seven years later ...