Evaluation of the parallel rural community curriculum at flinders university of south Australia: lessons learnt for Africa

Objectives. To review data collected during an evaluation of the Flinders University Parallel Rural Community Curriculum (PRCC) in order to reflect on its relevance for medical education in Africa.Setting. The PRCC offers a community-based longitudinal curriculum as an alternative for students in their pre-final year of medical training. Design. Individual and focus group interviews were conducted with students; staff; health service managers; preceptors and community members. Results. Students are exposed to comprehensive; holistic; relationship-based care of patients; with a graded increase in responsibility. Students have varying experience at different sites; yet achieve the same outcomes. There is a strong partnership with the health service.Conclusions. The principle of balancing sound education and exposure to a variety of contexts; including longitudinal community-based attachments; deserves consideration by medical educators in Africa

A new model to understand the career choice and practice location decisions of medical graduates.

INTRODUCTION: Australian medical education is increasingly influenced by rural workforce policy. Therefore, understanding the influences on medical graduates' practice location and specialty choice is crucial for medical educators and medical workforce planners. The South Australian Flinders University Parallel Rural Community Curriculum (PRCC) was funded by the Australian Government to help address the rural doctor workforce shortage. The PRCC was the first community based medical education program in Australia to teach a full academic year of medicine in South Australian rural general practices. The aim of this research was to identify what factors influence the career choices of PRCC graduates. METHODS: A retrospective survey of all contactable graduates of the PRCC was undertaken. Quantitative data were analysed using SPSS 14.0 for Windows. Qualitative data were entered into NVIVO 7 software for coding, and analysed using content analysis. RESULTS: Usable data were collected from 46 of the 86 contactable graduates (53%). More than half of the respondents (54%) reported being on a rural career path. A significant relationship exists between being on a rural career pathway and making the decision prior to or during medical school (p = 0.027), and between graduates in vocational training who are on an urban career path and making a decision on career specialty after graduation from medical school (p = .004). Graduates in a general practice vocational training program are more likely to be on a rural career pathway than graduates in a specialty other than general practice (p = .003). A key influence on graduates' practice location is geographic location prior to entering medical school. Key influences on graduates choosing a rural career pathway are: having a spouse/partner with a rural background; clinical teachers and mentors; the extended rural based undergraduate learning experience; and a specialty preference for general practice. A lack of rural based internships and specialist training places is influencing both urban- and rural-origin graduates to practise in urban locations. Further analysis of graduates' career pathway choices (rural or urban) and geographic background (rural or urban) was conducted. This resulted in the development of a new model, 'The Four Qs Model'. This model consists of four quadrants derived from the variables career pathway choice (rural or urban) and geographic background (rural or urban). Clustering of consistent demographic and qualitative trends unique to each quadrant was demonstrated. The distinctive clustering that emerged from the data resulted in the quadrants being renamed 'The True Believers', 'The Convertibles' 'The Frustrated' and 'The Metro Docs'. CONCLUSIONS: The PRCC is influencing graduates to choose a rural career path. The PRCC program affirms the career preferences of rural origin students while graduates with little rural exposure prior to the PRCC report being positively influenced to pursue a rural career path. The Four Qs Model is a useful model in that it demonstrates consistent themes in the characteristics of PRCC graduates and assists understanding of why they choose a rural medical career. This could be relevant to the selection of medical students into rural medical education programs and in the construction of rural curricula. The model also offers a useful framework for further research in this field.

The impact of medical students on rural general practitioner perceptors.

INTRODUCTION: As universities rely more heavily on rural GPs to precept medical students, the formation of symbiotic partnerships benefiting students, universities and GPs, becomes imperative. In order to develop and consolidate these partnerships Universities must understand who their rural GP preceptors are and how precepting impacts on them. METHODS: A review of the literature was undertaken to determine the significant themes of student impacts from articles where conclusions were clearly based on empirical findings. RESULTS: Forty-three articles were included in the final review, but only nine specifically looked at impacts on rural GPs. Impacts were categorised into six domains: personal; time; patient care; professional relationships and professional development; business and infrastructure; and recognition and remuneration. CONCLUSIONS: Literature specifically addressing the impact of precepting on rural GPs is scarce. Further studies are required to evaluate the relationship between the quality of teaching delivered to students, the type and length of student attachments and the likely impacts on rural GPs.

Vertical integration of medical education: Riverland experience, South Australia.

INTRODUCTION: Vertical integration of medical education is currently a prominent international topic, resulting from recent strategic initiatives to improve medical education and service delivery in areas of poorly met medical need. In this article, vertical integration of medical education is defined as 'a grouping of curricular content and delivery mechanisms, traversing the traditional boundaries of undergraduate, postgraduate and continuing medical education, with the intent of enhancing the transfer of knowledge and skills between those involved in the learning-teaching process'. METHODS: Educators closely involved with vertically integrated teaching in the Riverland of South Australia present an analytical description of the educational dynamics of this system. RESULTS: From this analysis, five elements are identified which underpin the process of successful vertical integration: (1) raised educational stakes; (2) local ownership; (3) broad university role; (4) longer attachments; and (5) shared workforce vision. CONCLUSIONS: Given the benefits to the Riverland medical education programs described in this paper, it is not surprising that vertical integration of medical education is a popular goal in many rural regions throughout the world. Although different contexts will result in different functional arrangements, it could be argued that the five principles outlined in this article can be applied in any region.

Change of place, change of pace, change of status: rural community training for junior doctors, does it influence choices of training and career?

INTRODUCTION: The Rural and Remote Area Placement Program (RRAPP) began in April 2000 to provide a rural community practice training term for junior doctors and to increase the opportunities for junior doctors to experience training outside the hospital setting. Recent research into the community-based training and experience for junior doctors in Australia suggests that such experience contributes to their decision-making about future training and career. METHODS: A structured national survey was undertaken of all 107 junior doctors who had participated in RRAPP prior to October 2003 and included semi-structured interviews of 54 participants from prior to October 2002. RESULTS: Data indicated that rural and community experience influenced the choice of further rural and general practice training and also provided a useful setting for junior doctors to reflect on, and confirm, future training plans. This study provided evidence of the positive influence of RRAPP on the career choices of junior doctors, with greater than 70% of participants confirming RRAPP's influence on their plans. This study also provided insight into the process of these career decisions. Decision-making was precipitated by taking junior doctors 'outside their comfort zone' of the tertiary hospital and providing a different perspective on both the present and the future. CONCLUSION: In addition to the contrast in setting and the expansion of knowledge about rural community practice, RRAPP junior doctors identified the change of place, the change of pace, and the change of status as instrumental in their decision-making about future training and careers.

Parallel Rural Community Curriculum: is it a transferable model?

BACKGROUND: The chronic shortage of doctors in rural Australia has been well documented. Enabling medical students to undertake positive rural experiences during their undergraduate course is a well-supported long-term strategy to provide a sustainable solution to this problem. The Parallel Rural Community Curriculum (PRCC) was developed by Flinders University, South Australia, in 1997 to enable senior medical students to undertake an entire clinical year based in rural general practice in the Riverland region of South Australia. The academic success of this program has been widely acknowledged. Many institutions are planning to use this model as a basis for their own curriculum reform. However, questions have been asked as to how well this program would translate into another region. Due to the success of the Riverland program, Flinders University decided to commence a second PRCC program in 2002, this time in the Greater Green Triangle (GGT) region of South Australia and Victoria, Australia. This new program was developed collaboratively by the GGT University Department of Rural Health and the Flinders University Rural Clinical School. RESULTS AND DISCUSSION: The mean student rank improved by an average of 17 places out of a class of 90 students. Partnership development took time. General practitioners (GPs) initially showed significant anxiety particularly in regard to their teaching capacity, time commitment of students and the infrastructure demands on their practices. Specialists' engagement was a challenge, requiring a significant change to their teaching paradigms. Horizontal and vertical integration of teaching was complex and required ongoing effort to maximize efficiency. The community had high expectations of the workforce outcome and these needed to be tempered with realistic expectations about the length of time required to train doctors, and an understanding of workforce mobility. CONCLUSIONS: The initial evaluation of the GGT PRCC suggests that the Riverland PRCC is translatable. Successes, including student performance, GP acceptance and community ownership have been replicated in the GGT community-based medical education program. A key to the success has been the recognition of the crucial role of partnerships in an environment where, for clinicians, clinical service provision and other personal needs take precedence over teaching roles and responsibilities.

Hypothetical model of the financial impact of student attachments on rural general practices.

BACKGROUND: Is teaching a medical student always a financial burden on rural general practice? If so, is the current trend towards increasing placement of students in rural practice sustainable? Retrospective studies of short-term attachments to rural general practice have repeatedly shown a financial cost to the practice. Might the results be different for extended attachments? This paper presents the results of a small prospective study of the financial impact of undergraduate medical students undertaking the Parallel Rural Community Curriculum, a 12 month clinical attachment to rural general practice in the Riverland region of South Australia. METHODS: Students and doctors involved in the program kept separate logs of patient contact time. These data were triangulated with third-party direct observation of consultations and an exit questionnaire on patient satisfaction. RESULTS: In this study, where students had already been actively involved in all aspects of the practice for at least 5 months, it was found that students had a positive effect on general practitioner productivity, without any loss in patient satisfaction. DISCUSSION: To account for these findings, a hypothetical model has been developed of the financial impact of a student on a rural general practice over time. With the current trend in medical schools to undertake increasing amounts of teaching in rural general practice, it is suggested that it may be more economically sustainable if curricula are adapted to allow extended attachments, likely to be at least 5-6 months, rather than traditional shorter rotations.

Rural intern training.

In recent times, legislative initiatives in Australia have changed the method by which doctors enter general practice. One result of this tightening has been to restrict the access of junior doctors to medical experiences outside the hospital environment, and force a closer examination of the 'generalist training' provided to junior doctors. The Australian Medical Training Review Panel, created as part of these legislative changes, developed a series of recommendations about general training in 1996, one of which was to provide for rural and community experiences for junior doctors. This article describes the experience of a 'rural intern' rotation from Flinders Medical Centre to the rural community of Jamestown, in South Australia.

Why we should teach undergraduate medical students in rural communities.

In the eyes of many, the critical shortage of doctors in rural areas is the only reason for providing rural experiences for medical students. This article reviews the body of evidence supporting rural placements as a long-term medical workforce strategy and additional evidence regarding the apparent educational benefits of such placements. By enabling medical students to learn for significant periods of time in rural communities, it is now possible for universities to address the medical workforce imperatives of the communities they serve at the same time as providing intrinsic educational advantages to their students.