Vocational career paths of graduate entry medical students at Flinders University: a comparison of rural, remote and tertiary tracks

OBJECTIVE

To provide data on the career trajectories of medical students from rural and remote workforce programs at Flinders University (the Parallel Rural Community Curriculum [PRCC] and the Northern Territory Clinical School [NTCS]), comparing them with students at the urban Flinders Medical Centre (FMC).

DESIGN

Retrospective postal survey of all 150 graduates who undertook their Year 3 study in the period 1998-2000.

OUTCOME MEASURE

Associations with career preference, assessed using univariate analyses and multivariate regression.

RESULTS

PRCC and NTCS graduates were more likely to choose rural career paths than graduates from FMC. The odds ratios were 19.1 (95% CI, 3.4-106.3; P < 0.001) and 4.3 (95% CI, 1.2-14.8; P = 0.026), respectively, after adjusting for age and rural background. There was no difference in the specialty choices of graduates of the three programs.

CONCLUSION

This study provides evidence that clinical attachments designed to increase the rural and remote medical workforce do fulfil this objective.

Do consultations in rural general practice take more time when practitioners are precepting medical students?

CONTEXT

At Flinders University, Adelaide, a subset of students on the 4-year, graduate-entry medical course chooses to spend Year 3 based in rural general practice as part of the Parallel Rural Community Curriculum (PRCC). This programme is equivalent to the tertiary teaching hospital option in terms of student educational outcomes. However, there is concern that this success comes at the cost of lost consulting time for the general practitioners (GPs) who supervise these students.

OBJECTIVE

This study aimed to quantify the impact of medical students on the consulting time of rural GP supervisors.

METHODS

We carried out a prospective cohort study using analysis of videotape recordings. Study subjects were GPs supervising PRCC medical students and working from their own consulting rooms in the clinic setting. Main outcome measures were mean consultation times in sessions with and without medical students.

RESULTS

Using mixed model analysis accounting for clustering of consultations within doctors, and controlling for confounding factors, the estimated marginal mean of regular consultation time was 13 minutes, 27 seconds, which was not significantly shorter than that of precepting consultations (12 minutes, 48 seconds) or parallel consultations (12 minutes, 24 seconds).

CONCLUSIONS

Consultation length does not increase when rural GPs supervise medical students using a parallel consulting model.

Where is the evidence that rural exposure increases uptake of rural medical practice?

Australian Government initiatives to address medical workforce shortages in rural Australia include increasing the intake of students of rural background and increasing exposure to rural medicine during training. Rural-orientated medical training programs in the USA that selectively admit students from rural backgrounds and who intend to practise as family practitioners have demonstrated success in increasing uptake of practice in rural/underserved areas. However, in examining the specific contribution of rural exposure towards increasing uptake of rural practice, the evidence is inconclusive, largely due to the failure to adjust for these critical independent predictors of rural practice. This paper identifies this evidence gap, examines the concept of rural exposure, and highlights the need to identify which aspects of rural exposure contribute to a positive attitude towards rural practice, thereby influencing students to return to rural areas. The cost of rural exposure through student placements is not insignificant, and there is a need to identify which aspects are most effective in increasing the uptake of rural practice, thereby helping to address the medical workforce shortage experienced in rural Australia.

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.

Glomerular expression of neuronal activity-regulated pentraxin precedes the development of anti-Thy-1-induced progressive glomerulosclerosis

Although it is clear that genetic predispositions play a role in progressive glomerulosclerosis, identification of specific genes is difficult because of natural genetic heterogeneity among individuals. We have reported a differential susceptibility to progressive glomerulosclerosis after induction of experimental glomerulonephritis anti-Thy-1 nephritis in Lewis rat substrains. Glomerular lesions in Lewis/Møllegard rats resolve spontaneously, whereas Lewis/Maastricht (Lew/Maa) rats develop progressive glomerulosclerosis. This predisposition for progressive glomerulosclerosis is governed by unknown genes that are expressed by renal cells. Here, differential gene expression analysis using a rat complementary DNA micro array revealed neuronal activity-regulated pentraxin (Narp) as a candidate gene involved in the remodeling or progression of damaged glomeruli. Glomerular Narp mRNA expression was monitored during disease in both Lewis sub strains. Immunohistochemistry revealed that Narp protein is exclusively expressed in Lew/Maa glomeruli 7 and 14 days after induction of anti-Thy-1 nephritis. Double-immunofluorescent staining showed that proliferating mesangial cells and parietal epithelial cells (PECs) at sites of adhesion to podocytes are partially Narp-positive, whereas podocytes fail to express Narp. Immunohistochemistry in nephritic Wistar, unilaterally nephrectomized Wistar and Sprague-Dawley rats showed that Narp protein is present only in strains that develop progressive glomerulosclerosis but never in strains that show remodeling. We conclude that Narp is a predictor for anti-Thy-1 nephritis-induced glomerulosclerosis and its expression by PECs may be involved in the progression to glomerulosclerosis.

Neuronal pentraxins mediate synaptic refinement in the developing visual system

Neuronal pentraxins (NPs) define a family of proteins that are homologous to C-reactive and acute-phase proteins in the immune system and have been hypothesized to be involved in activity-dependent synaptic plasticity. To investigate the role of NPs in vivo, we generated mice that lack one, two, or all three NPs. NP1/2 knock-out mice exhibited defects in the segregation of eye-specific retinal ganglion cell (RGC) projections to the dorsal lateral geniculate nucleus, a process that involves activity-dependent synapse formation and elimination. Retinas from mice lacking NP1 and NP2 had cholinergically driven waves of activity that occurred at a frequency similar to that of wild-type mice, but several other parameters of retinal activity were altered. RGCs cultured from these mice exhibited a significant delay in functional maturation of glutamatergic synapses. Other developmental processes, such as pathfinding of RGCs at the optic chiasm and hippocampal long-term potentiation and long-term depression, appeared normal in NP-deficient mice. These data indicate that NPs are necessary for early synaptic refinements in the mammalian retina and dorsal lateral geniculate nucleus. We speculate that NPs exert their effects through mechanisms that parallel the known role of short pentraxins outside the CNS.

Empirical evidence for symbiotic medical education: a comparative analysis of community and tertiary-based programmes

BACKGROUND

Flinders University has developed the Parallel Rural Community Curriculum (PRCC), a full year clinical curriculum based in rural general practice in South Australia. The examination performance of students on this course has been shown to be higher than that of their tertiary hospital-based peers.

AIM

To compare the learning experiences of students in the community-based programme with those of students in the tertiary hospital in order to explain these improved academic outcomes.

METHOD

A case study was undertaken, using an interpretivist perspective, with 3 structured interviews carried out over 2 academic years with each of 6 students from the community-based programme and 16 students from the tertiary hospital. The taped interviews were transcribed and analysed thematically using NUD*IST software.

RESULTS

The community-based programme was successful in immersing the students in the clinical environment in a meaningful way. Four key themes were found in the data. These represented clear differences between the experiences of the community-based and hospital-based students. These differences involved: the value that students perceived they were given by supervising doctors and their patients; the extent to which the student's presence realised a synergy between the work of the university and the health service; opportunities for students to meet the aspirations of both the community and government policy, and opportunities for students to learn how professional expectations can mesh with their own personal values.

CONCLUSION

This study has provided empirical evidence for the importance of the concept of symbiosis in understanding quality in medical education.