The impact of socially-accountable, community-engaged medical education on graduates in the Central Philippines: Implications for the global rural medical workforce

Community-engaged medical education is a way to develop health promoters: A comparative study

BACKGROUND

Although the importance of health promotion and empowerment of the community has been recognized for many years, there are still many barriers to adopting health promotion in the world. One of the solutions is socially accountable medical education and community engagement.

OBJECTIVE

This study aimed to compare the medical programs of five medical schools that practiced community-engaged medical education to medical education in Iran.

MATERIALS AND METHODS

This comparative study has been performed in 2022 by the four-stage Bereday method, including description (the educational programs of the selected medical schools were examined), interpretation (a validated checklist was prepared according to community-based strategies), proximity (similar and different information was identified), and comparison (solutions were recommended to improve health promotion and community engagement in Iran's medical education program. The purposive sampling method was used to select five universities.

RESULTS

Although successful initiatives have been attempted to integrate public health promotion and community orientation into the Iranian curriculum, they do not appear to be sufficient in comparison to leading countries. The main distinction is that the community is actively engaged in all stages of curriculum design, implementation, and evaluation.

CONCLUSIONS

Although Iran's medical education program has a long way to go in terms of social accountability, by including more community-oriented initiatives into the curriculum, health needs of the community can be met and physician shortages in poor areas can be alleviated. It is recommended to implement modern teaching methods, to recruit diverse faculty and community members, and to increase the community placement in medical education.

Strategies to Facilitate Improved Recruitment, Development, and Retention of the Rural and Remote Medical Workforce: A Scoping Review

BACKGROUND

Medical workforce shortages in rural and remote areas are a global issue. High-income countries (HICs) and low- and middle-income countries (LMICs) seek to implement strategies to address this problem, regardless of local challenges and contexts. This study distilled strategies with positive outcomes and success from international peer-reviewed literature regarding recruitment, retention, and rural and remote medical workforce development in HICs and LMICs.

METHODS

The Arksey and O'Malley scoping review framework was utilised. Articles were retrieved from electronic databases Medline, Embase, Global Health, CINAHL Plus, and PubMed from 2010-2020. The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guideline was used to ensure rigour in reporting the methodology in the interim, and PRISMA extension for scoping review (PRISMA-ScR) was used as a guide to report the findings. The success of strategies was examined against the following outcomes: for recruitment - rural and remote practice location; for development - personal and professional development; and for retention - continuity in rural and remote practice and low turnover rates.

RESULTS

Sixty-one studies were included according to the restriction criteria. Most studies (n=53; 87%) were undertaken in HICs, with only eight studies from LMICs. This scoping review found implementation strategies classified as Educational, Financial, and Multidimensional were successful for recruitment, retention, and development of the rural and remote medical workforce.

CONCLUSION

This scoping review shows that effective strategies to recruit and retain rural and remote medical workforce are feasible worldwide despite differences in socio-economic factors. While adjustment and adaptation to match the strategies to the local context are required, the country's commitment to act to improve the rural medical workforce shortage is most critical.

Nurses’ Contributions in Rural Family Medicine Education: A Mixed-Method Approach

Family medicine residents frequently collaborate with nurses regarding clinical decisions and treatments, which contributes to their education. In rural areas, these residents experience a wider scope of practice by collaborating with nurses. However, nurses’ contributions to rural family medicine education have not been clarified. This study measured the contributions of 88 rural community hospital nurses to family medicine education using a quantitative questionnaire and interviews. The interviews were recorded, transcribed verbatim, and analyzed using the grounded theory approach. Nurses’ average clinical experience was 20.16 years. Nurses’ contributions to the roles of teacher and provider of emotional support were statistically lower among participants working in acute care wards than those working in chronic care wards (p = 0.024 and 0.047, respectively). The qualitative analysis indicated that rural nurses’ contributions to family medicine education focused on professionalism, interprofessional collaboration, and respect for nurses’ working culture and competence. Additionally, nurses struggled to educate medical residents amid their busy routine; this education should be supported by other professionals. Rural family medicine education should incorporate clinical nurses as educators for professionalism and interprofessional collaboration and as facilitators of residents’ transition to new workplaces. Subsequently, other professionals should be more actively involved in improving education quality.

Increasing doctors working in specific rural regions through selection from and training in the same region: national evidence from Australia

BACKGROUND

'Grow your own' strategies are considered important for developing rural workforce capacity. They involve selecting health students from specific rural regions and training them for extended periods in the same regions, to improve local retention. However, most research about these strategies is limited to single institution studies that lack granularity as to whether the specific regions of origin, training and work are related. This national study aims to explore whether doctors working in specific rural regions also entered medicine from that region and/or trained in the same region, compared with those without these connections to the region. A secondary aim is to explore these associations with duration of rural training.

METHODS

Utilising a cross-sectional survey of Australian doctors in 2017 (n = 6627), rural region of work was defined as the doctor's main work location geocoded to one of 42 rural regions. This was matched to both (1) Rural region of undergraduate training (< 12 weeks, 3-12 months, > 1 university year) and (2) Rural region of childhood origin (6+ years), to test association with returning to work in communities of the same rural region.

RESULTS

Multinomial logistic regression, which adjusted for specialty, career stage and gender, showed those with > 1 year (RRR 5.2, 4.0-6.9) and 3-12 month rural training (RRR 1.4, 1.1-1.9) were more likely to work in the same rural region compared with < 12 week rural training. Those selected from a specific region and having > 1-year rural training there related to 17.4 times increased chance of working in the same rural region compared with < 12 week rural training and metropolitan origin.

CONCLUSION

This study provides the first national-scale empirical evidence supporting that 'grow your own' may be a key workforce capacity building strategy. It supports underserviced rural areas selecting and training more doctors, which may be preferable over policies that select from or train doctors in 'any' rural location. Longer training in the same region enhances these outcomes. Reorienting medical training to selecting and training in specific rural regions where doctors are needed is likely to be an efficient means to correcting healthcare access inequalities.

Family Medicine Education at a Rural Hospital in Japan: Impact on Institution and Trainees

Family medicine is vital in Japan as its society ages, especially in rural areas. However, the implementation of family medicine educational systems has an impact on medical institutions and requires effective communication with stakeholders. This research—based on a mixed-method study—clarifies the changes in a rural hospital and its medical trainees achieved by implementing the family medicine educational curriculum. The quantitative aspect measured the scope of practice and the change in the clinical performance of family medicine trainees through their experience of cases—categorized according to the 10th revision of the International Statistical Classification of Disease and Related Health Problems. During the one-year training program, the trainees’ scope of practice expanded significantly in both outpatient and inpatient departments. The qualitative aspect used the grounded theory approach—observations, a focus group, and one-on-one interviews. Three themes emerged during the analysis—conflicts with the past, driving unlearning, and organizational change. Implementing family medicine education in rural community hospitals can improve trainees’ experiences as family physicians. To ensure the continuity of family medicine education, and to overcome conflicts caused by system and culture changes, methods for the moderation of conflicts and effective unlearning should be promoted in community hospitals.

"We learnt it, then we lived it": Influencing medical students' intentions toward rural practice and generalist careers via a socially-accountable curriculum

OBJECTIVE

The James Cook University (JCU) medical school has a mission to produce graduates committed to practising with underserved populations. This study explores the views of final-year students regarding the influence of the JCU medical curriculum on their self-reported commitment to socially-accountable practice, intentions for rural practice, and desired postgraduate training pathway.

METHODS

Cross-sectional survey of final year JCU medical students (n = 113; response rate = 65%) to determine whether their future career directions (intentions for future practice rurality and postgraduate specialty training pathway) are driven more by altruism (commitment to socially accountable practice/community service) or by financial reward and/or prestige.

RESULTS

Overall, 96% of responding students reported their JCU medical course experiences had cultivated a greater commitment towards 'socially-accountable' practice. A commitment to socially-accountable practice over financial reward and/or prestige was also significantly associated with preferring to practise Medicine in non-metropolitan areas (p = 0.036) and intending to choose a 'generalist' medical discipline (p = 0.003).

CONCLUSIONS

The findings suggest the JCU medical curriculum has positively influenced the commitment of its graduating students towards more socially accountable practice. This influence is a likely result of pre-clinical teachings around health inequalities and socially-accountable medical practice in combination with real-world, immersive experiences on rural and international placements.

Factors associated with increasing rural doctor supply in Asia-Pacific LMICs: a scoping review

BACKGROUND

More than 60% of the world's rural population live in the Asia-Pacific region. Of these, more than 90% reside in low- and middle-income countries (LMICs). Asia-Pacific LMICs rural populations are more impoverished and have poorer access to medical care, placing them at greater risk of poor health outcomes. Understanding factors associated with doctors working in rural areas is imperative in identifying effective strategies to improve rural medical workforce supply in Asia-Pacific LMICs.

METHOD

We performed a scoping review of peer-reviewed and grey literature from Asia-Pacific LMICs (1999 to 2019), searching major online databases and web-based resources. The literature was synthesized based on the World Health Organization Global Policy Recommendation categories for increasing access to rural health workers.

RESULT

Seventy-one articles from 12 LMICs were included. Most were about educational factors (82%), followed by personal and professional support (57%), financial incentives (45%), regulatory (20%), and health systems (13%). Rural background showed strong association with both rural preference and actual work in most studies. There was a paucity in literature on the effect of rural pathway in medical education such as rural-oriented curricula, rural clerkships and internship; however, when combined with other educational and regulatory interventions, they were effective. An additional area, atop of the WHO categories was identified, relating to health system factors, such as governance, health service organization and financing. Studies generally were of low quality-frequently overlooking potential confounding variables, such as respondents' demographic characteristics and career stage-and 39% did not clearly define 'rural'.

CONCLUSION

This review is consistent with, and extends, most of the existing evidence on effective strategies to recruit and retain rural doctors while specifically informing the range of evidence within the Asia-Pacific LMIC context. Evidence, though confined to 12 countries, is drawn from 20 years' research about a wide range of factors that can be targeted to strengthen strategies to increase rural medical workforce supply in Asia-Pacific LMICs. Multi-faceted approaches were evident, including selecting more students into medical school with a rural background, increasing public-funded universities, in combination with rural-focused education and rural scholarships, workplace and rural living support and ensuring an appropriately financed rural health system. The review identifies the need for more studies in a broader range of Asia-Pacific countries, which expand on all strategy areas, define rural clearly, use multivariate analyses, and test how various strategies relate to doctor's career stages.

A Checklist for Implementing Rural Pathways to Train, Develop and Support Health Workers in Low and Middle-Income Countries

Background: There is an urgent need to scale up global action on rural workforce development. This World Health Organization-sponsored research aimed to develop a Rural Pathways Checklist. Its purpose was to guide the practical implementation of rural workforce training, development, and support strategies in low and middle-income countries (LMICs). It was intended for any LMICs, stakeholder, health worker, context, or health problem. Method: Multi-methods involved: (1) focus group concept testing; (2) a policy analysis; (3) a scoping review of LMIC literature; (4) consultation with a global Expert Reference Group and; (5) field-testing over an 18-month period. Results: The Checklist included eight actions for implementing rural pathways in LMICs: establishing community needs; policies and partners; exploring existing workers and scope; selecting health workers; education and training; working conditions for recruitment and retention; accreditation and recognition of workers; professional support/up-skilling and; monitoring and evaluation. For each action, a summary of LMICs-specific evidence and prompts was developed to stimulate reflection and learning. To support implementation, rural pathways exemplars from different WHO regions were also compiled. Field-testing showed the Checklist is fit for purpose to guide holistic planning and benchmarking of rural pathways, irrespective of LMICs, stakeholder, or health worker type. Conclusion: The Rural Pathways Checklist provides an agreed global conceptual framework for the practical implementation of "grow your own" strategies in LMICs. It can be applied to scale-up activity for rural workforce training and development in LMICs, where health workers are most limited and health needs are greatest.

Does a socially-accountable curriculum transform health professional students into competent, work-ready graduates? A cross-sectional study of three medical schools across three countries

Background: Socially-accountable health professional education (SAHPE) is committed to achieving health equity through training health-workers to meet local health needs and serve disadvantaged populations. This research assesses the biomedical and socially-accountable competencies and work-readiness of first year graduates from socially-accountable medical schools in Australia, the United States and Sudan.Method: A self-administered survey to hospital and community health facility staff closely associated with the training and/or supervision of first year medical graduates from three SAHPE medical schools.Main outcome measure: Likert scale ratings of key competencies of SAHPE graduates (as a group) employed as first-year doctors, compared to first year doctors from other medical schools in that country (as a group).Findings: Supervisors rated medical graduates from the 3 SAHPE schools highly for socially-accountable competencies ('communication skills', 'teamwork', 'professionalism', 'work-readiness', 'commitment to practise in rural communities', 'commitment to practise with underserved ethnic and cultural populations'), as well as 'overall performance' and 'overall clinical skills'.Interpretation: These findings suggest SAHPE medical graduates are well regarded by their immediate hospital supervisors, and SAHPE can produce a medical workforce as competent as from more traditional medical schools, but with greater commitment to health equity, working with underserved populations, and addressing local health needs.

Using poster presentation to assess large classes: a case study of a first-year undergraduate module at a South African university

BACKGROUND

The massification of higher education is often associated with poor student engagement, poor development of their critical thinking, inadequate feedback and poor student throughput. These factors necessitate the need to devise novel, innovative methods to teach, assess and provide feedback to learners to counter the restrictions imposed due to the large class learning environments. This study was conducted to ascertain the perceptions of 1st year medical students and staff at the Nelson Mandela School of Medicine regarding the value of poster presentations as a strategy to enhance learning, assessment and feedback.

METHODS

This was an exploratory observational, descriptive cross-sectional, case study. Data was collected through separate student and staff questionnaires that required participant responses on a five-point Likert scale. The data was extracted into Excel spreadsheets for quantitative analysis.

RESULTS

Two-hundred- and-thirty (92%) student questionnaires were returned (N = 250). Most students indicated that the design and presentation of the poster had helped them to select important material (92%), understand and describe disadvantage (86%) and to make a difference in the community (92%). The students agreed that the poster assessment was an efficient (81%) and fair method (75%) that provided opportunities for meaningful feedback. Ten staff members responded to the questionnaire. Most staff members (90%) indicated that the poster presentation had allowed students to demonstrate their engagement in a meaningful and appropriate way around issues of disadvantage and HIV and agreed that the poster presentations allowed for immediate and effective feedback.

CONCLUSION

Students' interactions in the tasks promoted active engagement with others and course material; the development of higher order thinking and skills which added to students' accounts of transformative learning experiences. They could describe and illustrate the difference that they had made in their chosen community. The poster presentations allowed for quick and efficient marking, immediate feedback and an opportunity to validate the students' participation. Poster presentations offered an innovative way to encourage deep meaningful engagement and learning amongst peers and facilitators. Poster presentations should be more widely considered as an innovative way of encouraging deeper engagement and learning in a large class setting.

Several Ways Generation Z May Shape the Medical School Landscape

Just as medical colleges have adapted to the Millennial generation of students, a new generation is poised to enter as matriculants. Learner attributes of this generation, Generation Z, are in stark contrast to previous ones, but more than that, they provide new challenges that undergraduate universities are already facing. This article aims to highlight some of these challenges, including those relating to student counseling services, volunteering activities, learning environments, and learner perspectives. These challenges are framed and discussed within the context of medical education.

Board certification and urban-rural migration of physicians in Japan

Background

The board certification system serves as a quality assurance system for physicians, and its design and operation are important health policy issues. In Japan, board certification was established and operated independently by academic societies and has not been directly linked to reimbursement systems. The phenomenon of younger physicians seeking specialist careers has raised concerns about acceleration of the tendency of fewer physicians working in rural areas and the maldistribution of physicians. Little is known about the associations between physicians’ geographical migration patterns and board certification status changes or between the continuation of urban/rural practice and the maintenance of board certification. This study aimed to identify these associations and to discuss their policy implications.

Methods

We analyzed 2012 and 2014 data from the Survey of Physicians, Dentists, and Pharmacists, a national census survey. To analyze geographical migration patterns, transitions in practice location (rural, intermediate, and urban) were analyzed by board certification status change (new, lost, consistently certified, and consistently uncertified). Logistic regression analysis was conducted to assess whether the odds of migrating to more urban/rural municipalities were associated with board certification status changes, adjusting for covariates, and whether practicing in a rural area was associated with maintaining board certification.

Results

Among 18,726 newly board-certified physicians, 94.9% (13,435/14,150) of those working in urban areas before certification remained in urban areas, whereas 64.6% (393/608) of those working in rural areas stayed in rural areas. Those who were newly certified had higher odds of moving to more urban areas, adjusting for covariates. Those who stayed in rural areas showed lower odds of maintaining board certification, adjusting for covariates.

Conclusions

Newly board-certified physicians are more likely to migrate to other types of areas, particularly more urban areas, than other physicians. Allocating more training quotas to rural areas could be one option for leveling the distribution of specialists. It also appeared that those practicing in rural areas have difficulty maintaining their certification, so the need to establish a support system for already-certified physicians in rural areas should be emphasized.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3441-y) contains supplementary material, which is available to authorized users.

Work settings of the first seven cohorts of James Cook University Bachelor of Medicine, Bachelor of Surgery graduates: Meeting a social accountability mandate through contribution to the public sector and Indigenous health services

OBJECTIVE

The James Cook University medical school's mission is to produce a workforce appropriate for the health needs of northern Australia.

DESIGN, SETTING AND PARTICIPANTS

James Cook University medical graduate data were obtained via cross-sectional survey of 180 early-career James Cook University medical graduates from 2005-2011 (response rate of 180/298 contactable graduates = 60%). Australian medical practitioner data for 2005-2009 graduates were obtained via the 2015 'Medicine in Australia: Balancing Employment and Life' wave 8 dataset.

MAIN OUTCOME MEASURE

Comparison of the range of work settings and hours worked by James Cook University medical graduates to Australian medical graduates.

RESULTS

Compared to a similar group of Australian medical graduates, James Cook University Bachelor of Medicine, Bachelor of Surgery graduates are significantly more likely to work in government-funded 'public' organisations (hospitals, community health centres, Aboriginal Community Controlled Health Services, government departments, agencies or defence forces). In particular, James Cook University medical graduates were more likely to work in Aboriginal Community Controlled Health Services and community health centres and other state-run primary health care organisations than other Australian medical graduates.

CONCLUSION

James Cook University medical graduates appear to work in a higher proportion of public settings; in particular, primary care settings, than Australian medical graduates. This is an appropriate mix for the predominantly rural and remote geography of Queensland and its associated medical workforce priorities. Reporting medical graduate outcomes by their nature of practice could be an important adjunct to other measures, such as geographic location and choice of specialty.

Socially accountable medical education strengthens community health services

CONTEXT

Socially accountable health professional education (SAHPE) is committed to achieving health equity through training health professionals to meet local health needs and serve disadvantaged populations. This Philippines study investigates the impact of SAHPE students and graduates on child and maternal health services and outcomes.

METHODS

This is a non-randomised, controlled study involving a researcher-administered survey to 827 recent mothers (≥1 child aged 0-5 years). Five communities were serviced by SAHPE medical graduates or final-year medical students (interns) in Eastern Visayas and the Zamboanga Peninsula, and five communities in the same regions were serviced by conventionally trained (non-SAHPE) graduates.

FINDINGS

Mothers in communities serviced by SAHPE-trained medical graduates and interns were more likely than their counterpart mothers in communities serviced by non-SAPHE trained graduates to: have lower gross family income (p < 0.001); have laboratory results of blood and urine samples taken during pregnancy discussed (p < 0.001, respectively); have first pre-natal check-up before 4th month of pregnancy (p = 0.003); receive their first postnatal check-up <7 days of birth (p < 0.001); and have a youngest child with normal (>2500 g) birthweight (p = 0.003). In addition, mothers from SAHPE-serviced communities were more likely to have a youngest child that: was still breastfed at 6 months of age (p = 0.045); received a vitamin K injection soon after birth (p = 0.026); and was fully immunised against polio (p < 0.001), hepatitis B (p < 0.001), measles (p = 0.008) and diphtheria/pertussis/tetanus (p < 0.001). In communities serviced by conventional medical graduates, mothers from lower socio-economic quartiles (<20 000 Php) were less likely (p < 0.05) than higher socio-economic mothers to: report that their youngest child's delivery was assisted by a doctor; have their weight measured during pregnancy; and receive iron syrups or tablets.

CONCLUSIONS

The presence of SAHPE medical graduates or interns in Philippine communities significantly strengthens many recommended core elements of child and maternal health services irrespective of existing income constraints, and is associated with positive child health outcomes.