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

Comparison of attitudes toward community-based medicine between regional-quota and general-selected medical student in Japan

Objective: This study compared the regional-quota and general-selected medical students' understanding, interest, and confidence in the community medicine practice and their attitudes toward the concept guidelines. Methods: We conducted a Web-based questionnaire survey regarding the understanding, interest, and confidence in future community medicine practice and attitudes toward concept guidelines among medical students of all grades (regional-quota and general-selected: n=82 and n=617, respectively). Results: The overall response rates were 68.5% (56/82) and 66.0% (409/617) in the regional-quota and general-selected groups, respectively. Although there was no significant difference between the groups in terms of understanding (P=0.998), interest and confidence in future practice were significantly higher in the regional-quota group (both P<0.001). There was no significant difference between the two groups for any of the six questions regarding community medicine guidelines. Conclusion: The understanding of community medicine or its conceptual guidelines did not significantly differ between the two groups; however, interest and confidence in future practice were significantly higher in the regional-quota group. These results suggest that the regional-quota system positively upregulates the interest in community medicine, which could be associated with confidence in future practice. Comprehensive and longitudinal improvements in the regional-quota system may be effective in cultivating community medicine.

The impact of Longitudinal Integrated Foundation Training: preliminary experiences in the United Kingdom

BACKGROUND

The United Kingdom health system is challenged with retaining doctors entering specialty training directly after their second foundation year. Improving doctors' training experience during the foundation programme may aid such retention. The Longitudinal Integrated Foundation Training (LIFT) pilot scheme aimed to provide a programme that improves the quality of their foundation training experience, advance patient-centred care and provide doctors with more experience in the primary care settings.

METHODS

During this pilot study, three methods were employed to evaluate and compare doctors' experiences across their 2-year foundation training programme: Horus ePortfolio assessment of six domains for good medical practice analysed using a T-test, online survey assessments analysed using a 2-tailed chi-square test, and focus group feedback sessions with thematic analysis.

RESULTS

Doctors completing LIFT (n = 47) scored a higher but non-significant mean score on all six domains for good medical practice versus doctors completing traditional foundation training (n = 94). By the end of foundation training, 100% of LIFT doctors rated their understanding of how primary and secondary care work together as high versus 78.7% of traditional doctors (p < 0.05). Improvements in wellbeing were observed among LIFT doctors, along with a reduction in the proportion of doctors considering leaving medical training. A significantly greater number of LIFT doctors versus traditional doctors rated their compassion for patients as high (100% versus 86.8%; p < 0.05), intended to become general practitioners (23.1% versus 13.5%; p < 0.05) and rated the extent to which they felt well informed and able to consider a general practice career rather than a hospital career as high (91.7% versus 72.3%, respectively; p < 0.05). Some LIFT doctors felt they had reduced exposure to secondary care, received less on-call experience and considered working a half-day to be problematic; challenges ameliorated by the end of the 2-year foundation programme.

CONCLUSION

The LIFT programme enhanced the quality of foundation training and improved doctors' experiences and competencies, generating valuable insights for the future of education and healthcare delivery. Applying the principles of LIFT to foundation training helps doctors to be more compassionate and patient-centred, leading to enhanced individualised patient care.

Australian rural medical students' perceived readiness for work as a junior doctor: A cross-sectional national survey

OBJECTIVE

To report self-perceived readiness for work as a junior doctor in a national cohort of rural clinical school students.

DESIGN

Cross-sectional study using a self-report questionnaire. Independent variables included 14 individual readiness items related to clinical and professional tasks, sociodemographic data and reported experience of rural clinical school (RCS) training. Participants were 668 medical students (55.3% females) completing a full academic year in rural Australia. Multivariable analysis explored factors associated with overall readiness for work as a junior doctor.

FINDINGS

86% agreed that RCS experience prepared them to undertake the roles and responsibilities of a junior doctor. Self-ratings for specific clinical and professional tasks varied from a mean score of 5.9-8.0 out of 10, and 13 of the 14 items were associated with the outcome (p-value <0.001, except for performing spirometry). Lowest readiness scores were seen for some aspects including raising concerns about a colleague (mean score 6.1) or responding to workplace bullying (mean score 6.0). Aspects of the RCS experience that were strongly associated with overall readiness included: feeling a valued team-member (OR 9.28, 95%CI 2.43-35.39), feeling well-supported academically (OR 6.64, 95%CI 3.39-13.00), having opportunity for unsupervised but supported clinical practice (OR 4.67, 95%CI 1.45-15.00), having a rural mentor (OR 3.38, 95%CI 1.89-6.06) and having a previous health professional qualification (OR 2.7, 95%CI 1.32-5.54).

DISCUSSION

Most RCS students felt ready for work as a junior doctor. Important aspects of RCS experience are likely to include students feeling integrated within the clinical team and having opportunities for authentic clinical roles. There remains a significant challenge for medical school curricula to address professional areas where graduates felt less prepared.

Exploring the learning environment afforded by an Aboriginal Community Controlled Health service in a rural longitudinal integrated clerkship

OBJECTIVES

Despite the extensive literature regarding longitudinal integrated clerkships (LICs), there is very little evidence about this model in non-traditional settings, such as Aboriginal Community Controlled Health Organisations (ACCHOs). This study explored the key elements of the learning experience in a rural LIC programme, within an ACCHO from the perspective of multiple stakeholders including medical students, the general practice supervisory team, Aboriginal health workers (AHWs) and cultural mentors.

METHODS

The study was conducted using a qualitative case-study design. Participants included Year 3 medical students and the health care team (general practitioners, practice nurse, AHWs, and a practice manager in the role of cultural mentor) from an ACCHO in regional Queensland. Data was collected through semi-structured interviews and analysed using inductive thematic analysis.

RESULTS

Three key features were identified within the learning experience of students undertaking an LIC in the ACCHO setting. This study showed it was a safe context for learners to learn about 'culturally safe practice', 'putting relationships at the centre', and to 'try new things', reinforcing ACCHO as an invaluable site for learning.

CONCLUSION

The extended clinical placement in an ACCHO setting afforded an increase in the number of opportunities to develop students' cultural safety, communication skills and relationships with patients and the supervisory team, including AHWs and cultural mentors.

Reflection in Rural Family Medicine Education

Reflection in medical education is vital for students' development as professionals. The lack of medical educators in rural family medicine can impinge on the effective reflection of residents' learning. Hence, based on qualitative research, we proposed a framework regarding reflection in rural family medicine education, indicating when, where, and how reflection is performed and progresses. The contents of reflection include clinical issues regarding knowledge and skills, professionalism in clinical decisions, and work-life balance. The settings of reflection include conference rooms, clinical wards, residents' desks, and hospital hallways. The timing of educational reflection includes during and after patient examination and discussion with various professionals, before finishing work, and during "doorknob" times (right before going back home). Rural medical teachers need competence as clinicians and medical educators to promote learning in medical residents and sustain rural medical care. Furthermore, medical teachers must communicate and collaborate with medical residents and nurses for educational reflection to take place in rural family medicine education, especially regarding professionalism. In rural family medicine education, reflection can be performed in various clinical situations through collaboration with learners and various medical professionals, aiding the enrichment of residents' learning and sustainability of rural medical care.

Widening how we see the impact of culture on learning, practice and identity development in clinical environments

As part of this State of the Science series on Self, Society and Situation, we focus on how we might see the situation of the workplace as a learning environment in the future. Research to date into how health professionals learn while working in clinical workplace environments has mostly focused on the supervisor-trainee relationship or on the interaction between the affordances of a workplace and the receptiveness of trainees. However, the wider environment has not received as much focus-though frequently mentioned, it is seldom investigated. We suggest there is a need to embrace the wider institution factors, recognise and acknowledge an organisation's values and culture as they impact on clinical learning in order to work with these, not around them or ignore them, to make what may be tacit visible through reflection and observation and to embrace a range of perspectives on culture.

Effect of Residents-as-Teachers in Rural Community-Based Medical Education on the Learning of Medical Students and Residents: A Thematic Analysis

Residents-as-teachers (RaT) is a theoretical framework emphasizing the significance of the similar learning background of teachers and learners. In Japan, community-based medical education (CBME) is a practical approach to teaching family medicine. This study aimed to investigate the impact and challenges of RaT on the learning of medical students and residents in CBME at a rural community hospital in Japan. Over the course of a year, the researchers conducted one-on-one interviews with three residents and ten medical students participating in family medicine training at the hospital. The interviews were recorded and transcribed verbatim. Grounded theory was used in the data analysis to clarify the findings. Three key themes emerged from the research: lack of educational experience with RaT, effectiveness of RaT, and challenges of RaT. Although participants were prejudiced against RaT, they felt its implementation could facilitate the establishment of beneficial relationships between learners and teachers. They were also able to participate in medical teams effectively. The findings suggest that the increased participation of senior doctors in RaT could strengthen its learning effects. RaT in rural CBME should be applied in various contexts, and its effectiveness should be further investigated both qualitatively and quantitatively.

The Uncertainty of COVID-19 Inducing Social Fear and Pressure on the Continuity of Rural, Community-Based Medical Education: A Thematic Analysis

Rural community-based medical education (CBME) enriches undergraduate and postgraduate students' learning but has been impacted by the coronavirus disease 2019 (COVID-19) pandemic. We identified the challenges faced by stakeholders as well as the relevant solutions to provide recommendations for sustainable CBME in community hospitals during the COVID-19 pandemic. A total of 31 pages of field and reflection notes were collated through direct observation and used for analysis. Five physicians, eight nurses, one clerk, fourteen medical trainees, and three rural citizens were interviewed between 1 April and 30 September 2020. The interviews were recorded and their contents were transcribed verbatim and analyzed using thematic analysis. Three themes emerged: uncertainty surrounding COVID-19, an overwhelming sense of social fear and pressure within and outside communities, and motivation and determination to continue providing CBME. Rural CBME was impacted by not only the fear of infection but also social fear and pressure within and outside communities. Constant assessment of the risks associated with the pandemic and the implications for CMBE is essential to ensure the sustainability of CBME in rural settings, not only for medical educators and students but also stakeholders who administrate rural CBME.

The Contribution of Citizens to Community-Based Medical Education in Japan: A Systematic Review

Community-based medical education (CBME) offers vital support to healthcare professionals in aging societies, which need medical trainees who understand comprehensive care. In teaching comprehensive care practices, CBME can involve citizens from the relevant community. This research synthesizes the impact of the involvement of communities on the learning of medical trainees in CBME. We conducted a systematic review, in which we searched ten databases from April 1990 to August 2020 for original articles in Japan regarding CBME involving citizens and descriptively analyzed them. The Kirkpatrick model was used to categorize the outcomes. Our search for studies following the protocol returned 1240 results; 21 articles were included in this systematic review. Medical trainees reported satisfaction with the content, teaching processes, and teachers' qualities. Medical trainees' attitudes toward community and rural medicine improved; they were motivated to become family physicians and work in communities and remote areas. This review clarified that citizen involvement in CBME had an effective impact on medical trainees, positively affecting perceptions of this type of education, as well as improving trainees' knowledge about and attitude toward community and rural medicine.

Social Accountability Frameworks and Their Implications for Medical Education and Program Evaluation: A Narrative Review

PURPOSE

Medical schools face growing pressures to produce stronger evidence of their social accountability, but measuring social accountability remains a global challenge. This narrative review aimed to identify and document common themes and indicators across large-scale social accountability frameworks to facilitate development of initial operational constructs to evaluate social accountability in medical education.

METHOD

The authors searched 5 electronic databases and platforms and the World Wide Web to identify social accountability frameworks applicable to medical education, with a focus on medical schools. English-language, peer-reviewed documents published between 1990 and March 2019 were eligible for inclusion. Primary source social accountability frameworks that represented foundational values, principles, and parameters and were cited in subsequent papers to conceptualize social accountability were included in the analysis. Thematic synthesis was used to describe common elements across included frameworks. Descriptive themes were characterized using the context-input-process-product (CIPP) evaluation model as an organizational framework.

RESULTS

From the initial sample of 33 documents, 4 key social accountability frameworks were selected and analyzed. Six themes (with subthemes) emerged across frameworks, including shared values (core social values of relevance, quality, effectiveness, and equity; professionalism; academic freedom and clinical autonomy) and 5 indicators related to the CIPP model: context (mission statements, community partnerships, active contributions to health care policy); inputs (diversity/equity in recruitment/selection, community population health profiles); processes (curricular activities, community-based clinical training opportunities/learning exposures); products (physician resource planning, quality assurance, program evaluation and accreditation); and impacts (overall improvement in community health outcomes, reduction/prevention of health risks, morbidity/mortality of community diseases).

CONCLUSIONS

As more emphasis is placed on social accountability of medical schools, it is imperative to shift focus from educational inputs and processes to educational products and impacts. A way to begin to establish links between inputs, products, and impacts is by using the CIPP evaluation model.

Evaluation of a Preceptorship Model on Third-Year General Surgery Clerkship

BACKGROUND

Medical students increasingly report not feeling meaningfully involved during surgical clerkships. Preceptorship and mentorship through longitudinal experiences ameliorate this problem. A preceptorship model was introduced into the surgery clerkship at our institution to increase contact and improve relationships between students and faculty.

METHODS

The preceptorship model was introduced at select sites in 2017. In contrast to the standard structure in which students are assigned to cases and clinics as needed, preceptorship students are assigned to attending surgeons and follow the surgeons' schedules for the rotation. Student performance data, including final grades, clinical evaluations, and shelf examination scores, were collected for clerkship students from May 2017 to November 2018. Formative and summative evaluations for each student were collected. Qualitative content analysis was used to explore evaluations for themes.

RESULTS

Two hundred and seventy-four students completed the clerkship during the study period; 41 experienced a preceptorship model. There was no difference in student performance across clerkship structures. Summative and formative evaluations for preceptorship students were longer than for traditional students (137 words vs 78 words; p < 0.0001 and 46 words vs 16 words, p = 0.03 respectively). Preceptorship student evaluations contained higher-quality feedback relating to clerkship objectives than those of traditional students. Preceptorship comments also contained more frequent mentions of response to feedback.

CONCLUSIONS

A preceptorship model was successfully implemented on the third-year surgical clerkship at our institution. Although there was no difference between top performers on either clerkship structure, preceptorship students received written evaluations with better feedback as a result of their direct relationship with faculty. Strategies such as this, which improve student-faculty relationships, will be needed as programs find new ways to assess residency applicants.

Reflective Writing as a Window on Medical Students' Professional Identity Development in a Longitudinal Integrated Clerkship

Phenomenon: Integral to the formation of a professional identity is the concept of professional identity construction, an essential part of becoming a competent physician. In this framework, identity is dynamic and shaped by experiences and relationships. Minimal work has addressed the impact that clinical care settings and relationships with patients have in the construction of professional identity for medical students. This study explores how patient interactions and intentional curriculum design support professional identity construction in students participating in a longitudinal integrated clerkship focused on care for the underserved. Approach: This qualitative analysis investigated students' professional identity construction as detailed in 45 reflective essays from 15 students while enrolled in an 11-month longitudinal integrated clerkship (LIC) in a safety-net hospital system. Researchers used an inductive analytic approach. Findings: Students provided rich and complex descriptions of their experiences. Six themes emerged: care for the underserved; therapeutic alliance; humility and gratitude; altruism; resilience; and aspirations. Insights: Professional identity construction was observable through students' reflective essays. Student interactions with patients provided rich material for professional identity construction, and role models in patient care enhanced this process. This study suggests that clinical learning in a safety-net hospital system, coupled with an LIC curriculum that prioritizes continuity with vulnerable patients, faculty role models, and ongoing reflection, supported the professional identity construction of students as patient-centered caregivers providing equitable care and advocacy for the underserved, described here as an Equity Identity.

'It's so rich, you know, what they could be experiencing': rural places for general practitioner learning

Globally there is an urban/rural divide in relation to health and healthcare access. A key strategy for addressing general practitioner shortages in rural areas is GP vocational training in rural places, as this may aid in developing practitioners' scope, values and community orientation, and increase propensity for rural practice. This creates a need for deeper understanding of the nature and quality of this training. Rural GPs are well-positioned to reflect on vocational learning in 'place'. We aimed to explore rural GPs' perceptions and experiences of GP vocational learning in relation to rural places. Semi-structured interviews were conducted with 25 GPs based in smaller rural communities in Tasmania. Inductive and theoretical thematic analysis was undertaken. Rural places provide learning opportunities for GP registrars, which shape the relationships between GPs and registrars and their communities. Rural GPs are committed to developing the next generation and improving access to primary care for their communities. Rural places provide unique learning environments for general practice, including rich learning, relationships and community commitment.

The do's, don'ts and don't knows of establishing a sustainable longitudinal integrated clerkship

INTRODUCTION

The longitudinal integrated clerkship is a model of clinical medical education that is increasingly employed by medical schools around the world. These guidelines are a result of a narrative review of the literature which considered the question of how to maximize the sustainability of a new longitudinal integrated clerkship program.

METHOD

All four authors have practical experience of establishing longitudinal integrated clerkship programs. Each author individually constructed their Do's, Don'ts and Don't Knows and the literature that underpinned them. The lists were compiled and revised in discussion and a final set of guidelines was agreed. A statement of the strength of the evidence is included for each guideline.

RESULTS

The final set of 18 Do's, Don'ts and Don't Knows is presented with an appraisal of the evidence for each one.

CONCLUSION

Implementing a longitudinal integrated clerkship is a complex process requiring the involvement of a wide group of stakeholders in both hospitals and communities. The complexity of the change management processes requires careful and sustained attention, with a particular focus on the outcomes of the programs for students and the communities in which they learn. Effective and consistent leadership and adequate resourcing are important. There is a need to select teaching sites carefully, involve students and faculty in allocation of students to sites and support students and faculty though the implementation phase and beyond. Work is needed to address the Don't Knows, in particular the question of how cost-effectiveness is best measured.

Twelve tips for distributed health professions training

Increasing numbers of health professions students are being trained in healthcare facilities that are geographically removed from central academic hospitals. Consequently, studies have evaluated this distributed training, assessed the impact that it has on student learning as well as on the facilities where the training occurs, and explored factors that enable and constrain successful clinical training at such sites. The 12 tips presented in this article have been developed from a longitudinal project that has focused on developing a framework for effective distributed health professions training through an extensive review of the literature and a national consultative process. These 12 tips should, therefore, have applicability across multiple contexts. The purpose of this article is to assist people in implementing, adapting, upscaling, maintaining, and evaluating the distributed training of students in the health professions.

Alliance, Trust, and Loss: Experiences of Patients Cared for by Students in a Longitudinal Integrated Clerkship

PURPOSE

The longitudinal integrated clerkship (LIC) model, which allows medical students to participate in comprehensive care of a panel of patients over time, is rapidly expanding because of recognized benefits to students and faculty. This study aimed to determine how LIC student contact affected patients' experiences and self-described health outcomes.

METHOD

This qualitative case study used semistructured patient interviews to understand the impact of LIC learners at the University of Colorado School of Medicine on patients at Denver Health. Patients with at least 3 encounters with an LIC student and over age 18 were selected. Thirty patients were invited to participate in 2016-2017; 14 (47%) completed interviews before the thematic analysis reached saturation. Four researchers independently analyzed interview transcripts and reached consensus on emergent categories and themes.

RESULTS

Six broad themes were identified: beginnings of a relationship, caring demonstrated by student, growing to trust student, reaching a therapeutic alliance, improvement of patient outcomes due to student involvement, and a sense of loss after students completed the LIC program.

CONCLUSIONS

Patients deeply valued the therapeutic alliances built with LIC students involved in their care over time. These alliances led to improved patient experience, mitigation of perceived health system failures, and subjective improvement in health outcomes. Patients described a sense of loss at the end of the LIC when students were no longer involved in their care. Curricula that support students building longitudinal therapeutic relationships with their patients are an opportunity to improve patient experience while promoting students' professional development.

Enhancing learning in longitudinal clinical placements in community primary care clinics: undergraduate medical students' voices

Longitudinal clinical placements are increasingly adopted by medical training institutions. However, there seems to be little evidence regarding their implementation in primary care settings in the developing world. This paper explored medical students' perceptions of their learning experiences in longitudinal placements in primary care clinics. The Manchester clinical placement index (MCPI) survey was offered to second-year medical students at the University of Botswana to determine perceptions of their 16 weeks clinical placement in primary care clinics. The MCPI provided data on eight aspects of clinical placements which were analysed to gain insight into students learning experiences while on placement. The eight items in the tool were grouped into four themes, namely, teaching and learning, learning environment, relationships and organisation of placements. Students cited the feedback they received whilst on placement and the learning environment in primary care clinics as aspects of clinical placements which could be improved to enhance their learning experience. For an enriched learning experience in primary care settings in a developing world context, there are critical aspects to be considered. Based on the students' perspective we suggest an approach of how learning in such placements could be enhanced.

Leasing a medical curriculum: What's it worth?

Introduction: The early part of this century saw an unprecedented growth in number and size of Australian medical schools. There was some partnering of the new schools with existing programs. Griffith, Deakin and Curtin Universities leased an established curriculum from Flinders University. Nature and rationale for curriculum leasing: The new schools had short startup times and leasing a curriculum enabled them to appoint key staff, develop facilities and meet accreditation requirements in a timely way. However, the lease arrangements were costly and the curriculum was largely determined before the Dean and key staff appointments. Outcomes of leasing: There was differential adoption of the leased curriculum. The first two years of the courses at Flinders were transferred with little change. The final two years of predominantly clinical studies were developed differently. This is explained through Michael Fullan's work on context in educational change. The context of the clinical years of the courses involved negotiations with local health services and other schools using those health services. The advantage of the leasing arrangements was that the new schools could proceed through early development and accreditation, while having time and opportunity to negotiate a clinical curriculum that engaged local health services and fulfilled the new schools' missions.

Consequences, conditions and caveats: a qualitative exploration of the influence of undergraduate health professions students at distributed clinical training sites

BACKGROUND

Traditionally, the clinical training of health professionals has been located in central academic hospitals. This is changing. As academic institutions explore ways to produce a health workforce that meets the needs of both the health system and the communities it serves, the placement of students in these communities is becoming increasingly common. While there is a growing literature on the student experience at such distributed sites, we know less about how the presence of students influences the site itself. We therefore set out to elicit insights from key role-players at a number of distributed health service-based training sites about the contribution that students make and the influence their presence has on that site.

METHODS

This interpretivist study analysed qualitative data generated during twenty-four semi-structured interviews with facility managers, clinical supervisors and other clinicians working at eight distributed sites. A sampling grid was used to select sites that proportionally represented location, level of care and mix of health professions students. Transcribed data were subjected to thematic analysis. Following an iterative process, initial analyses and code lists were discussed and compared between team members after which the data were coded systematically across the entire data set.

RESULTS

The clustering and categorising of codes led to the generation of three over-arching themes: influence on the facility (culturally and materially); on patient care and community (contribution to service; improved patient outcomes); and on supervisors (enriched work experience, attitude towards teaching role). A subsequent stratified analysis of emergent events identified some consequences of taking clinical training to distributed sites. These consequences occurred when certain conditions were present. Further critical reflection pointed to a set of caveats that modulated the nature of these conditions, emphasising the complexity inherent in this context.

CONCLUSIONS

The move towards training health professions students at distributed sites potentially offers many affordances for the facilities where the training takes places, for those responsible for student supervision, and for the patients and communities that these facilities serve. In establishing and maintaining relationships with the facilities, academic institutions will need to be mindful of the conditions and caveats that can influence these affordances.

Challenges, success factors and pitfalls: implementation of distributed medical education

OBJECTIVES

There are only a few descriptive reports on the implementation of distributed medical education (DME) and these provide accounts of successful implementation from the senior leadership perspective. In Saskatchewan, over a period of 4 years (2010-2014), four family medicine residency sites were established and two additional sites could not be developed. The aim of this study was to identify challenges, success factors and pitfalls in DME implementation based upon experiences of multiple stakeholders with both successful and unsuccessful outcomes.

METHODS

Data were obtained through document analysis (n = 64, spanning 2009-2016; perspectives of government, senior leadership, management and learners), focus groups of management and operations personnel (n = 10) and interviews of senior leaders (n = 4). Challenges and success factors were ascertained through categorisation. Iterative coding guided by three sensitising frameworks was used to determine themes in organisational dynamics.

RESULTS

Both challenges and success factors included contextual variables, governance, inter- and intra-organisational relationships (most common success factor), resources (most common challenge), the learning environment and pedagogy. Management and operations were only a challenge. Organisational themes affecting the outcome and the pitfalls included the pace of development across multiple sites, collaborative governance, continuity in senior leadership, operations alignment and reconciliation of competing goals.

CONCLUSIONS

Emerging opportunities for DME can be leveraged through collaborative governance, aligned operations and resolution of competing goals, even in constrained contexts, to translate political will into success; however, there are pitfalls that need to be avoided. Our findings based upon multi-stakeholder perspectives add to the body of knowledge on deployment, carefully considering the conditions for success and associated pitfalls.

Stakeholder views of rural community-based medical education: a narrative review of the international literature

CONTEXT

Rural community-based medical education (RCBME), in which medical student learning activities take place within a rural community, requires students, clinical teachers, patients, community members and representatives of health and government sectors to actively contribute to the educational process. Therefore, academics seeking to develop RCBME need to understand the rural context, and the views and needs of local stakeholders.

OBJECTIVES

The aim of this review is to examine stakeholder experiences of RCBME programmes internationally.

METHODS

This narrative literature review of original research articles published after 1970 utilises Worley's symbiosis model of medical education as an analysis framework. This model proposes that students experience RCBME through their intersection with multiple clinical, social and institutional relationships. This model seeks to provide a framework for considering the intersecting relationships in which RCBME programmes are situated.

RESULTS

Thirty RCBME programmes are described in 52 articles, representing a wide range of rural clinical placements. One-year longitudinal integrated clerkships for penultimate-year students in Anglosphere countries were most common. Such RCBME enables students to engage in work-integrated learning in a feasible manner that is acceptable to many rural clinicians and patients. Academic results are not compromised, and a few papers demonstrate quality improvement for rural health services engaged in RCBME. These programmes have delivered some rural medical workforce outcomes to communities and governments. Medical students also provide social capital to rural communities. However, these programmes have significant financial cost and risk student social and educational isolation.

CONCLUSIONS

Rural community-based medical education programmes are seen as academically acceptable and can facilitate symbiotic relationships among students, rural clinicians, patients and community stakeholders. These relationships can influence students' clinical competency and professional identity, increase graduates' interest in rural careers, and potentially improve rural health service stability. Formal prospective stakeholder consultations should be published in the literature.

Current efforts in medical education to incorporate national health priorities

As a reflection on the Edinburgh Declaration, this conceptual synthesis presents six important challenges in relation to the role of medical education in meeting current national health priorities.

CONTEXT

This paper presents a conceptual synthesis of current efforts in medical education to incorporate national health priorities as a reflection on how the field has evolved since the Edinburgh Declaration. Considering that health needs vary from country to country, our paper focuses on three broad and cross-cutting themes: health equity, health systems strengthening, and changing patterns of disease.

METHODS

Considering the complexity of this topic, we conducted a targeted search to broadly sample and critically review the literature in two phases. Phase 1: within each theme, we assessed the current challenges in the field of medical education to meet the health priority. Phase 2: a search for various strategies in undergraduate and postgraduate education that have been tested in an effort to address the identified challenges. We conducted a qualitative synthesis of the literature followed by mapping of the identified challenges within each of the three themes with targeted efforts.

FINDINGS

We identified six important challenges: (i) mismatch between the need for generalist models of health care and medical education curricula's specialist focus; (ii) attitudes of health care providers contributing to disparities in health care; (iii) the lack of a universal approach in preparing medical students for 21st century health systems; (iv) the inability of medical education to keep up with the abundance of new health care technologies; (v) a mismatch between educational requirements for integrated care and poorly integrated, specialised health care systems; and (vi) development of a globally interdependent education system to meet global health challenges. Examples of efforts being made to address these challenges are offered.

DISCUSSION

Although strategies for combatting these challenges exist, the effectiveness of educational models depends on them being locally adaptable and applicable. Curricular reform must go hand-in-hand with research and evaluation to develop comprehensive futuristic models of teaching and learning that will adequately prepare health professionals to address the challenges.

Medical Education in Decentralized Settings: How Medical Students Contribute to Health Care in 10 Sub-Saharan African Countries

PURPOSE

African medical schools are expanding, straining resources at tertiary health facilities. Decentralizing clinical training can alleviate this tension. This study assessed the impact of decentralized training and contribution of undergraduate medical students at health facilities.

METHOD

Participants were from 11 Medical Education Partnership Initiative-funded medical schools in 10 African countries. Each school identified two clinical training sites-one rural and the other either peri-urban or urban. Qualitative and quantitative data collection tools were used to gather information about the sites, student activities, and staff perspectives between March 2015 and February 2016. Interviews with site staff were analyzed using a collaborative directed approach to content analysis, and frequencies were generated to describe site characteristics and student experiences.

RESULTS

The clinical sites varied in level of care but were similar in scope of clinical services and types of clinical and nonclinical student activities. Staff indicated that students have a positive effect on job satisfaction and workload. Respondents reported that students improved the work environment, institutional reputation, and introduced evidence-based approaches. Students also contributed to perceived improvements in quality of care, patient experience, and community outreach. Staff highlighted the need for resources to support students.

CONCLUSIONS

Students were seen as valuable resources for health facilities. They strengthened health care quality by supporting overburdened staff and by bringing rigor and accountability into the work environment. As medical schools expand, especially in low-resource settings, mobilizing new and existing resources for decentralized clinical training could transform health facilities into vibrant service and learning environments.

Decentralised training for medical students: a scoping review

BACKGROUND

Increasingly, medical students are trained at sites away from the tertiary academic health centre. A growing body of literature identifies the benefits of decentralised clinical training for students, the health services and the community. A scoping review was done to identify approaches to decentralised training, how these have been implemented and what the outcomes of these approaches have been in an effort to provide a knowledge base towards developing a model for decentralised training for undergraduate medical students in lower and middle-income countries (LMICs).

METHODS

Using a comprehensive search strategy, the following databases were searched, namely EBSCO Host, ERIC, HRH Global Resources, Index Medicus, MEDLINE and WHO Repository, generating 3383 references. The review team identified 288 key additional records from other sources. Using prespecified eligibility criteria, the publications were screened through several rounds. Variables for the data-charting process were developed, and the data were entered into a custom-made online Smartsheet database. The data were analysed qualitatively and quantitatively.

RESULTS

One hundred and five articles were included. Terminology most commonly used to describe decentralised training included 'rural', 'community based' and 'longitudinal rural'. The publications largely originated from Australia, the United States of America (USA), Canada and South Africa. Fifty-five percent described decentralised training rotations for periods of more than six months. Thematic analysis of the literature on practice in decentralised medical training identified four themes, each with a number of subthemes. These themes were student learning, the training environment, the role of the community, and leadership and governance.

CONCLUSIONS

Evident from our findings are the multiplicity and interconnectedness of factors that characterise approaches to decentralised training. The student experience is nested within a particular context that is framed by the leadership and governance that direct it, and the site and the community in which the training is happening. Each decentralised site is seen to have its own dynamic that may foreground certain elements, responding differently to enabling student learning and influencing the student experience. The insights that have been established through this review have relevance in informing the further expansion of decentralised clinical training, including in LMIC contexts.

Decentralised training for medical students: Towards a South African consensus

INTRODUCTION

Health professions training institutions are challenged to produce greater numbers of graduates who are more relevantly trained to provide quality healthcare. Decentralised training offers opportunities to address these quantity, quality and relevance factors. We wanted to draw together existing expertise in decentralised training for the benefit of all health professionals to develop a model for decentralised training for health professions students.

METHOD

An expert panel workshop was held in October 2015 initiating a process to develop a model for decentralised training in South Africa. Presentations on the status quo in decentralised training at all nine medical schools in South Africa were made and 33 delegates engaged in discussing potential models for decentralised training.

RESULTS

Five factors were found to be crucial for the success of decentralised training, namely the availability of information and communication technology, longitudinal continuous rotations, a focus on primary care, the alignment of medical schools' mission with decentralised training and responsiveness to student needs.

CONCLUSION

The workshop concluded that training institutions should continue to work together towards formulating decentralised training models and that the involvement of all health professions should be ensured. A tripartite approach between the universities, the Department of Health and the relevant local communities is important in decentralised training. Lastly, curricula should place more emphasis on how students learn rather than how they are taught.

Otolaryngology exposure in a longitudinal integrated clerkship setting

BACKGROUND

Although 20-40% of primary care complaints are Otolaryngology-Head and Neck Surgery (OtoHNS) related, little emphasis is placed on OtoHNS instruction at the undergraduate medical education level. An OtoHNS clerkship rotation is not required at most Canadian medical schools. Furthermore, at institutions offering an OtoHNS rotation, less than 20% of students are able to complete a placement. Given that a large percentage of medical students in Canada will pursue primary care as a career, there remains a gap in providing OtoHNS clinical training. During the longitudinal integrated clerkship at the Northern Ontario School of Medicine (NOSM), students are assigned to one of 14 sites, and not all have access to an otolaryngologist. This study looks to quantify the level of exposure students are receiving in OtoHNS at NOSM and to assess their comfort level with diagnosing and treating common otolaryngologic conditions.

METHODS

A structured 13-item survey was administered to second, third and fourth year medical students at NOSM.

RESULTS

A majority (67.9%) of medical students surveyed had not observed an otolaryngologist. Furthermore, most students (90.6%) reported receiving very little OtoHNS classroom based and clinical instruction during medical school.

CONCLUSIONS

A discrepancy exists between the quantity and breadth of OtoHNS training received in undergraduate medical education and the volume of OtoHNS encounters in primary care practice. Although geographic dissemination of students in the distributed learning model may be a challenge, strategies such as standardized objectives and supplemental electronic resources may serve to solidify clinical knowledge.

Faculty experience and engagement in a longitudinal integrated clerkship

The authors sought to understand rewards and challenges of teaching third-year medical students in the University of Colorado School of Medicine (CUSOM) Denver Health Longitudinal Integrated Clerkship (DH-LIC) compared to teaching in rotation-based clerkships (RBCs). The authors considered implications for the recruitment and retention of faculty in clinical educational programs. Preceptors completed surveys at baseline and year-end. Of eligible faculty, 28 of 40 completed both baseline and year-end surveys. The majority (85.2%) of faculty were satisfied with the DH-LIC and 85.7% continued to teach in year-two of the program. Faculty reported increased satisfaction from teaching and improved teaching and mentoring skills. Faculty familiarity with DH-LIC students was significantly higher than with students previously taught (p = .004); 89.3% of faculty knew their DH-LIC student well enough to tailor instruction to individual learning needs. Teaching techniques utilized at baseline and end of year differed significantly; faculty reported asking questions to promote thinking, providing feedback to students, and providing students with practice in clinical reasoning more frequently in the DH-LIC. Innovative models of education such as LICs offer a strategy to recruit and retain excellent, invested faculty in outpatient settings.

The social accountability of doctors: a relationship based framework for understanding emergent community concepts of caring

BACKGROUND

Social accountability is defined as the responsibility of institutions to respond to the health priorities of a community. There is an international movement towards the education of health professionals who are accountable to communities. There is little evidence of how communities experience or articulate this accountability.

METHODS

In this grounded theory study eight community based focus group discussions were conducted in rural and urban South Africa to explore community members' perceptions of the social accountability of doctors. The discussions were conducted across one urban and two rural provinces. Group discussions were recorded and transcribed verbatim.

RESULTS

Initial coding was done and three main themes emerged following data analysis: the consultation as a place of love and respect (participants have an expectation of care yet are often engaged with disregard); relationships of people and systems (participants reflect on their health priorities and the links with the social determinants of health) and Ubuntu as engagement of the community (reflected in their expectation of Ubuntu based relationships as well as part of the education system). These themes were related through a framework which integrates three levels of relationship: a central community of reciprocal relationships with the doctor-patient relationship as core; a level in which the systems of health and education interact and together with social determinants of health mediate the insertion of communities into a broader discourse. An ubuntu framing in which the tensions between vulnerability and power interact and reflect rights and responsibility. The space between these concepts is important for social accountability.

CONCLUSION

Social accountability has been a concept better articulated by academics and centralized agencies. Communities bring a richer dimension to social accountability through their understanding of being human and caring. This study also creates the connection between ubuntu and social accountability and their mutual transformative capacity as agents for social justice.

A qualitative exploration of anesthesia trainees' experiences during transition to a children's hospital

BACKGROUND

The stresses of starting a new job can make anyone feel tired and inefficient. In health care, this may impair the ability to learn at a time when there is most to learn, and increase the risk of error in a context where errors may lead to patient harm.

AIM

The aim of this study was to understand issues which influence anesthesia trainees' transition to a pediatric setting.

METHODS

This qualitative study utilized in-depth semi-structured interviews to gather data from 31 anesthesia trainees who had commenced work at a tertiary children's hospital between 4 and 6 weeks previously. Data were examined using thematic analysis.

RESULTS

Two key themes were identified: feeling ineffective, which appeared to have both a cognitive component (feeling disoriented) and an emotional component (feeling useless), and feeling anxious or afraid. Trainees found the pediatric environment highly unfamiliar, which made them feel disoriented, inefficient, and at times incompetent. Many experienced difficulty identifying a useful role in a highly specialized area of practice, leading to loss of identity as an expert clinician. Many described an ever-present fear of making an anesthetic error or being unable to manage a rapidly evolving clinical situation. Some trainees developed a negative mindset, which was reinforced by subsequent perceived failures. Overall, these experiences impeded trainees' ability to concentrate and learn.

CONCLUSIONS

The impact of disorientation and anxiety on anesthesia trainees as they adapt to a highly specialized clinical environment such as a children's hospital should not be underestimated. Study findings illustrate the importance of helping new trainees to feel less afraid, more useful, and more realistic in assessing their own performance during the transition period.

Exposure of undergraduates to authentic GP teaching and subsequent entry to GP training: a quantitative study of UK medical schools

BACKGROUND

It has been suggested that the quantity of exposure to general practice teaching at medical school is associated with future choice of a career as a GP.

AIM

To examine the relationship between general practice exposure at medical school and the percentage of each school's graduates appointed to a general practice training programme after foundation training (postgraduate years 1 and 2).

DESIGN AND SETTING

A quantitative study of 29 UK medical schools.

METHOD

The UK Foundation Programme Office (UKFPO) destination surveys of 2014 and 2015 were used to determine the percentage of graduates of each UK medical school who were appointed to a GP training programme after foundation year 2. The Spearman rank correlation was used to examine the correlation between these data and the number of sessions spent in placements in general practice at each medical school.

RESULTS

A statistically significant association was demonstrated between the quantity of authentic general practice teaching at each medical school and the percentage of its graduates who entered GP training after foundation programme year 2 in both 2014 (correlation coefficient [r] 0.41, P = 0.027) and 2015 (r 0.3, P = 0.044). Authentic general practice teaching here is described as teaching in a practice with patient contact, in contrast to non-clinical sessions such as group tutorials in the medical school.

DISCUSSION

The authors have demonstrated, for the first time in the UK, an association between the quantity of clinical GP teaching at medical school and entry to general practice training. This study suggests that an increased use of, and investment in, undergraduate general practice placements would help to ensure that the UK meets its target of 50% of medical graduates entering general practice.

A typology of longitudinal integrated clerkships

CONTEXT

Longitudinal integrated clerkships (LICs) represent a model of the structural redesign of clinical education that is growing in the USA, Canada, Australia and South Africa. By contrast with time-limited traditional block rotations, medical students in LICs provide comprehensive care of patients and populations in continuing learning relationships over time and across disciplines and venues. The evidence base for LICs reveals transformational professional and workforce outcomes derived from a number of small institution-specific studies.

OBJECTIVES

This study is the first from an international collaborative formed to study the processes and outcomes of LICs across multiple institutions in different countries. It aims to establish a baseline reference typology to inform further research in this field.

METHODS

Data on all LIC and LIC-like programmes known to the members of the international Consortium of Longitudinal Integrated Clerkships were collected using a survey tool developed through a Delphi process and subsequently analysed. Data were collected from 54 programmes, 44 medical schools, seven countries and over 15 000 student-years of LIC-like curricula.

RESULTS

Wide variation in programme length, student numbers, health care settings and principal supervision was found. Three distinct typological programme clusters were identified and named according to programme length and discipline coverage: Comprehensive LICs; Blended LICs, and LIC-like Amalgamative Clerkships. Two major approaches emerged in terms of the sizes of communities and types of clinical supervision. These referred to programmes based in smaller communities with mainly family physicians or general practitioners as clinical supervisors, and those in more urban settings in which subspecialists were more prevalent.

CONCLUSIONS

Three distinct LIC clusters are classified. These provide a foundational reference point for future studies on the processes and outcomes of LICs. The study also exemplifies a collaborative approach to medical education research that focuses on typology rather than on individual programme or context.

Adapting the forms of yesterday to the functions of today and the needs of tomorrow: a genealogical case study of clinical teaching units in Canada

Emergent discourses of social responsibility and accountability have in part fuelled the expansion of distributed medical education (DME). In addition to its potential for redressing physician maldistribution, DME has conferred multiple unexpected educational benefits. In several countries, its recent rise has occurred around the boundaries of traditional medical education practices. Canada has been no exception, with DME proliferating against a backdrop of its longstanding central node, the clinical teaching unit (CTU). The CTU first appeared just over 50 years ago with its position in Canadian health care largely taken-for-granted. Given the increasing prominence of DME, however, it is timely to reconsider what the place of tertiary centre-based practices such as the CTU might be in shifting medical education systems. From a genealogical perspective, it becomes clear that the CTU did not just "happen". Rather, its creation was made possible by multiple interrelated cultural, social, and political changes in Canadian society that, while subtle, are powerfully influential. Making them visible offers a better opportunity to harmonize the benefits of longstanding entities such as the CTU with novel practices such as DME. In so doing, the medical education field may sidestep the pitfalls of investing significant resources that may only produce superficial changes while unwittingly obstructing deeper transformations and improvements. Although this work is refracted through a Canadian prism, reconceptualizing the overall design of medical education systems to take advantage of both tradition and innovation is a persistent challenge across the international spectrum, resistant to tests of time and constraints of context.

Integrating Community Expertise into the Academy: South Los Angeles' Community-Academic Model for Partnered Research

THE PROBLEM

Charles R. Drew University (CDU) and community partners wanted to create a structure to transcend traditional community-academic partnerships. They wanted community leaders integrated into CDU's research goals and education of medical professionals.

PURPOSE OF ARTICLE

To explain the establishment of the Community Faculty Program, a new model of community-academic partnership that integrates community and academic knowledge.

KEY POINTS

Using CBPR principles, CDU and community partners re-conceptualized the faculty appointment process and established the Division of Community Engagement (DCE). CDU initially offered academic appointments to nine community leaders. Community Faculty contributes to CDU's governance, education, research, and publication goals. This model engaged communities in translational research and transformed the education of future healthcare professionals.

CONCLUSION

The Community Faculty Program is a new vision of partnership. Using a CBPR approach with committed partners, a Community Faculty Program can be created that embodies the values of both the community and the academy.

Clinical participation of medical students in three contemporary training models

OBJECTIVES

As community settings are being used increasingly in undergraduate medical programmes, this study aimed to explore and compare the clinical experiences of students in hospital-based and community-based training programmes. It measured students' clinical participation and compared the perspectives of Year 3 medical students in three different models of clinical education: a tertiary hospital block programme; a community hybrid programme, and a rural longitudinal integrated clerkship (LIC) programme.

METHODS

The study used a mixed methodology approach to examine the clinical experiences of students through the analysis of logbooks and semi-structured student interviews. This involved the quantitative analysis of 88 logbook weeks, data from which were triangulated through the analysis of 101 individual interviews using grounded theory.

RESULTS

A total of 35 students across the three different clinical training models participated in the study. The results demonstrate significant differences among the three models in students' clinical participation and suggest that community settings provide more opportunities to students for meaningful engagement in patient care activities.

CONCLUSIONS

Consistent wider and more direct access to patients for students, as found in the community-based model, provides a pathway for engaging students in the learning processes, and a step towards making them aware of their learning needs and knowledge. Interviews provide evidence that authentic clinical activities can be enhanced through structured systems of supervision and through the provision of authentic roles for students in clinical teams.

Putting communities in the driver's seat: the realities of community-engaged medical education

"Community" has featured in the discourse about medical education for over half a century. This discourse has explored relationships between medical education programs and communities in community-oriented medical education and community-based medical education and, in recent years, has extended to community-engaged medical education (CEME). This Perspective explores the developing focus on "community" in medical education, describes CEME as a concept, and presents examples of CEME in action at Flinders University School of Medicine (Australia), the Northern Ontario School of Medicine (Canada), and Ateneo de Zamboanga University School of Medicine (Philippines).The authors describe the ways in which CEME, which features active community participation, can improve medical education while meeting community needs and advancing national and international health equity agendas. They suggest that CEME can redefine student learning as taking place at the center of the partnership between communities and medical schools. They also consider the challenges of CEME and caution that criteria for community engagement must be sensitive to cultural variations and to the nature of the social contract in different sociocultural settings.The authors argue that CEME is effective in producing physicians who choose to practice in rural and underserved areas. Further research is required to demonstrate that CEME contributes to improved health, and ultimately health equity, for the populations served by the medical school.

Student Continuity with Patients: A System Delivery Innovation to Benefit Patient Care and Learning (Continuity Patient Benefit)

Medical education is continuing to evolve to meet the healthcare needs of the future. The longitudinal integrated clerkship (LIC) model is an important innovation in medical education. It has in its vision and structure “patient- and learner-centered education”, using longitudinal relationships between patients and students as a foundational element in its design. LIC students have shown more patient-centered attitudes and behaviors that persist after medical school. They remain connected with the patient experience of care, which supports empathy and student moral development. The time that LIC students spend acting independently with patients also supports the development of higher order clinical and cognitive skills and professional identity formation. Student participation in a more meaningful way in the care of their patients promotes patient wellbeing, and helps patients with transitions of care, communication and preventative care. Patients report feeling empowered to be more active agents in their own care and feel an accountability and pleasure in the training of new physicians. Focusing on the patient/student relationship as a foundational element of clinical education has meaningful benefits to the patient and student with the potential to improve patient care directly and in the future, as these students become physicians.

Learners, performers, caregivers, and team players: Descriptions of the ideal medical student in longitudinal integrated and block clerkships

BACKGROUND

Hidden curriculum literature suggests that different learning environments and curricular designs reinforce disparate values and behaviors.

AIM

This study explores potential differences in learning environments afforded by two clerkship models through perceptions of the ideal student.

METHODS

In this qualitative study, research assistants interviewed 48 third-year students and 26 clinical supervisors from three US medical schools. Students and supervisors participated in longitudinal integrated clerkships (LICs) or block clerkships. Students and supervisors described the ideal student in their clerkship. Using phenomenographic techniques, authors identified five ideal student profiles and coded students' and supervisors' descriptions for alignment with one or more profiles.

RESULTS

Most students in both models described an ideal student who matched a learner profile (proactive and self-directed). More LIC students described an ideal student who fit a caregiver profile (engaging with and advocating for patients) and more block students described performer (appearing knowledgeable and competent) and team-player (working well with others) profiles. Supervisors' descriptions paralleled students' descriptions but with less emphasis on caregiving.

CONCLUSIONS

Ideal student descriptions in LIC and block models may reflect different learning experiences and values emphasized in each model. These findings suggest implications for students' construction of professional identities that warrant further exploration.

Academic outcomes of a community-based longitudinal integrated clerkships program

BACKGROUND

Longitudinal integrated clerkships (LICs) receive recognition internationally as effective, innovative alternatives to traditional block rotations (TBRs) in undergraduate medical education. No studies of LICs in the USA have assessed how students perform on all the standardized exams.

AIM

To compare performance on standardized tests of students in the first four years of LICs at the University of North Carolina School of Medicine-Asheville (UNC SOM-Asheville) with students from UNC SOM's Chapel Hill main campus in TBRs.

METHODS

LIC and TBR students' previous academic performance was considered using Medical College Admissions Test (MCAT) and United States Medical Licensing Examination (USMLE) Step 1 scores. Step 1 exam tests students' pre-clinical, basic science knowledge. Outcome measures included all eight standardized National Board of Medical Examiners (NBME) Subject Shelf Examinations and USMLE Step 2 Clinical Knowledge (CK) examinations, which are used widely in the US to assess students' progress and as prerequisites to eventual licensure. TBR students were selected using propensity scores to match LIC students. Groups were also compared on the required core clinical conditions documented, and on residency specialty choice.

RESULTS

Asheville LIC students earned higher scores on the Step 2 CK examination and the six shelf examinations linked to longitudinal clerkships than the matched TBR students (Step 2 CK exam, Family Medicine and Ambulatory Medicine shelf exams reached statistical significance). LIC students logged greater percentages of core conditions than TBR students and more often chose primary care residencies.

CONCLUSIONS

UNC School of Medicine medical students participating in a longitudinal integrated curriculum in a community setting outperformed fellow students who completed a more TBR curriculum within the school's academic medical center. Differences were found in performance on standard tests of clinical knowledge (six NBME exams and Step 2 CK exam), documented breadth of clinical experiences, and likelihood of choosing primary care residency programs.

Using a framework to implement large-scale innovation in medical education with the intent of achieving sustainability

BACKGROUND

Particularly when undertaken on a large scale, implementing innovation in higher education poses many challenges. Sustaining the innovation requires early adoption of a coherent implementation strategy. Using an example from clinical education, this article describes a process used to implement a large-scale innovation with the intent of achieving sustainability. Desire to improve the effectiveness of undergraduate medical education has led to growing support for a longitudinal integrated clerkship (LIC) model. This involves a move away from the traditional clerkship of 'block rotations' with frequent changes in disciplines, to a focus upon clerkships with longer duration and opportunity for students to build sustained relationships with supervisors, mentors, colleagues and patients. A growing number of medical schools have adopted the LIC model for a small percentage of their students. At a time when increasing medical school numbers and class sizes are leading to competition for clinical supervisors it is however a daunting challenge to provide a longitudinal clerkship for an entire medical school class. This challenge is presented to illustrate the strategy used to implement sustainable large scale innovation.

WHAT WAS DONE

A strategy to implement and build a sustainable longitudinal integrated community-based clerkship experience for all students was derived from a framework arising from Roberto and Levesque's research in business. The framework's four core processes: chartering, learning, mobilising and realigning, provided guidance in preparing and rolling out the 'whole of class' innovation.

DISCUSSION

Roberto and Levesque's framework proved useful for identifying the foundations of the implementation strategy, with special emphasis on the relationship building required to implement such an ambitious initiative. Although this was innovation in a new School it required change within the school, wider university and health community. Challenges encountered included some resistance to moving away from traditional hospital-centred education, initial student concern, resource limitations, workforce shortage and potential burnout of the innovators. Large-scale innovations in medical education may productively draw upon research from other disciplines for guidance on how to lay the foundations for successfully achieving sustainability.

Establishing a new medical school: Botswana's experience

Having adequate numbers of qualified human resources for health is essential for any effective health care system. However, there is a global shortage of skilled health care workers, especially in Sub-Saharan African countries. This shortage is exacerbated by a disproportionately high rate of infectious diseases, the burden of emerging chronic, noncommunicable diseases, and the emigration of medical doctors. Botswana has also experienced this critical shortage of doctors for many years. To address the shortage, the country in the 1990 s embarked on an aggressive program to train its students at foreign medical schools. Despite intensified training, many graduates have not returned. As a result, the country decided to establish a medical school within Botswana. The newly established school was awarded a grant from the Medical Education Partnership Initiative, which has helped to accelerate the school's development. This paper describes the authors' experiences, highlighting curriculum, staffing, infrastructure approaches, key successes, and challenges encountered. The paper concludes by proposing solutions. The authors' experiences and the lessons learned can inform colleagues in other countries considering similar endeavors.

Community-based education programs in Africa: faculty experience within the Medical Education Partnership Initiative (MEPI) network

PURPOSE

This paper examines the various models, challenges, and evaluative efforts of community-based education (CBE) programs at Medical Education Partnership Initiative (MEPI) schools and makes recommendations to strengthen those programs in the African context.

METHODS

Data were gathered from 12 MEPI schools through self-completion of a standardized questionnaire on goals, activities, challenges, and evaluation of CBE programs over the study period, from November to December 2013. Data were analyzed manually through the collation of inputs from the schools included in the survey.

RESULTS

CBE programs are a major component of the curricula of the surveyed schools. CBE experiences are used in sensitizing students to community health problems, attracting them to rural primary health care practice, and preparing them to perform effectively within health systems. All schools reported a number of challenges in meeting the demands of increased student enrollment. Planned strategies used to tackle these challenges include motivating faculty, deploying students across expanded centers, and adopting innovations. In most cases, evaluation of CBE was limited to assessment of student performance and program processes.

CONCLUSIONS

Although the CBE programs have similar goals, their strategies for achieving these goals vary. To identify approaches that successfully address the challenges, particularly with increasing enrollment, medical schools need to develop structured models and tools for evaluating the processes, outcomes, and impacts of CBE programs. Such efforts should be accompanied by training faculty and embracing technology, improving curricula, and using global/regional networking opportunities.

How clerkship students learn from real patients in practice settings

PURPOSE

To explore how undergraduate medical students learn from real patients in practice settings, the factors that affect their learning, and how clerkship learning might be enhanced.

METHOD

In 2009, 22 medical students in the three clerkship years of an undergraduate medical program in the United Kingdom made 119 near-contemporaneous audio diary entries reflecting how they learned from real patients. Nineteen attended focus groups; 18 were individually interviewed. The authors used a qualitative theory-building methodology with a conceptual orientation toward Communities of Practice theory. A learning theorist guided selective coding of a constant-comparative analysis.

RESULTS

Participants learned informally by participating in the communicative practices of workplaces. Two overlapping practices, patient care and education, were identified. Patient care created learning opportunities, which were enriched when practitioners intentionally supported participants' learning. Education, however, was not always coupled with patient care. So, talk positioned the boundaries of two practices in three configurations: education without patient care, education within patient care, and patient care without education. The nature and quality of participants' learning depended on how practitioners entered dialogue with them and linked the dialogue to authentic patient care.

CONCLUSIONS

Findings strongly suggest that medical students learn from real patients by participating in patient care within an educational practice. Their learning is affected by clinicians' willingness to engage in supportive dialogue. Promoting an informal, inclusive discourse of workplace learning might enhance clerkship education. This approach should take its place alongside-and perhaps ahead of-the currently dominant discourse of "clinical teaching."

What factors in rural and remote extended clinical placements may contribute to preparedness for practice from the perspective of students and clinicians?

BACKGROUND

Community-based rural education opportunities have expanded in Australia, attracting more medical students to placements in rural and remote settings.

AIM

To identify the factors in an integrated, community-engaged rural placement that may contribute to preparedness for practice (P4P) from the perspective of students and clinicians.

METHOD

Forty-two semi-structured interviews with medical students, supervisors and clinicians analysed thematically.

RESULTS

Opportunities for clinical learning, personal and professional development and cultural awareness were reported by students and clinicians as key factors that contribute to P4P. Potential barriers in rural and remote settings included geographical and academic isolation, perceived educational risk and differing degrees of program engagement.

CONCLUSIONS

A longitudinal clinical placement in a rural setting may enable development of enhanced competencies leading to P4P. A rural setting can provide a unique experience through hands-on learning, enhanced personal and professional development opportunities and observation of the cultural and contextual impact on health.

A systematic literature review of undergraduate clinical placements in underserved areas

CONTEXT

The delivery of undergraduate clinical education in underserved areas is increasing in various contexts across the world in response to local workforce needs. A collective understanding of the impact of these placements is lacking. Previous reviews have often taken a positivist approach by only looking at outcome measures. This review addresses the question: What are the strengths and weaknesses for medical students and supervisors of community placements in underserved areas?

METHODS

A systematic literature review was carried out by database searching, citation searching, pearl growing, reference list checking and use of own literature. The databases included MEDLINE, EMBASE, PsycINFO, Web of Science and ERIC. The search terms used were combinations and variations of four key concepts exploring general practitioner (GP) primary care, medical students, placements and location characteristics. The papers were analysed using a textual narrative synthesis.

FINDINGS

The initial search identified 4923 results. After the removal of duplicates and the screening of titles and abstracts, 185 met the inclusion criteria. These full articles were obtained and assessed for their relevance to the research question; 54 were then included in the final review. Four main categories were identified: student performance, student perceptions, career pathways and supervisor experiences.

CONCLUSIONS

This review reflects the emergent qualitative data as well as the quantitative data used to assess initiatives. Underserved area placements have produced many beneficial implications for students, supervisors and the community. There is a growing amount of evidence regarding rural, underserved areas, but little in relation to inner city, deprived areas, and none in the UK.

Developing Symbiotic Clinical Educators: Using Program Logic to Evaluate a Clinical Education Course

Developing health professional clinical educators able to meet the shifting health care requirements of this century is a current government priority. To change practices in the clinic, those who teach need to change and that is best achieved by specific curricula designed for faculty development. Principles revealed during an investigation of a successful community-based medical education program underpin the Master of Clinical Education (MCE) course, a new faculty development curriculum. After six years, it is timely to evaluate whether the educational goals of the MCE course are being met.

The MCE faculty employed an independent research officer to conduct the study. A two-phase approach used semi-structured interviews and content analysis to develop and assess outcomes against an outcomes logic model.

The program achieved all short-term goals: understanding the symbiotic model; commitment to self as teacher; and changes in the way to give feedback. It achieved two of three medium-term goals: belief of transformation; and relationship development. One medium-term goal was not met: developing a sense of community.

This evaluation of the MCE course shows the program develops clinicians as committed educators and also as change agents who see building relationships as the key to operating effectively within complex health services and systems.