Living and working with the people of 'the bush': a foundation for rural and remote clinical placements in undergraduate medical education

Building a sustainable rural physician workforce

CHAPTER 1: CHARACTERISING AUSTRALIA'S RURAL SPECIALIST PHYSICIAN WORKFORCE: THE PROFESSIONAL PROFILE AND PROFESSIONAL SATISFACTION OF JUNIOR DOCTORS AND CONSULTANTS: Objective: To assess differences in the demographic characteristics, professional profile and professional satisfaction of rural and metropolitan junior physicians and physician consultants in Australia.

DESIGN, SETTING AND PARTICIPANTS

Cross-sectional, population level national survey of the Medicine in Australia: Balancing Employment and Life longitudinal cohort study (collected 2008-2016). Participants were specialist physicians from four career stage groups: pre-registrars (physician intent); registrars; new consultants (< 5 years since Fellowship); and consultants.

MAIN OUTCOME MEASURES

Level of professional satisfaction across various job aspects, such as hours worked, working conditions, support networks and educational opportunities, comparing rural and metropolitan based physicians.

RESULTS

Participants included 1587 pre-registrars (15% rural), 1745 physician registrars (9% rural), 421 new consultants (20% rural) and 1143 consultants (13% rural). Rural physicians of all career stages demonstrated equivalent professional satisfaction across most job aspects, compared with metropolitan physician counterparts. Some examples of differences in satisfaction included rural pre-registrars being less likely to agree they had good access to support and supervision from qualified consultants (odds ratio [OR], 0.6; 95% CI, 0.3-0.9) and rural consultants being more likely to agree they had a poorer professional support network (OR, 1.9; 95% CI, 1.2-2.9). In terms of demographics, relatively more rural physicians had a rural background or were trained overseas. Although most junior physicians were women, female consultants were less likely to be working in a rural location (OR, 0.6; 95% CI, 0.4-0.8).

CONCLUSION

Junior physicians in metropolitan or rural settings have a similar professional experience, which is important in attracting future trainees. Increased opportunities for rural training should be prioritised, along with addressing concerns about the professional isolation and poorer support network of those in rural areas, not only among junior doctors but also consultants. Finally, making rural practice more attractive to female junior physicians could greatly improve the consultant physician distribution. CHAPTER 2: GENERAL PHYSICIANS AND PAEDIATRICIANS IN RURAL AUSTRALIA: THE SOCIAL CONSTRUCTION OF PROFESSIONAL IDENTITY: Objective: To explore the construction of professional identity among general physicians and paediatricians working in non-metropolitan areas.

DESIGN, SETTING AND PARTICIPANTS

In-depth qualitative interviews were conducted with general physicians and paediatricians, plus informants from specialist colleges, government agencies and academia who were involved in policy and programs for the training and recruitment of specialists in rural locations across three states and two territories. This research is part of the Training Pathways and Professional Support for Building a Rural Physician Workforce Study, 2018-19.

MAIN OUTCOME MEASURES

Individual and collective descriptors of professional identity.

RESULTS

We interviewed 36 key informants. Professional identity for general physicians and paediatricians working in regional, rural and remote Australia is grounded in the breadth of their training, but qualified by location - geographic location, population served or specific location, where social and cultural context specifically shapes practice. General physicians and paediatricians were deeply engaged with their local community and its economic vulnerability, and they described the population size and dynamics of local economies as determinants of viable practice. They often complemented their practice with formal or informal training in areas of special interest, but balanced their practice against subspecialist availability, also dependent on demographics. While valuing their professional roles, they showed limited inclination for industrial organisation.

CONCLUSION

Despite limited consensus on identity descriptors, rural general physicians and paediatricians highly value generalism and their rural engagement. The structural and geographic bias that preferences urban areas will need to be addressed to further develop coordinated strategies for advanced training in rural contexts, for which collective identity is integral. CHAPTER 3: SUSTAINABLE RURAL PHYSICIAN TRAINING: LEADERSHIP IN A FRAGILE ENVIRONMENT: Objectives: To understand Royal Australasian College of Physicians (RACP) training contexts, including supervisor and trainee perspectives, and to identify contributors to the sustainability of training sites, including training quality.

DESIGN, SETTING AND PARTICIPANTS

A cross-sectional mixed-methods design was used. A national sample of RACP trainees and Fellows completed online surveys. Survey respondents who indicated willingness to participate in interviews were purposively recruited to cover perspectives from a range of geographic, demographic and training context parameters.

MAIN OUTCOME MEASURES

Fellows' and trainees' work and life satisfaction, and their experiences of supervision and training, respectively, by geographic location.

RESULTS

Fellows and trainees reported high levels of satisfaction, with one exception - inner regional Fellows reported lower satisfaction regarding opportunities to use their abilities. Not having a good support network was associated with lower satisfaction. Our qualitative findings indicate that a culture of undermining rural practice is prevalent and that good leadership at all levels is important to reduce negative impacts on supervisor and trainee availability, site accreditation and viability. Trainees described challenges in navigating training pathways, ensuring career development, and having the flexibility to meet family needs. The small number of Fellows in some sites poses challenges for supervisors and trainees and results in a blurring of roles; accreditation is an obstacle to provision of training at rural sites; and the overlap between service and training roles can be difficult for supervisors.

CONCLUSION

Our qualitative findings emphasise the distinctive nature of regional specialist training, which can make it a fragile environment. Leadership at all levels is critical to sustaining accreditation and support for supervisors and trainees. CHAPTER 4: PRINCIPLES TO GUIDE TRAINING AND PROFESSIONAL SUPPORT FOR A SUSTAINABLE RURAL SPECIALIST PHYSICIAN WORKFORCE: Objective: To draw on research conducted in the Building a Rural Physician Workforce project, the first national study on rural specialist physicians, to define a set of principles applicable to guiding training and professional support action.

DESIGN

We used elements of the Delphi approach for systematic data collection and codesign, and applied a hybrid participatory action planning approach to achieve consensus on a set of principles.

RESULTS

Eight interconnected foundational principles built around rural regions and rural people were identified: FP1, grow your own "connected to" place; FP2, select trainees invested in rural practice; FP3, ground training in community need; FP4, rural immersion - not exposure; FP5, optimise and invest in general medicine; FP6, include service and academic learning components; FP7, join up the steps in rural training; and FP8, plan sustainable specialist roles.

CONCLUSION

These eight principles can guide training and professional support to build a sustainable rural physician workforce. Application of the principles, and coordinated action by stakeholders and the responsible organisations, are needed at national, state and local levels to achieve a sustainable rural physician workforce.

"[It's] more than just medicine": The value and sustainability of mandatory, non-clinical, short-term rural placements in a Western Australian medical school

Introduction: In 2005, the University of Notre Dame School of Medicine (Western Australia) established a mandatory, non-clinical rural and remote (hereafter termed rural) health placement program delivered in 2 weeks over 2 years, largely resourced by voluntary human capital. Our study investigated whether the program: (1) encouraged medical graduates to seek rural employment; (2) enhanced their ability to meet rural people's health needs; and (3) was sustainable.Methods: A qualitative descriptive study collected data using semi-structured, in-depth interviews with graduates and placement hosts. Data were transcribed, coded and analysed using Framework Analysis to identify key themes.Results: Twenty-eight medical graduates and 15 community hosts participated. The program validated pre-existing interest in, or positively influenced graduates' attitudes towards, rural practice, and enabled empathy and responsiveness when caring for rural patients in urban, as well as rural, health services. Placement hosts unanimously supported the program and contributed social capital, to ensure its sustainability.Discussion: The program influenced a broad spectrum of students over 15 years and reflects a socially-accountable approach to medical education.Conclusions: This study demonstrates the sustainability and value of mandatory short-term community-based placements in improving medical graduates' responsiveness to the health needs of rural Australians.

Cultural Competency Interventions During Medical School: a Scoping Review and Narrative Synthesis

Many medical accreditation bodies agree that medical students should be trained to care for diverse patient populations. However, the teaching methods that medical schools employ to accomplish this goal vary widely. The purpose of this work is to summarize current cultural competency teaching for medical students and their evaluation methods. A scoping review was completed by searching the databases PubMed, Scopus, MedEdPORTAL, and MEDLINE for the search terms "medical education" and "cultural competency" or "cultural competence." Results were summarized using a narrative synthesis technique. One hundred fifty-four articles on cultural competency interventions for medical students were systematically identified from the literature and categorized by teaching methods, length of intervention, and content. Fifty-six articles had a general focus, and ninety-eight articles were focused on specific populations including race/ethnicity, global health, socioeconomic status, language, immigration status, disability, spirituality at the end of life, rurality, and lesbian, gay, bisexual, transgender, and queer. About 54% of interventions used lectures as a teaching modality, 45% of the interventions described were mandatory, and 9.7% of interventions were not formally evaluated. The authors advocate for expansion and more rigorous analysis of teaching methods, teaching philosophies, and outcome evaluations with randomized controlled trials that compare the relative effectiveness of general and population-specific cultural competency interventions.

Health Profession Education in Remote or Geographically Isolated Settings: A Scoping Review

Remote health has been differentiated from rural health in Australia and defined as isolated, with poor service access and a relatively high proportion of Indigenous residents, necessitating different models of care. Educational strategies for remote health practice are often needs driven and the characteristics of remote health may be used to categorise remote health professional education. This scoping review aims to identify the purpose of health professional education for remote settings, the type of educational strategies implemented and the reported outcomes. A broad search of published literature available in online bibliographic databases was conducted. A total of 33 articles met the review inclusion criteria. A further 7 articles were identified for inclusion in the review through citation searches and the authors' networks giving a total of 40 articles. Six primary themes were established based on the educational purpose: (1) cultural competency; (2) social accountability; (3) rural and remote skill development for the general workforce; (4) remote specialisation; (5) specialist skills required for a remote workforce; and (6) remote teaching. These themes also reflect the philosophical change over time recognising remote health as a separate discipline and its value as a distinctive and efficacious learning environment. The concept of education for remote practice is proposed to describe this unique leaning environment which encompasses critical pedagogy to develop a sense of agency and social accountability, embedding the delivery of primary health care through service learning and developing relationships in a context which is transformative.

The relationship between sense of a life worth living and local self-governance: A cross-sectional study

BACKGROUND

Aging populations are facing increasing health problems, with social conditions often exacerbating such maladies. Although local self-governance might effectively solve these problems, such civic participation can increase citizens' mental and physical fatigue, which, in turn, may decrease their sense of leading productive lives.

METHODS

This cross-sectional study examined the relationship between citizens' participation in and perceptions of local self-governance and their sense of life worth living. The study was conducted in Unnan City, which is located in the southeastern part of Shimane Prefecture. A questionnaire measuring local self-governance and participant backgrounds was distributed. Completed questionnaires were collected between March 1 and 31, 2018. A binomial logistic regression model was used.

RESULTS

Of the distributed questionnaires, 38.5% (769/2000) were completed and returned. Responses from women and those over 65 years of age comprised 54.2% (417/769) and 35.1% (270/769) of the completed questionnaires, respectively. Analysis of the data using binomial logistic regression showed that age (≥65), health management, social interaction, learning habits, and interest in local self-governance were significantly correlated with a sense of life worth living (odds ratio for the variables were 0.56 (P = .002), 2.58 (P < .001), 3.05 (P < .001), 2.51 (P < .001), and 1.61 (P = .009), respectively).

CONCLUSION

Promoting local self-governance may lead to a better sense of life worth living for citizens of rural communities. Therefore, when assessing the effectiveness of local self-governance regarding citizens' sense of life worth living, their interest in local self-governance should be taken into consideration.

The teaching and learning of health advocacy in an Australian medical school

OBJECTIVES

To determine if medical graduates from an Australian university are educated and skilled in health advocacy for their future practice with patients and the wider community.

METHODS

The authors used an exploratory mixed methodology starting with curriculum mapping of the medical curriculum, followed by key informant interviews with the University of Notre Dame, School of Medicine academics (n = 6) and alumni (n = 5) on teaching/learning and practice of health advocacy.  The final stage consisted of a cross-sectional survey on teaching/learning health advocacy among third and fourth (final) year medical students (N = 195).

RESULTS

The medical curriculum contained no explicit learning objectives on health advocacy. Key informant interviews demonstrated an appreciation of health advocacy and its importance in the medical curriculum but a deficit in explicit and practical 'hands-on' teaching. Survey response rate was 47% (n = 92). A majority of students (76%, n = 70) had heard of health advocacy, with this being more likely among third (92%, n = 33) compared with fourth-year students (67%, n = 37) (Fisher's Exact Test χ² (2, N = 91) = 7.311, p = 0.02). Students reported having opportunities to observe (76%, n = 70) and practise health advocacy (50%, n = 46) in the curriculum.

CONCLUSIONS

Students and medical graduates demonstrated sound recognition of the term health advocacy. Deficits identified in the curriculum include lack of explicit learning objectives and "hands-on" learning opportunities in health advocacy.

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.

Engaging Australian Aboriginal narratives to challenge attitudes and create empathy in health care: a methodological perspective

BACKGROUND

Unconscious bias and negative attitudes towards minority groups have detrimental effects on the way health care is, or is not, provided to these groups. Recognition of racist attitudes and behaviours as well as understanding clients' experiences of health and health care are pivotal to developing better health care strategies to positively impact on the quality and safety of care provided to Indigenous people. Indigenous research demands inclusive research processes and the use of culturally appropriate methodologies. This paper presents a methodological account of collecting narratives which accurately and respectfully reflect Aboriginal Australians' experiences with health care in Western Australia. The purpose of these narratives is to provide health students and professionals with an opportunity to 'walk-in the shoes' of Aboriginal people where face-to-face interaction is not feasible.

METHODS

With the incorporation of Indigenous peoples' voices being an important link in cultural safety, the project was led by an Indigenous Reference group, who encouraged active participation of Aboriginal people in all areas of the project. Using a phenomenological approach and guided by the Indigenous Reference group, yarning data collection was implemented to collect stories focusing on Aboriginal people's experiences with health care services. An open-access, on-line website was established to host education resources developed from these "yarns".

RESULTS

Yarning provided a rich source of information on personal experiences and encouraged the story provider to recognise their facilitative role in the research process. While the methodology used in this project was lengthy and labour-intensive it afforded a respectful manner for story collection and highlighted several innate flaws when Western methods are applied to an Indigenous context.

CONCLUSION

Engagement of an Indigenous Reference Group was pivotal to designing an appropriate methodology that incorporated the voices of Aboriginal people in a multimedia resource of Aboriginal narratives. However further research is warranted to understand how the resources are being used and integrated into curricula, and their impact on students and health care outcomes.