Smyrnakis et al describe a fascinating innovation that enabled the education of a large number of medical students in rural and remote locations1. However their article misses out on two important issues in medical education in rural and remote locations - those of costs of implementation and long-term return on investments.
Let's look at costs in the first instance. All forms of medical education are expensive - however there are certain features of education in rural and remote locations that particularly need to be taken in account2. The following is not an exhaustive account of all the components of rural and remote medical education - this is not necessary as much of the cost would be mirrored by delivery in urban areas (for example tutors need to be paid - regardless of whether they are located in a rural or urban area). Rather, the following cost components are likely to be unique to rural medical education or result in considerably higher costs as a result of delivery in this location. First there is the cost of travel and accommodation for students. Travel to remote areas will often be expensive and often students have to pay accommodation costs in remote locations whilst at the same time retaining (and paying for) their normal living place. Second, as students are far away from the library they are often more reliant on technology to enable them to learn and remain in contact with their central institution (so the increased costs of hardware and software needed to be added). Third, tutor support and communication is always necessary in all forms of medical education, but this is particularly so for distant tutors - so they know what is going on at the centre and what they are supposed to be doing and so that they can tell the centre what they are doing. As a result more budget may need to be allocated to this activity2. Last, some students in remote locations will feel isolated and sometimes lonely. As a result more attention and, once again, more budget may need to be assigned to pastoral care activities.
The article by Smyrnakis et al described the innovation well - but the short time since the innovation started means that it is too early to know what the long-term impact of the project might be and whether the health service will reap returns on the investment. It is tempting to surmise that some of the students, having had a taste of rural medicine, will return when they are fully qualified practitioners. If this were to happen, it is likely that the initial investment in the program would be returned many fold. Smyrnakis et al should ideally conduct a long-term follow up to see if this hypothesis is correct.
Kieran Walsh, FRCPI
BMJ Learning, BMJ Group
London, United Kingdom
1. Smyrnakis E, Gavana M, Kondilis E, Giannakopoulos S, Panos A, Chainoglou A et al. Primary health care and general practice attachment: establishing an undergraduate teaching network in rural Greek health centers. Rural Remote Health 13: 1946. (Online) 2013. Available: www.rrh.org.au (Accessed 14 March 2013).
2. Rourke J, Rourke L. Rural and remote locations. In: JA Dent, RM Harden (Eds); A Practical Guide for Medical Teachers, 3rd edn. Oxford: Churchill Livingstone, 2009.