Rural placements are effective for teaching medicine in Australia : evaluation of a cohort of students studying in rural placements

Introduction: Medical education in Australia is increasingly delivered through longitudinal placements in general practice and other community settings. Early meaningful exposure to patients has been shown to improve the transition from medical student to junior doctor. This study examines the experience of the first year cohort of the University of Western Sydney (UWS) Medical School long-term rural placement students. Results have been placed in the context of other published results for rural training schemes, comparing and contrasting the present results to those of others. Methods: Students undertaking a rural placement in their final year of the UWS medical program (n=21) participated in a mixed methods evaluation. Students filled out a quantitative survey, modified from a validated instrument, and also participated in a focus group. Class ranking of students, and changes over the time of their placement, were also examined. Results: Overall, students were very pleased with their rural experience, both clinically and socially. Students found the rural experience more comprehensive than they had expected. They considered that they had a stronger learning experience in most aspects than they expect they would have received in a metropolitan area. The smaller realm of the medical world in a rural area was considered an advantage in providing more hands-on experience and more interprofessional team approaches to healthcare provision. It was also considered a drawback by some that more advanced cases of all kinds were sent out of the area to metropolitan


A B S T R A C T
Introduction: Medical education in Australia is increasingly delivered through longitudinal placements in general practice and other community settings. Early meaningful exposure to patients has been shown to improve the transition from medical student to junior doctor. This study examines the experience of the first year cohort of the University of Western Sydney (UWS) Medical School long-term rural placement students. Results have been placed in the context of other published results for rural training schemes, comparing and contrasting the present results to those of others. Methods: Students undertaking a rural placement in their final year of the UWS medical program (n=21) participated in a mixed methods evaluation. Students filled out a quantitative survey, modified from a validated instrument, and also participated in a focus group. Class ranking of students, and changes over the time of their placement, were also examined. Results: Overall, students were very pleased with their rural experience, both clinically and socially. Students found the rural experience more comprehensive than they had expected. They considered that they had a stronger learning experience in most aspects than they expect they would have received in a metropolitan area. The smaller realm of the medical world in a rural area was considered an advantage in providing more hands-on experience and more interprofessional team approaches to healthcare provision. It was also considered a drawback by some that more advanced cases of all kinds were sent out of the area to metropolitan Introduction

Rural medical education in Australia
The trend for medical education to be delivered through longitudinal placements in general practice and other community settings 1,2 is now firmly in place in medical schools worldwide 3,4 . Curriculum components and methods that optimise effective teaching in rural placement have been developed 5-8 , and early meaningful exposure to patients has been shown to improve the transition from medical student to junior doctor 9,10 .
There is robust evidence that rural placements provide incentive for a decision to practise in a rural setting [11][12][13][14][15][16][17][18][19] , although this evidence is still contentious 20 . It has also been established that students who take training through rural placement do at least as well as students who study in traditional, metropolitan hospital-based training sites [21][22][23][24][25][26][27][28] . Clinical placements also facilitate the transfer from the learning orientation of medical school to the performance orientation of the clinical setting 29 . The informal curriculum is influential in determining the perceived worth of a primary care placement experience 30 .
Delivery of a rural educational program relies heavily on local practitioners. Placements are with a mix of rural General Practitioners (GPs), rural hospitals and local patient care services of other types, including mental health, community health and population health centres. Support systems for rural practitioners have been developed 31,32 .
It has been shown that students' individual resilience and ability to adapt to new and sometimes strange-seeming situations is a major determinant in whether a student thrives in a rural setting 33 . Student success in rural placements requires clinical educators who are well organised and develop close one-on-one relationships with students 34 .
The negative effects of social displacement must be balanced against the positive results of rural placements 33 , although even students raised exclusively in metropolitan environments consider rural training attractive for the benefits of enhanced patient access 35 .

This study
The medical program at the University of Western Sydney (UWS) is a 5 year program, established in 2007, that accepts school leavers and those with part or completed degrees. There is a strong focus on the health issues of western Sydney, but the program aims to produce doctors who can work comfortably in any community setting. The UWS curriculum incorporates an immersion experience in rural practice settings as an integral component of assimilation of clinical skills. These longitudinal community placements are modelled on the Flinders University Parallel Rural Community Curriculum (PRCC) 21 .
This study examines the experience of the first year cohort of the UWS Medical School long-term rural placement students. Results are placed in the context of other published results for rural training schemes, comparing and contrasting the present results to those of others.

Design
A mixed methods approach was taken for the evaluation. Each student completed a survey and participated in a focus group.

Population
All students who had completed a rural placement during the final year of their UWS medical program were invited to complete the evaluation. None declined. A total of 21 students completed the evaluation.

Data collection
Students filled out a 46 item quantitative survey consisting of 37 closed-ended and nine open-ended questions. The survey was modified from a validated instrument 36 . Closed-ended responses were captured in six item Likert 37 scales.
Students also participated in one of two focus groups 38 . An audio recording was made of each focus group and the recording transcribed verbatim.
Class rankings of students, and changes over the time of their placement, were also examined. The evaluation was carried out at the end of the placement year.

Data analysis
Quantitative data were analysed in Microsoft Excel (descriptive statistics) and Statistical Package for Social Sciences (Pearson's χ 2 test, paired t-test; SPSS Inc; www. spss.com). Data analysis for qualitative results was aided by NVivo v9 (QSR International; www.qsrinternational.com).

Ethics approval
The evaluation was carried out under approval of the University of Sydney Human Research Ethics Committee, protocol number 13006, issued 8 September 2010.

Results
Overall, students were very pleased with their rural experience, both clinically and socially. Logistics and administrative support, both before the beginning of the placement and on arrival, were well regarded.

Survey results
Rating scores submitted by students regarding all aspects of the placement are summarised (Table 1). Clinical experiences in all areas received uniformly high scores across both groups. Clinical preceptors were highly regarded. The smaller realm of the medical world in a rural area was considered an advantage in providing more hands on experience and more interprofessional team approaches to health care provision. It was also considered a drawback by some in that more advanced cases of all kinds were sent out of the area to metropolitan hospitals. All students were critical of their required community medicine group research project, rating it collectively at less than 2.9 on a scale of 5.
In the social realm, the placement experience was highly rated. Criticisms of the experience both socially and clinically were essentially anecdotal, with only one or two students voicing any particular criticism. Accommodation and local transport were universally mentioned as needing improvement. Students considered it likely or highly likely that they would consider working in a rural location in future, although only three of 21 actually applied to do their internship in a rural setting. Students' future intentions regarding rural work are summarised ( Table 2). Rural lifestyle, the nature of the rural clinical experience and work/life balance were the most frequently cited decision criteria in selecting a practice location. There was no statistically significant association of factors motivating for or against future rural practice nor for subsequent rural internship placement.

Improvement in class standing
Between their ranking in the end of Year 3 examination and the examination in the middle of Year 5, during which period students undertook their year-long placement, 14 of 22 students increased their class rank while two experienced no change and six decreased their class rank. Overall, the rural cohort advanced on average 4.2 places compared to their urban-placed peers in the full cohort. The change in class rank was not statistically significant (p=0.138, paired ttest), but the improvement in test scores (mean=3.8, SD=2.28) between Year 3 and 5 exams (for rural placement students) was significant at p<0.0001 (paired t-test).

Focus group results
Verbatim quotes are included to exemplify major themes raised. Numbers are used to differentiate speakers within a dialogue and (I) is used to denote the interviewer. So as to maintain de-identification of speakers, no gender or ethnicity data are included.
Student participants in focus groups were quite enthusiastic about their experience away from the main campus. Students found the rural experience more comprehensive than they expected, or that they expect they would have received in a metropolitan area.
…when I heard [from fellow students] of the orthopaedics rotations in [city hospital] often they would focus on one or two joints, but in [rural clinical placement site] it really was everything and I think there was aspects of that in all the other rotations as well ... in [rural clinical placement site] they just sort of cover everything.
The staff support is immense. Especially in medicine and surgery they really went out of their way to give us teaching sessions and things.
... and physical examinations, we expected to learn them, but not as well as we were taught ... I think I got really good at them at the end, and I'm sure everybody else did as well.
They found their communities welcoming and supportive: We were on the front page of the newspaper several times and people were stopping us on the street and saying, 'Oh, were you in that -?' They recognise you. They were very excited to have you. I: How did that feel? Being sort of celebrities? Awesome.
They also felt that they received more quality time from clinical educators: 1: I felt like I learned more in my year in [rural clinical placement site] than I probably did in the last two years before that in [city hospital] just because of the amount of time that you get to spend with your patients and the sort of breadth of experience that you get, and just the fact that so many of the clinicians are more willing to teach out there, as well. 2: I think I got a lot more direct contact with the specialists than I thought I would get ... and because of that there was a lot of not just clinical teaching, but about life as well. 3: I think I found several mentors ... that I hadn't found in any hospital, despite having a great time and a great learning experience in the city.
And they sensed that there was a camaraderie in rural placement that they would not have experienced elsewhere: I ... liked the friendly sort of atmosphere between the consultants in the area and ... the students, so you sort of form a friendship with the consultants that are supervising you but they're also friends with each other, and they're also friends with the students from the other universities. And that whole atmosphere is just really nice ... You don't really get that in the city.
I think just being able to talk to them in the social environment, so when the time comes that we're in the clinical environment we're not scared to ask a question that we may have previously been, 'Oh, that's too stupid to ask out loud.' ... Also, they're more willing to engage with us.
And it's much easier to raise things that you're concerned about in a social environment rather than in the hospital, like you can just be like, 'Oh, man, I'm not doing that well at cannulating,' or something like that and the next day he'll take you around and be like, 'Oh, this is what you told me. Come on, let's do this.' And it's much easier to do that with a friend than with somebody that you see as your superior ...
Students came to their rural placement with some preconceived notions that they discovered were false: When you think of going rural, you think makeshift contraptions they use to do so-and-so procedure because they don't have it because they're rural . 3: The practice I went to, it was pretty good in terms of asking me what I needed to get done and making sure they organised that. ... And seeing procedures in rural GP is really good, because they have a bigger role, I think ... in terms of procedural GPs I got to see circumcisions and things like that that I didn't even know a general practitioner could even do.
An intriguing dialogue was captured in one focus group regarding Aboriginal patients, who did not conform to the students' concept of Indigenous Australians: 1: ... one of the things I find that it was, maybe it was just the practice we went to, the Aboriginal Medical Service, a lot of the Aboriginals that turned up were mainstreams, so we didn't have very much in terms of -I: What do you mean by mainstream?
[laughter] 1: Maybe not mainstream, but close to -to be honest, it was kind of like they could have gone to a general practitioner -I'm just digging a hole for myself. 2: They identified themselves as Aboriginal, but they may not have looked that way, I guess.
[laughter] 1: I guess the problem is, when you talk about Aboriginal health in lectures, they're always talking about the -I: The big problems. 1: Yeah, the diseases .... 3: We have to keep in mind that we were seeing Aboriginal people in [regional centre], which isn't the outback.  I think clinically one of my favourite experiences in the whole of the medical course to date was an indigenous attachment of a drug and alcohol rehab place out sort of the back of [rural town] that involved a lot of Aboriginal men who had come straight from prison, and I felt like that was a very useful experience for me to have as a [person with a different cultural background], to sort of learn to try and relate to people that I don't share very many cultural similarities with. It was both very, very challenging and very useful.
Students were concerned that if they continued in rural practice through their internship that they would have difficulty integrating into a metropolitan environment: 1:... a lot of training programs you have to go to a city hospital, ... and it's sort of scary, the idea of doing an internship at a rural hospital and then ... having the city interns ahead of you in terms of getting into those training programs because they're more well-known to the supervisors or they're already working at the hospital where the training program is based. 2: I think that's what deterred me from going rural straight away as an intern, because of the differing opinions of the people I talked to as to how easy it is to get into a registrar training program after going to a rural hospital. I think that was one of the factors.
The students felt that a rural setting was a good place to learn medicine because they saw more of the patient's journey: I think I've had more of a chance to see and to follow patients through for quite a while because of the general term or general team you see everyone on the ward, and you can follow them through when you're doing oncology. At the same time you're doing oncology you might see them in their oncology context over at [outpatient clinic] and you might see them back in the hospital, and you might see them in the community and I got to see some of the communication between healthcare providers, whether it was good or bad, and how people reacted to it and reflected on it and I thought that was very interesting.

Discussion
The students in this study reported an overall high level of satisfaction along with some problems, which were mainly systems issues and early-days logistics issues. Findings were similar to other evaluations of rural medical training programs in that students: • found the teaching and learning program satisfactory 6-8, 17,21,27,[39][40][41] • relied on local coordinators to help them with the transition to, and functioning in, the new environment 6,40 , • were apprehensive about whether their learning in the rural setting would adequately prepare them for assessment back on the main campus 21,39 , • appreciated the collegiality and perceived beneficial life/work balance of rural living/practice 6,21,40 , • considered themselves better prepared to advance to internship because of the perceived additional attention afforded in a rural location with higher student/educator interaction 17,21,40 , • experienced a longitudinal, rather than crosssectional, experience of a patient's journey 7,21,42 , • were able to actively participate in providing actual patent care 6, 17,21,40 • appreciated the differences between rural and metropolitan general practice 43 • developed trust and confidence in their clinical educators as role models 44 • felt that they were part of a healthcare team, as opposed to learning observers 45 • increased their receptiveness to a rural medical career 12,13,27,46,47 • assimilated the concept that permissive boundary definitions and dual relationships, which are usually avoided or cautioned against in urban settings, are not only acceptable but can be beneficial when practising in a rural area [48][49][50][51] .
Some findings of evaluations of rural students published early in the history of rural placements in Australia were not evident here. These include: • anxiety over the rural experience 21,39 • frustration with the rural experience 8 • lack of exposure to essential basic procedures such as suturing and airway management 52 .

Experience with Aboriginal health services
With regards to the comments of some of these students regarding their Aboriginal health experience, these students did recognise that part of this was context: they did not see Aboriginal people in their own environments. This is an example of the hidden curriculum at work 53 , and the inherent disconnection between the classroom and the clinic when it comes to the cultural and social realities of practice 54 . While these students are not racist, their use of language and their conceptual frameworks indicate that their training thus far had not completely prepared them for the reality of Aboriginal health work. They held a stereotypical view of Aboriginal people and Aboriginal health status, one founded on the 'plight' 55 of Indigenous people. Knowing that the health status of Indigenous Australians is on aggregate worse than that of other ethnic groups, they had fallen into an ecological fallacy where they expected that the ill health (and a certain physical appearance) of all Aboriginal Australians was uniform. This expectation was so strong that it made them question whether the patients they saw -who did not conform to their mental models of what an Aboriginal

Conclusion
Future research is warranted examining: • the extent to which the apprehension of students in rural placements (especially postgraduate years) regarding their ability to re-integrate into a metropolitan setting is warranted • the 'cultural' effects of rural immersion programs -Are there important differences in the hidden and informal curricula between metropolitan and rural Australian medical education settings? What are the important dynamics of the interaction between metropolitan medical students and rural people?
• the reasons why rural students appear to perform better than their peers in traditional hospital-based clerkships.
The major criticisms revealed in this study are easily remedied; they are indications of start-up logistics problems, not fundamental deficits in program planning or delivery. The students in this study considered their experience worthwhile and indicated that it contributed to their interest in working in rural or regional Australia.
The results of this study are encouraging not only because they indicate that the UWS medical education program is off to a good start, but also because they confirm that rural placements have come into their own in Australia. Taken together, the results reported by Australian medical schools now offering long-term rural placements suggest that such placements are at least as effective as, and may even be more effective than, metropolitan hospital placements in providing clinical education to medical students in their senior years.