Teaching undergraduate students in rural general practice : an evaluation of a new rural campus in England

Introduction: One approach to facilitating student interactions with patient pathways at Keele University School of Medicine, England, is the placement of medical students for 25% of their clinical placement time in general practices. The largest component is a 15-week ‘student attachment’ in primary care during the final year, which required the development of a new network of teaching practices in a rural district of England about 90 km (60 mi) from the main campus in North Staffordshire. The new accommodation and education hub was established in 2011–2012 to enable students to become immersed in those communities and learn about medical practice within a rural and remote context. Objectives were to evaluate the rural teaching from the perspectives of four groups: patients, general practice tutors, community hospital staff and students. Learning outcomes (as measured by objective structured clinical examinations) of students learning in rural practices in the final year were compared with those in other practices. Methods: Data were gathered from a variety of sources. Students’ scores in cohort-wide clinical assessment were compared with those in other locations. Semi-structured interviews were conducted with general practice tutors and community hospital staff. Serial focus groups explored the perceptions of the students, and questionnaires were used to gather the views of patients. Results: Patients reported positive experiences of students in their consultations, with 97% expressing willingness to see students. The majority of patients considered that teaching in general practice was a good thing. They also expressed altruistic ideas about facilitating learning. The tutors were enthusiastic and perceived that teaching had positive impacts on their practices despite negative effects on their workload. The community hospital staff welcomed students and expressed altruistic ideas about helping them learn.


Introduction
Keele University School of Medicine was established in 2002, in a largely rural region.The main campus is in North Staffordshire in England.In the region in which Keele University's undergraduate medical education takes place, the largest city is Stoke-on-Trent (population 247 000) and there are three smaller cities with populations of about 100 000-170 000 1 .The overall population density is 0.92 people per hectare (the national average is 4) 2 .According to international definitions, Keele University School of Medicine would be regarded as a 'rural' medical school, by virtue of having 'a large rural hinterland' 3 , although within the context of the UK the major teaching sites are situated in environments that would be described as very urban.
A new curriculum was introduced in 2007, with increased emphasis on healthcare challenges in the surrounding population reflecting a growing international focus on social accountability 4 .The innovative 5-year curriculum design is both spiral and integrated 5 .The final year includes two 15-week clinical assistantships, one each in general practice and teaching hospital contexts, consistent with the requirements (at the time of the study) of the UK's General Medical Council 6 .The general practice component of the curriculum is primarily about providing appropriate exposure to a suitable clinical caseload 7,8 .
Students from the third and final years of the program spend time in the rural campus (see below).The 15-week placement in final year is based on the principles of a longitudinal integrated clerkship 9 .Students have educational and clinical continuity with a small group of clinical teachers and the practice population.They can learn much about professionalism from their close relationships with practice staff, and they help provide integrated care across 'speciality boundaries'.Students are expected to have become part of the practice team and to have taken the lead role in about 375 consultations.In year 3, students spend 4 weeks in general practice and are expected to lead in 60 consultations in order to consolidate their emergent clinical skills 7 .Half of the 14 ten-minute stations in the final-year objective structured clinical examination (OSCE) are based in primary care practice.
As part of the expansion in community teaching in the new curriculum, a 'rural campus' was established in 2011-2012, to allow students to base their learning in the most rural part of the region (population density 0.57 per hectare 2 ), which before the rural campus establishment was inaccessible for student learning due to longer travel times 10 .This campus is in Ludlow, in a rural district of England about 90 km (60 mi) from the main campus, in the neighbouring county of Shropshire.In collaboration with the Institute of Rural Health 11 , a process of community engagement resulted in strong support for this development from local government and other organisations.
The rural campus consists of an accommodation hub for 11 students, and 10 local general practices with four associated community hospitals (with 13-40 beds).In addition to learning generic clinical skills in the community setting (which is common to all Keele University School of Medicine's community placements), the students have seminars on rural health led by a specialist in the field.Forty percent of each graduation cohort spends time in the campus, either as a 4-week placement in year 3 or a 15-week placement in year 5.
In the UK, general practice in a rural setting may involve working with populations who historically have had better 'overall health outcomes' than urban populations 12 -a lower infant mortality, higher average life expectancy, and fewer potential years of life lost from common disease such as cancer and some chronic diseases.However, populations tend to be static or declining, and are increasingly aged.Ambulance response times tend to be longer, leading to more acute care being provided by primary care clinicians, higher rates of accidents and of suicide amongst some groups in rural compared with urban populations, and increasing difficulties with access to services.Community hospitals exist, but they are not facilities for acute care; they provide integrated care for the elderly and frail, and end-of-life care 13 .
There is an increasing literature, much of it arising from North America and Australia, describing rural medical education as part of the strategy for addressing the shortages of rural clinicians 14 .Despite similar shortages in the UK 13 , rural medical education there is relatively undeveloped 15 .The authors are cautious about the transferability of evidence from Australia and North America to the UK because of the differences in definitions of 'rurality' 16 and in how rural health care and medical education are organised and delivered; however, it is likely that there is some commonality.Barrett et al 14 , in their review of the literature, reported that the clinical skill development and examination performance of students in rural placements was at least as good as, and often better than, that of students in urban settings.Students reported high levels of satisfaction with their learning, and tended to see more patients than those in urban settings.However, many of the studies included in the review were from schools where the rural placements were longitudinal integrated clerkships 9 , and it may have been this educational method rather than the rurality itself that explains these findings.The authors were interested to know about the experience of Keele University School of Medicine's rurally placed students, their clinical teachers and their patients in this British rural environment, which had not previously hosted undergraduate medical students.An evaluation of the rural campus from multiple perspectives was conducted to gain a broad indication of its effectiveness and acceptability.This article reports the results of that evaluation.

Methods
Patients' perceptions: A questionnaire was developed by the research team.Members of the patient participation groups from two practices were asked to comment on the questionnaires, which were then amended in light of their comments (Appendix I).Practice staff distributed the questionnaires to patients attending the practices.
Tutors' perceptions: All general practice tutors were invited by email to participate in semi-structured telephone interviews lasting for up to 1 hour.This method was chosen for practical reasons related to the general practice tutors' workload.The interviews were recorded and transcribed with the consent of the GPs, who also gave consent for direct quotations to be used in presentations and publications.Interviews took place during 2013.
Community hospital staff perceptions: All staff at each of the four community hospitals were invited to participate in the study.Because staff from only one hospital agreed to take part, a single group interview was undertaken.Had there been more, a focus group would have been preferable in order to stimulate more discussion and bring out a variety of experiences and viewpoints.
Outcomes for students as measured by objective structured clinical examination (OSCE): Final-year students' OSCE scores from three consecutive academic years (2011-2014) were collated.
Students' perceptions: Three focus groups were conducted with a single group of final-year students during one rotation (August-December 2013), during weeks 0, 7 and 15, led by a medical student peer.
The analysis of the quantitative data obtained from the patient survey was descriptive and analysis of the free text components was thematic, the themes arising from the data.An independent t-test was performed to compare the mean of the OSCE scores of the rural campus students with that of the rest of the year group.The qualitative data obtained from the focus group meetings with the students, the individual semistructured interviews with the tutors and the group interview with the community hospital staff were analysed thematically using a reiterative process to categorise data, and identify and refine the principal themes.

Ethics approval
The Keele University School of Medicine ethics committee approved the focus group study with the students on 11 August 2012.The students gave specific written consent that quotes could be used.Using the National Health Service (NHS) Ethics decision tree 17 , the rest of the project was clearly categorised as evaluation rather than research and as such did not need formal NHS ethical approval.The project was discussed with the research and development leads of the appropriate NHS organisations.All aspects of the project were carried out with adherence to the principles of ethical practice 18 .

Results
At the time of the study, a total of 122 students, 72 from year 3 and 50 from year 5, had been placed at the rural campus.

Patients' perceptions
Six of the nine practices agreed to take part in the patient surveys.A total of 305 valid responses were obtained.Of these patients, 53% had seen a student at least once in the preceding year.
Of the 305 patient respondents, 53% indicated they were 'very comfortable' and 44% 'comfortable' with students in the consultation, either observing or leading it, and 97% said that they would be happy to have a student involved in a future consultation.
Six patient respondents (1.96%) indicated that they felt 'uncomfortable' or 'very uncomfortable' with the presence of a student in their consultation.Three of these said that they would not want to see a student in the future; the other three said that it would depend on the reason for the consultation.Four of the six patient respondents had never seen a student, one had seen a student in the preceding year and the other had seen a student on the same day on which they had completed the survey.
Of those patients who had seen a student at least once in the preceding year, 24% felt that the doctor gave them more time because there was a student present, 35% felt that they learnt more about their condition and 22% felt that they were given more information.Forty-one percent said that the presence of a student made no difference to the consultation and 4% felt that they received less attention from the doctor.
Regarding teaching in practices in general, the majority of patients thought that teaching is a good thing (77%), and only 1.4% thought it is not.
Five themes were identified in the patients' free text comments: • altruistic ideas about helping students to learn • the value of students being present in consultations (more time with the doctor, more explanation) • the problems of students being present in the consultations (confidentiality, inhibition, less attention) • increased consultation lengths and waiting times • the importance of choice.
The patients showed considerable altruism and variable but essentially positive perceptions of students being involved in their consultations.They were concerned about delays and having choice about student involvement in their consultations.

Tutors' perceptions
Eight general practice tutors from eight practices agreed to participate.All of them had been involved in teaching Keele University medical students for either two or three academic years.
Four major themes were identified from the data.
Impacts on the practice: The general practice tutors perceived that there was an impact on the operation of the practice, in that workload was increased for doctors (teaching leads to longer and therefore fewer consultations for the teaching general practitioner (GP), with implications for the others consulting on the day) and for practice staff (time taken to seek consent from patients to see students and administrative tasks such as timetabling).However, most saw these effects as being mitigated by the team involvement in teaching, placement fees, the benefits of having students in the practice (in terms of their contribution to the work and to the 'ethos' of the practice, and to GPs' own knowledge and skills), and the benefits for patients.
… they're not students so much an old fashioned assistant, so they're seeing patients, they're following them up to build a rapport with them.We gain from the students from an educational point of view, it lightens the practice having young people knocking around with ideas and conversation … they contribute not only in a medical way but also to the general ethos of the practice.
It's added to our practice and its added to our enjoyment and its made us happy to come to work … and I think that's definitely something the staff feel, you know, students literally breathe a breath of fresh air into the practice.

Impacts on individual general practice tutors:
The majority of the GPs interviewed had some prior interest or experience in teaching, and in general this interest, and an altruistic desire to help students learn, was their primary motivation for becoming involved.The benefits for personal and professional development were frequently described, some reporting increases in knowledge and skills, and others their own development as a doctor and teacher.Impacts on patients: The GPs were generally confident that patients enjoyed seeing students and that, with time, many would elect to see them.They perceived two reasons for this: first, the patients were 'getting two for the price of one' (seeing two 'doctors') and, second, patients like to help students to learn.
Most patients like it because they get a longer consulting time and they are able to express themselves a lot more … The patients love it.The patients really enjoy seeing the student … they enjoy having the time to talk to somebody, but they enjoy teaching the student … seeing the student, you know, learning … they're able to sort of take part in it, feel important in it ... it becomes a joint process, which they really like.
One GP explained their initial concern that a rural community might be 'stuck in their ways and not very keen' to see students 'especially from a multicultural point of view' but the experience did not support this idea.The tutor went on to say that there had not been any problem and that very few patients declined to see students, which was different from his own experience of being a student in a city environment.
Impacts on rural recruitment and retention: All of the GPs felt that students were having experiences that might influence their career plans, and five of them thought that this might impact positively on rural recruitment and retention.
None thought that the impact would be negative, although three were ambivalent and perceived that some students have no intention of becoming a GP and a rural experience does not change that.
When she came here she'd never done anything rural … she said it's completely changed her outlook … she's decided she doesn't like living in cities anymore and she probably wants to work in more of a rural atmosphere.
When they've spent a good few weeks in the practice, [they] actually begin to see the benefits of rural practice and we've had one or two who have been very keen.
One GP reported that the practice had been made more attractive to doctors looking for posts because of its teaching status.

Community hospital staff perceptions
Staff from only one of the four invited community hospitals agreed to participate in group interviews.The others cited a lack of involvement with the students (therefore feeling they had nothing to contribute to the discussion) or a lack of time.
The ward manager and the ward lead nurse were interviewed.
Three themes were identified from the data.
Medical students' operational involvement: The staff did not perceive themselves to have a teaching or mentoring role, but were 'a resource for them to come back to', having seen patients, providing information about the patients and the hospital.They saw that students were involved in assessing patients, taking blood samples and doing dressings, and could see the benefits to the students, especially in terms of their consultation skills and their knowledge of services for patients.Medical students' involvement with patients: The staff perceived that patients enjoy the contact with students.

It
If they've been checked over by a student and then by the proper doctor, they probably feel that they've had a really good going over … value for money so to speak.
Anyone who takes an interest in them [the patients] is always a benefit to the patients.
Impacts on hospital staff: The ward manager and lead nurse did not perceive any negative impact on the organisation, administration or clinical work of the hospital.They perceived positive impacts in terms of the practical clinical activities undertaken by students, and also that the students 'remind you clinically where you're at' by asking questions and sharing ideas.They expressed altruistic ideas and suggested that they were common to all hospital staff, saying that students were welcomed in the hospital and that 'everyone is really happy to support and encourage anybody in their kind of career'.

Outcomes for students as measured by objective structured clinical examination
For the rural campus students the mean OSCE score was 72.05 (n=50, range=54.20-85.71)and for the rest of the year groups it was 73.32 (n=311, range=52.63-89.35).The p-value for the difference between the two means is 0.2.

Students' perceptions
All ten students attended the first focus group, five the second and eight the third.The overall analysis of the data from the three focus groups is presented here.
Throughout the three focus groups, isolation and travel were major negative themes.Both the teaching and learning and personal development themes were largely positive.
The students had mixed experiences of the facilities, having some concerns about internet access, the security of the accommodation and the lack of recreational facilities early in the placement.As time passed, they developed an appreciation of the social activities in Ludlow.
Injustice was a strongly negative theme, and this was largely focussed around travel and the idea that they had been 'forgotten' by Keele University in terms of provision of buses to transport them to centrally held events and regarding specific problems with administrative tasks (Box 1).
Nevertheless, by the end of the placement, the students had bonded as a group and referred to themselves as 'the Ludlowians'.They expressed some sadness at having to leave and recognised that they had had rich learning experiences, which mitigated their negative experiences with travel and isolation to an extent.

Principal findings
The patients, who were largely unaccustomed to the teaching of medical students in their consultations, reported benefits in terms of the time they spent with their GPs and the better explanations they were given about their illness and treatment.They expressed altruistic ideas about contributing to the learning of the next generation of doctors, but also that they wanted to retain an option to see students or not, depending on the problems they had.Tutors reported substantial rewards from teaching and benefits for their practices and patients, although their workload increased.The community hospital staff welcomed students into their wards and perceived a benefit for both their patients and the students.
Students placed in the rural campus gave positive feedback about the learning opportunities and relationships with practice teachers, but identified travel as a problem and felt isolated from resources and social opportunities.They had a strong sense of injustice about being placed in the rural campus, largely related to administrative and travel issues, which may have been mitigated to some degree by their positive experiences in the practices.Despite their concerns, the final OSCE performance of three cohorts of students in the rural practices was not significantly different from that of classmates in other localities.

Findings in the context of the literature
The rural campus can be regarded as a successful strategy in the delivery of the new curriculum.These findings echo much of the Australian experience of rural medical education in that it does not disadvantage students and may provide substantial collateral gains.What these data add is the first indication that much of what was learned about rural education there may also apply in the UK 14,19 .

Implications
These data are important to Keele University School of Medicine.They have shown no evidence of academic disadvantage to students placed in a relatively isolated rural campus and in smaller practices, which may have been perceived to struggle to provide sufficient clinical exposure.They reinforce previous work at Keele University, which showed that learning in rural practices has no predictive value for students' satisfaction with their placements 20 .Finally, these data are important nationally; in England, 9.5 million people (19.3% of the population) 2 live in rural areas where there are isolated pockets of intense social deprivation, with specific health issues such as reduced access to health professionals and services, and a reluctance to seek help 21 .The Department of Health aims for 50% of medical graduates to enter general practice 22,23 and recruitment to rural practices has recently been described as being at 'crisis point' 24 .These data suggest that an extended rural placement may provide substantial gains for rural health and potentially increase future rural recruitment and retention through exposing students to rural lifestyles and professional role models.Finally, it is likely that the proportion of undergraduate teaching delivered in general practice will need to increase, and these data support further expansion of undergraduate clinical teaching in rural practices.
Box 1: Examples of student comments about their placements in the six themes identified from the data from three serial focus groups.
Theme 1: Isolation (from university, administrative services, teaching hospitals, teaching activities, social groups and resources such as library facilities).
There are so few of us, and we're so cut off from everything.There are a couple of things I'm looking forward to as well, though.I feel that it's a different chapter; I've never gone into a rural environment and lived that sort of way.And even in that sort of isolation I think it's good to have some experience of the way of life, so I think it's quite good for that.It's nice to get a bit of a change from being in the city.(Student 8 group 1) Theme 2: Travel (time, cost, risk) Buses wise, it's good that the medical school and my GP have agreed on me going in later with a bus, but yeah, that's still slightly limiting.I don't mind too much, but it does limit the number of patients I see per day, or when I go to cluster sessions I have to use taxis which probably costs £20, £25 each time.
And sometimes the buses just don't, they don't come … the last bus they run is probably five o'clock.Sometimes it doesn't come and I have to get a taxi back.(Student 4 group 2) Theme 3: Teaching and learning I feel like the GPs might be taking a bit more of a role in managing patients in Ludlow as there is not a big teaching hospital nearby.I think it will be good to see how you can push your management to the limit in terms of not having the resources of a hospital but still being able to treat the pain, keep the patient comfortable until the resources arrive.(Student 5 group 1) Probably been the best GP placement in terms of the teaching that we have got and the people we've met and the support in terms of the teaching.Probably the best one in fact, in the course.(Student 5 group 3) I still feel like we're getting the bad end of the deal being in Ludlow, I don't think there are benefits to being put here as opposed to Shrewsbury † .I think we miss out on a lot; like facilities and library and having more people around, there is a much bigger student population in Shrewsbury and lots more to do.(Student 7 group 2) † A town with a hospital at which rural campus Keele medical students have secondary care placements However, the data have inevitably shown that there is room for improvement and some issues to be addressed.The problems of students feeling isolated from social and educational networks, worries about travel time and costs, and about impacts on educational performance, are widely described in the literature relating to rural and remote placements globally 25 .Keele University's rural campus includes all of the elements described in the Clinical Learning Environments Evaluation Framework as recommended by Health Workforce Australia 25 , except the recommendation of a minimum of two students in each practice (because of practice sizes, it is not possible in this context without compromising the level and standard of supervision).As a result of this evaluation, outreach teaching by faculty known to the students has been increased to maintain links with the base hospital site, resources such as relevant textbooks have been introduced into the accommodation hub and protected learning sessions have been formalised in the clinical skills laboratories in the base hospital sites for these students on days when they are scheduled to be there for other reasons.
In a similar way, the accessibility of administrative functions has also been increased.The travel bursary policy is under review.

Limitations
The students involved in the focus groups are from a single cohort in one rotation.The number of final-year students placed in the rural campus is small (50) compared with the number placed elsewhere (311) in the same period.Hence further analyses on more student cohorts are required to strengthen the findings.

Conclusions
This initial evaluation of undergraduate medical student teaching in a group of small general practices associated with an accommodation hub in a small market town in a very rural district of England suggests that students have access to excellent learning experiences and that their final examination performance is not compromised.Healthcare professionals and patients perceive benefits from the presence of medical students in their locality.The students' problems with travel and isolation that were identified are being addressed.

Patient survey
Your Medical Practice is a teaching practice which means that medical students from Keele University spend time learning with GPs in your practice.We hope that you will take a few minutes to complete this survey about your experience of receiving healthcare from a teaching practice where medical students may be involved in your consultations.We will use your feedback to inform and improve the way your practice manages medical students to ensure they gain the necessary experience and also benefit patient care.All information is confidential and anonymous.Welcome medical students to be involved in your all your medical consultations d6 Wish to decide depending on why you were seeing your doctor (sometimes yes and sometimes no) d7.

I
was just captivated by the concept of delivering more education for undergraduates in general practice … because I was in a rural practice, that I'd never thought I'd get the opportunity to do it [teach], so it was important to take that forwards … I have to polish my skills up definitely … because I know I'm having a student I feel motivated to read up a little bit more and brush up my skills … it definitely improves my consulting … should give them an absolutely better idea of what sort of person should go into a community hospital and how you can keep them out of the acute [service] … They tend to see walk-in poorlies [people who are unwell] … honing their assessment skills, I would have said, is what we allow them to do.
tick) A1.Before today, have you attended an appointment with your GP in the last six months?Yes / No (Please circle) a2.If 'Yes' how many times have you attended in the last six months?(Please tick box) Once Twice More than twice B1.Before today, were you aware your practice is a 'teaching practice' for medical students?Yes / No (Please circle) b2.In the last twelve months has a medical student been present during a consultation you have had with your GP? (Please tick) Once Twice More than twice b3.Have you been offered an appointment with a medical student (present) in the past?Yes / No (Please circle) 3.About Your Overall Experience E. OVERALL: Do you think being a training practice for medical students: (Please tick all that apply): e1 Is a good thing e2 I think it helps keep up standards e3 Makes no difference for patients e4 Is good for the community because students get involved in projects to improve health services e5 I don't know what difference it makes e6 I don't think it is a good thing Please comment: ………………………………THANK YOU Theme 4: Development (personal and professional) I think I've developed it really well here.They give us a lot more responsibility than we had before.That's what my experience has been.Sometimes we feel part of the team when, if there is someone with an urgent appointment, within the morning, the GP often asks why don't you go and see this person.Saves them some time as well.So that's pretty good and I'm getting more and more confident.(Student 5 group 2) I think it's really good in terms of, personally as a character I feel I've developed even though that's not medically related, even in a non-medical way, being in this sort of environment, different, rural, challenged everything I've been used to.(Student 8 group 3) You get to do a lot more and be involved in a lot more and you get to handle or manage people a lot more.If you're in inner city, send them to a hospital.Here you're out of your comfort zone.(Student 5 group 3) Theme 5: Facilities (accommodation, social activities, leisure pursuits, commercial) Seems like there is nothing really to do there, at the moment anyway, in the evenings, to let our hair down and relax, like hey you can go swimming or go to a bar or something.In Ludlow, I don't know, it seems like we work and then what do we do after that, nothing.It feels like a sort of sleepy retirement place.(Student 7 group 1) Theme 6: Injustice … public transport down there, it's not great, you know.It does seem a bit churlish to be sending somebody down there that isn't a driver and doesn't have a car, given that lots of medical students in my experience do have cars and do drive.(Student 3 group 1) How comfortable are you/would you be with having a medical student present during your consultation: (Please tick) d1.