Denese Playford

Impact of the Rural Clinical School of Western Australia on work location of medical graduates.

Objective: To determine whether completing a year of the Rural Clinical School of Western Australia (RCSWA) program is associated with entering the rural medical workforce.

Interprofessional Education in Australasia

In April 2006 at the ‘‘All Together Better Health 3’’ conference in London a small group of health professionals from Australia and New Zealand took the opportunity to meet face-toface and share their experiences of IPL (interprofessional learning). The irony was that these people were meeting half the world away from their institutions. They had heard each other’s names before but few had talked face-to-face. It took an international meeting to launch the idea of AIPPEN – the Australasian Interprofessional Practice and Education Network. Since my own move to Australia almost four years ago I have been stimulated by the increasing interest in IPE ‘‘down under’’. In 2005 in an editorial for this journal I wondered where the teamwork approach to health care was hidden in my new home (Thistlethwaite, 2005). Similarly I had trouble finding IPE initiatives within local universities. I realize now that there were in fact many projects going on, particularly in rural and remote areas, but that there was a lack of promotion of these. RIPEN (the Rural Interprofessional Education Network) was and is going strong but there was less focus on initiatives in other areas – hence the decision to form AIPPEN. AIPPEN is a network of individuals, groups, institutions and organizations committed to researching, delivering, promoting and supporting IPE and IPP (interprofessional practice). Its primary objective is to promote better health care outcomes and enhance IPE and IPP in Australia and New Zealand by developing a network to promote communication and collaboration among members. We also aim to influence workforce policy and practice change and disseminate information on IPL throughout the region (Nisbet et al., 2007). The steering group members are involved in a range of activities and meet regularly by teleconference. In line with international trends, IPL activity within Australia and New Zealand is rapidly expanding. Results of a 2005 survey of Australian universities (Thistlethwaite and Nisbet, unpublished) indicated that 19 of the 38 Australian universities offered campus-based IPL opportunities, particularly in undergraduate programs run by Faculties of Health, rural clinical schools and Departments of Nursing. These, however, tended to focus on content rather than specific IPL objectives, e.g., Indigenous studies; research methodologies. There was minimal indication that IPL was an embedded component of curricula. However, close to 60% of respondents indicated they aimed to increase the amount of IPE offered in the future, with 40% suggesting no change. Although two thirds of the courses had been evaluated, only three evaluations had been published, highlighting the need for more formal evaluation of programs and dissemination of findings. There is also a dearth of sociological and critical papers or monographs about IPE and IPP. To meet this need for scholarship the production of a critical text in the field is high on the agenda of the Monash University Department of Rural and Indigenous Health. Journal of Interprofessional Care, August 2007; 21(4): 369 – 372

Does teaching an entire nursing degree rurally have more workforce impact than rural placements

Abstract Education plays a key role in recruitment of health workforce to rural and remote locations. In Australia, Schools of Nursing have set up a variety of educational programmes to encourage rural workforce choices. These programmes include rural campuses and short-term rural placement programmes out of urban campuses. This study compares the relative workforce impacts of rural campus versus short-term rural placements out of urban campus. The single outcome measure – rural or urban location after graduation – showed that the rural school graduated a significantly higher proportion of rural-working graduates (x2 4.46, p = 0.04). However there was no difference in the rural workforce choices of students from rural backgrounds, irrespective of their university location (x2 = 1.45, p = 0.23). We conclude that both rural universities and affirmative action for selecting rural students into nursing programmes are effective workforce strategies, but that rural campuses have the added benefit of encouraging under-represented rural students to access university education.

Medical student selection criteria as predictors of intended rural practice following graduation

BackgroundRecruiting medical students from a rural background, together with offering them opportunities for prolonged immersion in rural clinical training environments, both lead to increased participation in the rural workforce after graduation. We have now assessed the extent to which medical students’ intentions to practice rurally may also be predicted by either medical school selection criteria and/or student socio-demographic profiles.MethodsThe study cohort included 538 secondary school-leaver entrants to The University of Western Australia Medical School from 2006 to 2011. On entry they completed a questionnaire indicating intention for either urban or rural practice following graduation. Selection factors (standardised interview score, percentile score from the Undergraduate Medicine and Health Sciences Admission Test (UMAT) and prior academic performance (Australian Tertiary Admissions Rank), together with socio-demographic factors (age, gender, decile for the Index of Relative Socioeconomic Advantage and Disadvantage (IRSAD) and an index of rurality) were examined in relation to intended rural or urban destination of practice.ResultsIn multivariate logistic regression, students from a rural background had a nearly 8-fold increase in the odds of intention to practice rurally after graduation compared to those from urban backgrounds (OR 7.84, 95% CI 4.10, 14.99, P < 0.001). Those intending to be generalists rather than specialists had a more than 4-fold increase in the odds of intention to practice rurally (OR 4.36, 95% CI 1.69, 11.22, P < 0.001). After controlling for these 2 factors, those with rural intent had significantly lower academic entry scores (P = 0.002) and marginally lower interview scores (P = 0.045). UMAT percentile scores were no different. Those intending to work in a rural location were also more likely to be female (OR 1.93, 95% CI 1.08, 3.48, P = 0.027), to come from the lower eight IRSAD deciles (OR 2.52, 95% CI 1.47, 4.32, P = 0.001) and to come from Government vs independent schools (OR 2.02, 95% CI 1.15, 3.55, P = 0.015).ConclusionsVery high academic scores generally required for medical school entry may have the unintended consequence of selecting fewer graduates interested in a rural practice destination. Increased efforts to recruit students from lower socioeconomic backgrounds may be beneficial in terms of an ultimate intended rural practice destination.

‘A world of difference’: a qualitative study of medical students’ views on professionalism and the ‘good doctor’

BackgroundThe importance of professional behaviour has been emphasized in medical school curricula. However, the lack of consensus on what constitutes professionalism poses a challenge to medical educators, who often resort to a negative model of assessment based on the identification of unacceptable behaviour. This paper presents results from a study exploring medical students’ views on professionalism, and reports on students’ constructs of the ‘good’ and the ‘professional’ doctor.MethodsData for this qualitative study were collected through focus groups conducted with medical students from one Western Australian university over a period of four years. Students were recruited through unit coordinators and invited to participate in a focus group. De-identified socio-demographic data were obtained through a brief questionnaire. Focus groups were audio-recorded, transcribed and subjected to inductive thematic analysis.ResultsA total of 49 medical students took part in 13 focus groups. Differences between students’ understandings of the ‘good’ and ‘professional’ doctor were observed. Being competent, a good communicator and a good teacher were the main characteristics of the ‘good’ doctor. Professionalism was strongly associated with the adoption of a professional persona; following a code of practice and professional guidelines, and treating others with respect were also associated with the ‘professional’ doctor.ConclusionsStudents felt more connected to the notion of the ‘good’ doctor, and perceived professionalism as an external and imposed construct. When both constructs were seen as acting in opposition, students tended to forgo professionalism in favour of becoming a ‘good’ doctor.Results suggest that the teaching of professionalism should incorporate more formal reflection on the complexities of medical practice, allowing students and educators to openly explore and articulate any perceived tensions between what is formally taught and what is being observed in clinical practice.

Longitudinal rural clerkships: increased likelihood of more remote rural medical practice following graduation

BackgroundExtended rural clerkships clearly increase the likelihood of rural practice post-graduation. What has not been determined is whether such rural interventions increase the likelihood of graduates practicing in more remote, versus inner regional, locations.MethodsThe Australian Health Practitioner Regulation Agency database was used to identify the current workplace of every graduate of the Medical School of Western Australia, 1980 to 2011. There were 324 graduates working in a primary practice location defined by the Australian Standard Geographical Classification as inner regional to very remote. They were divided into 3 groups - 200 graduates who entered medical school before commencement of the Rural Clinical School of Western Australia (RCSWA), 63 who entered after the RCSWA had started, but not participated in RCSWA, and 61 who participated in the RCSWA. The RCSWA offers a longitudinal rural clinical clerkship throughout level 5 of the MBBS course.ResultsThe two groups not participating in the RCSWA had 45.5% and 52.4% of subjects in outer regional/very remote locations, respectively. In comparison, 78.7% of those who had participated in the RCSWA were currently practicing in outer regional/very remote locations. When the 3 groups were compared, the significant predictors of working in a more remote practice compared to working in an inner regional area were being female (OR 1.75 95% CI 1.13, 2.72, P = 0.013) and participating in the RCSWA (OR 4.42, 95% CI 2.26, 8.67, P < 0.001). In multivariate logistic regression that corrected for gender and remoteness of rural address before entry to medical school, participation in the RCSWA still predicted a more than 4-fold increase in the odds of practicing in a more remote area (OR 4.11, 95% CI 2.04, 8.30, P < 0.001).ConclusionExtended rural clinical clerkship during an undergraduate MBBS course is related to a much greater likelihood of practicing in more remote, under-serviced rural locations.

Longitudinal assessment in an undergraduate longitudinal integrated clerkship: The mini Clinical Evaluation Exercise (mCEX) profile

Aim: Student and assessor performance were examined over three academic years using the mini Clinical Evaluation Exercise (mCEX) as a continuous feedback tool across all disciplines, in all learning contexts, for an entire integrated undergraduate year. Methods: Students could complete any number of mCEX, but had to submit a minimum number per discipline. Students were free to choose assessors. Assessors were not trained. Data were collected in a customised database, and analysed in SPSS ver 18.0.0. Results: 5686 mCEX were submitted during 2008–2010 (Cronbachs α = 0.80). Marks were affected by doctor grade (F = 146.6, p < 0.000), difficulty of clinical encounter (F = 33.3, p < 0.000) and clinical discipline (F = 13.8, p < 0.000). Students most frequently sought harder markers (experienced general practitioner/hospital specialists). Increases in mCEX marks were greatest during the early, formative months (F = 42.7, p < 0.000). More mCEX were submitted than required, without differentiation between weak or strong students (rxy = 0.22, p = 0.78). Conclusions: Undergraduate students in longitudinal clerkships acquire most skills during ‘formative’ learning. They seek ‘hard’ assessors, consistent with year-long mentoring relationships and educational/feedback value. Assessors mark consistent with a framework of encouraging student performance. Over an entire longitudinal clerkship, students complete mCEX in excess of course requirements. This study confirms the impact of the longitudinal context on assessor and student behaviour.

Growing rural doctors as teachers: a rural community of medical education practice.

This reflective work considered the journey of rural doctors from diverse backgrounds as teachers and academics during the establishment and rapid expansion of an Australian rural clinical school. The observed social and academic processes are analysed in the context of social learning theory. The extent to which the theoretical social processes match observations during a period of transformational change indicates how social learning processes contributed to the outcome. Ten areas of thematic teacher concerns were identified during teachers’ professional development and the strategies used to address these declared. Despite the concurrent evolution of both the overall organisation (teacher environment) and teachers’ task (curriculum approach), a community of rural educational practice (CREP) formed and thrived. It adopted a culture of sharing experiences which enabled ongoing knowledge brokering, engaged experts and transformed members. Critical reflection resulting from engagement in mutual activity and a supporting culture of enablement driven by senior leadership was central to success. A generic framework for building a successful CREP includes, leadership that ‘enables’ its members to flourish, a rural academic identity with a ‘Community of Practice’ governance, internal benchmarking by members to measure and refine practice, critical reflection ‘in’ and ‘on’ academic practice, vertical and horizontal mentoring.

The effect of alcohol sales and advertising restrictions on a remote Australian community

Aim: To evaluate the effect of restricting hours of sale for take-away alcohol, container sizes for beverages linked to risky consumption and advertising and promotion of certain high-strength beverages on community attitudes, consumption and proxy measures of related harm in a small remote community with high levels of problematic use. Methods: Community surveys were undertaken in the intervention community and an adjacent control community immediately prior to the introduction of the mandated restrictions and again 12 months later. Pre and post interviews were conducted with key informants in the intervention community at approximately the same times. Serial consumption and proxy harm data were collected from both intervention and control communities and changes measured over the period that voluntary and then mandatory restrictions were introduced. Findings: There was recognition of a substantial community alcohol problem. This was accompanied by good knowledge of, and support for, the nominated restrictions prior to their mandated introduction. Subsequently, there was little opposition to their ongoing operation. Consumption of the most problematic beverage, cask wine, has reduced. Proxy measures of alcohol harm: night-time hospital accident and emergency occasions of service; trauma-related ambulance call outs; and police-attended disturbances, also declined. Much of this change was associated with earlier, voluntary restrictions. Conclusions: The restrictions have had a beneficial effect, but most of this occurred prior to their mandated introduction. Continuing to mandate compliance is, however, important because it validates community action, crystallizes structural change and provides a basis for further local initiatives.

Opting for rural practice: the influence of medical student origin, intention and immersion experience

Objective: To compare the influence of rural background, rural intent at medical school entry, and Rural Clinical School (RCS) participation on the likelihood of later participation in rural practice.