increasing rural activity and curriculum content in ... - Semantic Scholar

Aust. J. Rural Health (2002) 10, 220–228

Original Article

© Blackwell 54 The AJR 1038-5282 93F AUSTRALIAN 319 RURAL 10.1046/j.1038-5282.2001.00408.x eburary 2001 University Australian National ACTIVITY 2001 Science Street, Journal JOURNAL Rural Asia AND POof Health Box Rural CURRICULUM OF 378, Alliance RURAL Health Carlton Inc. HEALTH South, CONTENT: VictoriaAPELAIDE 3053 Australia UNIVERSITY MEDICAL SCHOOL: C. LAURENCE ET AL.

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INCREASING RURAL ACTIVITY AND CURRICULUM CONTENT IN THE ADELAIDE UNIVERSITY MEDICAL SCHOOL Caroline Laurence,1,2 Jonathan Newbury2 and David Wilkinson1 1South

Australian Centre for Rural and Remote Health, Adelaide University and University of South Australia, Whyalla and Adelaide, and 2Department of General Practice, Adelaide University, Adelaide, South Australia

ABSTRACT: This study aimed to document the level of rural activity and curriculum content in the Adelaide University Medical School. A questionnaire was distributed to all heads of departments within the Medical School and additional information was obtained from reports and discussions with key personnel. There has been an increase in the proportion of students with a rural background enrolled from 9% in 1994 to 22% in 2000. There has also been an increase in the number of weeks available for rural placements from 12 (mostly optional) to 29 weeks (some mandatory), and an increase in the number of departments offering rural placements. There has also been improved academic support to rural practitioners and many departments directly provide services in rural communities. A new combined University Department of Rural Health (UDRH)/Rural Clinical School associated with the Adelaide University Medical School aims to provide at least half of all clinical training to 25% of all medical students of Australian origin. KEY WORDS: curriculum development, medical school, rural health.

INTRODUCTION Recruiting and retaining an adequate number of rural doctors is a problem faced by many countries.1,2 Research from Australia and overseas has identified several factors that impact on a doctor’s decision to choose rural practice. Rural exposure is associated with subsequent rural practice.3–6 Rural exposure can be divided into three levels: living in a rural area as a child;7–15 placement in a rural practice during undergraduate or postgraduate training;6,16–18 and studying medicine in a rural location.13,19–22 Location of undergraduate education and residency programs seems to influence location of practice. Medical schools clearly have a substantial impact on the career decisions of medical students through their selection, training and socialisation processes.19,22-24 Medical Correspondence: Professor David Wilkinson, SACRRH, University of South Australia, Whyalla Campus, Nicolson Avenue, Whyalla, South Australia 5608, Australia. Email: [email protected] Accepted for publication May 2001.

schools in North America vary greatly in the extent that their graduates select rural practice, with schools located in rural areas more likely to produce rural graduates.25 However, interest in rural practice wanes as medical education progresses.24 Options to maintain interest include sensitising faculty and staff to rural values and needs; orienting students to the school’s rural interests/ goals; developing early rural preceptorships; organising rural societies/clubs; assisting students to volunteer time to rural health services; and including the spouse/partner in rural activities. Curriculum reform also signals the school’s recognition that rural medical careers are valid.26 In Australia, the most concerted effort to increase undergraduate exposure to rural practice has been through the General Practice Rural Incentive Program’s Rural Undergraduate Support Steering Committee (RUSC) initiatives. Following the 1994 report on reforming undergraduate medical education for rural practice, $1.74 m has been provided annually to the 10 medical schools to implement initiatives that reform the undergraduate curriculum to include more rural content and experience

RURAL ACTIVITY AND CURRICULUM CONTENT: C. LAURENCE ET AL.

for medical students.27 The Rural Undergraduate Support Steering Committee set a target that at least 12% of all medical students should be of rural origin, with the aim of increasing this to 15%. The 1996 Federal Budget provided funding to establish University Departments of Rural Health (UDRH) whose aim is to support, educate and train rural and remote health workers.28 The 2000/ 2001 Budget announced funding for nine new rural clinical schools and three more UDRH that will provide the opportunity for medical and health science students to undertake their training in rural areas.29 After six years of RUSC funding, there have been significant changes to the Adelaide University Medical School’s approach to rural medicine. This paper outlines the key changes that have occurred and indicates what the future may hold.

METHODS The medical course at Adelaide University is six years long with a quota of 90 in 2001, of which at least 84 places are filled from school leavers. Under the University’s Aboriginal and Torres Strait Islander Access Schemes, six places are available for Indigenous students. In addition to the 90 places for Australian students, there are up to 35 places each year for international students. In July 2000, in developing our proposal for a rural clinical school in the Spencer Gulf region of South TABLE 1:

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Australia, a questionnaire was sent to all heads of departments in the medical school covering a range of questions relating to rural activity and rural curriculum content (Table 1). The departments were asked to provide information on seven questions. The first three related to current levels of rural activity such as undergraduate placement and other education activities, research and rural service provision such as locum cover, visiting and residential services. The last four questions looked at the potential each department had to ruralise the curriculum, including the amount of rural training that could occur in each discipline; the proportion of students that could do some of their training in a rural area; the resources required in terms of staff, budget, equipment to achieve this; and various options available such as a rural stream, extended placements and year long clinical rotations. In addition to the survey, information was obtained from RUSC reports provided to the Commonwealth Department of Health and Aged Care and discussions with heads of departments, the Dean and associate deans.

RESULTS

Structural changes The Department of General Practice provided the lead in developing rural activity and curriculum development in the medical school, with the establishment of rural academic practices,30 the appointment of a rural lecturer,

Survey questions

1. What form of rural involvement does your Department currently have in terms of undergraduate placements and other educational activities? For example, proportion of students on rural placement and duration. 2. What form of rural involvement does your Department currently have in terms of research? 3. What form of rural involvement does your Department currently have in terms of service provision? For example, visiting and residential services, locum cover. 4. Given substantial resources through a Rural Health School, how much rural undergraduate medical training could occur in your discipline? (Resources could provide a residential specialist/lecturer in a regional centre with an academic appointment and substantial teaching time, and other necessary training resources would be made available.) 5. What proportion of your students could do at least some of their training in the country, under optimal circumstances? And for how long? 6. What resources – in broad terms (staff, budget, equipment, costs) – would be need to achieve this? 7. The Commonwealth Department of Health and Aged Care wants 25% of all medical students to be trained in the country for a substantial part of the course. They have not indicated what proportion of allied health students they would like to see trained in the country, but we might propose a similar proportion. This might mean a number of options as listed below. Please comment on each. 7.1 A rural stream whereby a group of students receive the bulk of their training in the country. 7.2 Extended rural placements, for example, for several weeks. 7.3 A whole clinical year on rotation in the country through core disciplines. 7.4 Multidisciplinary placements with medical, nursing and other allied health workers, as appropriate. 8. Any other comments.

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and the push for more rural exposure in the curriculum. RUSC funding enabled this activity. The Department also was instrumental in developing the successful proposal for a UDRH in South Australia.31 More recently the Professor of Rural Health has been appointed to a newly created position of Associate Dean (Rural Affairs) within the Medical School Executive. With the newly announced combined UDRH/Rural Clinical School in Whyalla and the Spencer Gulf region, rural medicine has a secure and high profile in the medical school.

Students In 2000, 22% of the 90 enrolments were students with a rural background. This compares with just 9% in 1994, and clearly exceeds RUSC targets. This dramatic change over six years has mainly resulted from changes in the selection process for medicine and dentistry in 1997. In summary, the sequence of selection assessment now is: 1. Being placed within the top approximately 360 places in the Undergraduate Medicine and Health Sciences Admissions Test (UMAT). 2. Performance in a structured oral assessment. 3. Achieving a South Australian Certificate of Entry Score in the top 10% band (or equivalent in their own State year 12 examination or the International Baccalaureate). One of the University’s key strategies to increase access of rural and isolated students to study at the University is through the Fairway Scheme. Under this scheme students from ‘underrepresented schools’ have bonus points added to their tertiary entry score up to a maximum of 6 points. This scheme favours rural students as all South Australian

AUSTRALIAN JOURNAL OF RURAL HEALTH

rural schools are deemed ‘underrepresented schools’ and rural students receive the maximum bonus points to increase their tertiary entry score. Additionally the Faculty of Health Sciences has no pre-requisite subjects, accepting all year 12 subjects, whether assessed by external exams or internal school assessments or a combination.

Source of rural students Accurate data on the source of rural students are only available from 1998. The Medical School uses the applicant’s home address postcode to define rurality. The largest proportion of rural applicants over the last three years have come from Victoria, South Australia and New South Wales, with Western Australia and the Northern Territory providing fewer applicants (Figure 1). Following selection, the largest proportion of offers are made to students from rural Victoria, South Australia and New South Wales (Figure 2). This is consistent with the source of applications; however, there has been a decrease in the number of rural South Australian students offered places since 1998. Rural students from New South Wales, South Australia and Queensland make the largest source of rural students enrolled in the medical school (Figure 3).

Promotional Activities We have undertaken a number of promotional activities focussing on rural student entry. These include: 1. A database of contact details of career guidance officers within all schools in South Australia, western Victoria, New South Wales and the Northern Territory being created to enable effective future contacts.

FIGURE 1: Rural applicants to the Adelaide University Medical School.


2. Promotion of medicine as a career in country high schools by sending promotional material to all schools. 3. An annual information day being run for rural high school career guidance officers who are invited to the Medical School, with travel assistance provided to those travelling from remote South Australia. 4. Support for rural students sitting the UMAT test and attending the Oral Assessment if selected, including subsidising costs of travel for students from remote areas.

Medical school curriculum Rural placements There has been a gradual increase in the amount of rural exposure across all departments over the last four years. In 1996, the rural content of the medical school curriculum was limited to general practice and paediatrics with only 12 weeks placement available during the six-year course, and most of the placements were optional. By 2000, six departments offered rural placements (general practice, medicine, surgery, obstetrics and gynaecology, psychiatry and paediatrics) with more than 29 weeks available (Table 2). Most rural exposure occurs in the clinical years (4th– 6th years) of the course, while rural problem-based learning cases have been developed for 1st–3rd year students. In the first year there is a two-day field trip focussing on Indigenous health and cross-cultural awareness at The Camp Coorong Race Relations and Cultural Education Centre, which is an initiative of the Ngarrindjeri Lands and Progress Association.32 In second year the Family Attachment Scheme (FAS) is designed to allow medical students to consider the role of the family in a patient’s illness, and to understand the impact of a medical event on the patient and their family, as well as gaining awareness

FIGURE 2: Offers made to rural students.

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of the support networks that exist. In the fourth year all students undertake a 6-week full-time research project with rural options available. Since 1997, 28 rural projects have been undertaken. In fifth year students have the option to spend their 4-week obstetrics placement in a rural regional location, either at Mount Gambier Hospital or Whyalla Hospital. In sixth year the Specialist/Community Ambulatory Placement Program (SCAP) ensures all final year students complete a 16-week semester away from the in-patient setting of urban public hospitals. All medical students of Australian origin must complete at least one four-week SCAP in a rural location. Rural placements are predominately in general practice or surgery (Table 3). Most primary care SCAPs are undertaken in small rural and remote areas (RRMA 5–7),33,34 with surgery and medicine in larger rural centres (RRMA 3–4) which are the only rural locations in South Australia that can support resident specialists (Table 3).

Academic support To support the curriculum changes, we have increased the support offered to rural teachers and have increased the number of academic staff with a background in rural medicine. Apart from the UDRH, which is focussed on rural health, the Department of General Practice is the only other department employing a full-time rural lecturer. To create an effective link, he works three days each week in the medical school and two days in the rural academic practices on the Yorke Peninsula. The department also employs a general practitioner in each rural academic practice as a 0.2 full time equivalent lecturer for undergraduate teaching. Additionally, both SACRRH and the Department of General Practice have created a wide network of honorary clinical lecturers who do most of the student teaching.

Core Curricula (Medical Education Unit)

Paediatrics

Obstetrics & gynaecology

Psychiatry

Surgery

PBL rural cases PBL rural cases

Family Attachment Scheme – rural placements at Murray Bridge or Goolwa, 20 students

Camp Coorong for all medical students (140), 2 days

General practice/ Primary care

Medicine

2nd year

1st year

2000

TABLE 2: Rural content – medical curriculum 2000

PBL rural cases

3rd year 6-week rural research project, 7 students (SACRRH) 1-week placement in Alice Springs (elective)

4th year

18 students, 4-weeks in Mount Gambier Hospital or Whyalla Hospital (10 students)

5th year

16 students, 2-weeks, Port Augusta (optional)

8 students, 4-week rural placement 50 students, 4-week rural placement 5 students, 4-week rural placement

78 students, 4-week rural placement

6th year

224 AUSTRALIAN JOURNAL OF RURAL HEALTH

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They are supported by a series of ‘Teach the Teacher’ seminars each year, focussing on teaching methods required by the university. We are currently developing an interactive website to further support these teachers. Rural clinical teachers and supervisors have also been appointed in other departments, including obstetrics (1 supervisor), surgery (1 clinical lecturer and 4 supervisors), paediatrics (1 clinical lecturer) and psychiatry (2 supervisors). In obstetrics an Associate Professor in Rural Obstetrics has been appointed with the support of the Port Pirie Hospital.

focussed on Indigenous students with the objectives being to: • develop a recruitment and marketing strategy; • identify reasons why the allocated quota for Indigenous student intake has never been filled; • develop a strategy to increase cultural awareness in the Medical School; • identify and develop Indigenous student support strategies; and • develop a strategy to create a culturally inclusive curriculum at the Medical School.

Educational development and support

Paediatrics

Indigenous students program First funded by the Office of the National Health and Medical Research Council in 1999, the project has

A postgraduate educational program for rural practitioners, funded through a Rural Health, Support, Education and Training grant, is available through the Department of Paediatrics, based at the Women’s and Children’s Hospital.

TABLE 3: Location and number of SCAPs placements 1999–2000

SCAP 1999 Primary Care

Surgery

Psychiatry 2000 Primary Care

Surgery

RRMA

No. of practices

No. of placements

Other (overseas or special) Large Rural Centre (3) Small Rural Centre (4) Rural Other (5) Remote Other (7) Total Large Rural Centre (3) Small Rural Centre (4) Total Rural Other (5) Total

2 2 5 12 2 23 1 4 5 1 1

2 2 32 33 6 75 4 41 45 6 6

Other (overseas or special) Outer Metropolitan (2) Large Rural Centre (3) Small Rural Centre (4) Rural Other (5) Remote Other (7) Total Large Rural Centre (3) Small Rural Centre (4) Total

2 3 2 5 19 2 23 1 4 4

Total Other (overseas or special) Small Rural Centre (4) Total

1

5 4 8 14 45 2 78 7 43 50 5 5 4 4 8

Psychiatry Medicine

2 2

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Rural Undergraduate Placement Program (RUPP) This program enables medical students from throughout Australia to undertake rural attachments and electives in remote areas of the Top End of the Northern Territory and in Alice Springs. Students have been placed in Aboriginal communities under RUPP since 1997. Predominantly this comprises 6th year students in Darwin and 4th year students in Alice Springs, but also 5th year elective and 4th year research students.

Academic practices The university has established academic teaching practices on the Yorke and Eyre peninsulas of South Australia,30 forming the University Family Practice Network.35

Rural Undergraduate Medical Placement Scheme (RUMPS) The university has worked with partners to develop the RUMPS database of all general practitioners within South Australia. The database is used jointly by Adelaide University, Flinders University and the rural workforce agency to coordinate medical student placements.

Rural club The Adelaide University Rural Medical Society (AURMS) aims to stimulate interest in a career in rural medicine and currently has over 150 members. Activities include regular meetings with guest presenters on different aspects of rural health, trips to experience working and living in rural areas, and rural clinical skills days. The club has an office, computer, internet access, and other educational resources, and is located in the medical school.

FIGURE 3: Enrolments rural students.


Service provision Several departments provide services to rural communities. The South Australian Centre for Rural and Remote Health and the Department of General Practice recruit rural doctors and manage rural practices, while staff work regular clinical sessions and provide locum relief. The Department of Medicine provides visiting specialist services in diabetes, endocrinology and pulmonary medicine in rural areas, while the Department of Obstetrics and Gynaecology provides services to Coober Pedy, Darwin, Mount Gambier, Port Lincoln, Port Augusta and Yorketown. The Department’s Reproductive Medicine Unit provides rural services in Darwin, Mount Gambier, Port Augusta, Port Lincoln and Broken Hill. The Department of Surgery provides surgical services under a contract to the Port Augusta Hospital.

DISCUSSION Introducing change to an organisation that has been established for over 115 years is difficult and necessarily takes time. The Rural Undergraduate Support Steering Committee funding,3 a political climate focusing on rural issues, and the UDRH initiative have all facilitated change. There has been a clear system-wide commitment to rural medicine in the Adelaide University Medical School, reflected in the major increase in enrolment of students with a rural background, senior appointments focusing on rural health, and real changes to the curriculum in favour of rural health. While there is debate on how appropriate current selection processes to medical school are, there is common agreement on the need to select more students with a


rural background. The Rural Undergraduate Support Steering Committee initiatives have supported this and now all medical schools have strategies to improve the recruitment of rural students. An issue for further debate is to what extent medical schools should favour homeState students. We are unaware of any evidence that training students with a rural background in their home State increases the likelihood of them subsequently working in rural areas of that State, but further research is warranted to explore this issue. The early RUSC initiatives focussed on general practice, but more recently the emphasis has broadened to include other specialties, and our data show how this has occurred in Adelaide, with most major departments offering substantial rural education opportunities and supporting and providing rural services. Opportunities now exist in all clinical years of the curriculum for rural exposure. Academic staff who actively support rural practice are essential to enhancing medical students’ experience of rural medicine. Academic staff in Adelaide regularly provide and support rural practice, thereby reducing the perceived distinction between academia and practice. Locating the Department of Rural Health in a regional area,28,31 establishing rural practices owned or supported by the university, and the direct provision of services, have all improved the university’s credibility.30 In 2000, SACRRH received the University of South Australia’s Chancellor’s Award for Community Service. A critical mass of academic staff living and working in the country has been established, with high levels of research and project activity. What does the future hold? With the announcement of a new combined UDRH/Rural Clinical School in Whyalla and the Spencer Gulf region of South Australia, a new era beckons. The new school aims to provide at least half of the clinical training needs of at least 25% of all medical students. While details remain to be defined, options being considered include a rural stream receiving almost all clinical training in the country, enhanced rural opportunities for rural bonded scholars and rural club members, and a basic rural portion of the curriculum for all students. Our school aims to work in close partnership with regional health services, both public and private, strengthening services where necessary and hence providing strong, quality educational opportunities and experiences.

ACKNOWLEDGEMENTS We thank all heads of department for completing our survey.

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