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ENCOURAGING medical students from urban backgrounds to attend rural clinical schools will provide the most “bang for our buck” in boosting the rural medical workforce, says a rural health expert.
Associate Professor Gabriel Shannon, adjunct associate professor at the University of Sydney’s School of Rural Health, was commenting on research published in the MJA that found graduates from urban backgrounds who spent a year at the Rural Clinical School of WA (RCSWA) were almost four times more likely to be working in a rural area up to 10 years after graduation than their counterparts who did not attend a rural clinical school (RCS). (1)
Among a cohort of 1017 University of WA graduates who completed year 5 medical school between 2002 and 2009, 258 were RCSWA graduates, including 195 from urban backgrounds. Of these, 14.9% were working as rural doctors in 2013 compared with just 3.8% of controls.
“RCSWA graduates from an urban background were working as rural doctors at a similar rate as those from a rural background who did not participate in the RCSWA”, the researchers wrote.
Professor Shannon said enticing city-raised medical students to rural clinical schools was likely to be the most effective strategy in shifting some of the medical workforce from urban to rural areas.
“We certainly should be encouraging those of rural origin to come to rural clinical schools, but we’re probably going to get the most bang for our buck by supporting urban students to come to rural clinical schools”, he said. “[Urban students] are more likely to change their minds about their career pathway and commit themselves to a rural practice, which they may not have been thinking about before they came to a rural clinical school.”
Professor Shannon said the research findings sent a very “strong message to government” that the rural clinical school model was effective and should continue to be funded and perhaps expanded to include more or extended placements at rural clinical schools.
Professor Geoff Thompson, former (foundation) chair of the SA Institute of Medical Education and Training, said the study provided the best evidence to date for the ongoing support of the RCS approach.
However, he said, the link between rural clinical school attendance and rural practice was “not quite justified” by the data presented and more evidence was needed before expansion of the RCS program could be recommended.
“Despite the authors’ contention that their results justify the RCS approach, it remains possible, for example, that those who chose the RCS program may have chosen a rural career path for other reasons.
“It would have been useful to know if, after 2007 (after which there was an excess of applicants), the allocation to RCS was made randomly or was based on suitability for the program. If the latter, then selection bias would be a concern,” said Professor Thompson, a paediatrician and professorial fellow at SA’s Flinders University.
Professor Thompson said further research was also needed to determine the quality of care provided by RCS graduates because the approach was a significant departure from conventional medical school teaching.
“We know that RCS students do well in medical school examinations, but their subsequent performance as practitioners has not been well documented. This is a difficult parameter to measure, but if it could be shown that they make as good as, or even better, doctors than their non-RCS colleagues, the case for continuing the RCS approach would be made — especially if the cost benefit could also be demonstrated.”
Professor Shannon said most of the RCSs had “virtually identical” curriculums to their parent medical schools. “We at the school of rural health at the University of Sydney have exactly the same curriculum as Sydney Medical School and our students are performing very well in that, so I have no doubt that the quality of the graduate is equal to, if not even better than, the quality of the graduates who don’t come to the rural school,” he said.
When I went to WA in 2002 from New Zealand Rural Practice, the question of whether we could attract more graduates to work rurally through an RCS programme seemed a very remote possibility. Fortunately the Medical Faculty encouraged us to develop a unique programme called CLERC, Clinical Learning Embedded in Rural Communities, and we discovered an amazing group of rural professionals who linked up with academic staff to deliver the holistic package. We have published widely on the process and demonstrated that students could spend a year in rural and remote Western Australia and do just as well as students who studied in tertiary hospitals. We also demonstrated that the academic prowess of this “bush academy” was equivalent to those based on specialist outcomes.The question the research addressed was whether the RCS could ensure that more graduates returned to work in rural areas. The answer is YES.
The other questions are topics for another project. However Professor Thomson’s astonishing statement that the quality of care provided by RCS graduates should be investigated ” because the approach was a significant departure from conventional medical school teaching,” betrays an outdated attitude and needs further clarification. The problem with conventional medical school teaching was where it was delivered. The UWA Rural Clinical School demonstrated that teaching should be delivered where the people are, and the entire Faculty agreed that the performance of RCS students was equivalent if not better than those educated “conventionally.” I would have no doubt that their quality of care since has been exemplary.
Experience from nearly 30 years in rural pharmacy and some input in the first rural based pharmacy course at CSU and more recently at UNE, the issue is more complex than just geography.
The first cohorts of students at CSU were all rural based who went on complete their training with a reasonable percentage practicing in the bush. In subsequent years, the cohort changed due to many urban students applying as a backup if they missed out on a place in the city and reducing the number of regionally based students.
The next problem is that the best students from rural Australia are also the best graduates in all of Australia and these were offered and accepted good positions in the cities. There is even a stigma that exists amongst their peers, in some universities and even with some employers that if you only had a job in a rural area you were either lazy or not very competent.
This is the perception I believe needs to be changed. Rural Australia is the best and most rewarding (professionally and finacially) place to be a pharamcist. I know from many people in allied health that this is the same for their professions.
Rural background plus rural clinical school training was the greatest predictor of a rural career in the study quoted, a fact ignored by the above article and the study quoted.
Of all rural background students in the study, more than 17% were working rurally, almost 3 times as many as the 6% of urban background students.
This contradicts the statment in paragraph 5 of the above article, and the conclusions of the study, which appears to be aimed at jusitification of funding for RCS for urban universities , as opposed to funding for rural background students to get a place in any medical school.
The study draws a long bow of significance of RCS “given the limited pool of rural background students available to be recruited into medicine” -perhaps the authors can substantiate this given.
I agree with Prof. Thompson’s concerns about the data and evidence.
RCS and other medical graduates performance as practitioners should be addressed in the intern year.
I was in Dubbo and Broken Hill for the last two years of my medical degree and we were not taught the dermatology component of the curriculum due to lack of available teachers. I suffer to this day with gaps in my dermatology knowledge. That being said I’m currently working in a rural setting, but I also come from one, which I think is a bigger factor.
Thankyou for those observations.
We would just point out that in all the years before rural clinical schools, an inadequate number of doctors went rural. If RCSs are just working on those who already intended to go rural, there would be no major workforce effect. But to the contrary, RCSWA is boosting the trajectory of graduates.
It is astounding that the curricula for rural schools and urban schools are seen to be “virtually identical”. The fact is that, in all health professions, rural and urban practice are actually very different. Rural practitioners need a much broader skillset and scope of practice due to the relative lack of medical specialists and specialist clinics outside of our larger cities. Fortunately there is high level of positive collaboration and multidiciplinary support, especially for the few overworked local specialists. There is good evidence that a “rural pipeline” (sourcing and training students in their home region) is the best strategy to ensure a sustainable rural health workforce.