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| Journal of the New Zealand Medical Association,
24-September-2010, Vol 123 No 1323
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Development of the Rural Immersion Programme for
5th-year medical students at the University of Otago Patrick Farry, John Adams, Lucie Walters, Paul Worley, Susan
Dovey
By the turn of the 21st
Century, specialist disciplinary-based styles of medical education that had
developed in response to the Flexner Report of
19101 were intolerably stretched. This was
largely due to much shorter patient stays in highly technical and expensive
tertiary hospitals limiting students’ clinical exposure to patients.
Increasing sub-specialisation in an educational environment
aiming to produce generalist graduates also skewed students’ understanding
of the healthcare needs of their communities. Community expectations of a
patient-centred health system made explicit in
policy2 could be taught in the abstract but
were not well modelled to students.
Community-based education is increasingly being used
internationally to correct the mismatch between
20th Century educational models and the needs
of 21st Century
communities.3
A further consideration is that there is a shortage of
medical doctors in many countries.4–6
Currently, New Zealand is still reliant on overseas medical graduates for
providing healthcare, especially in rural
settings.7,8
Like other countries, recent health workforce policy has
changed to allow increased medical school
intakes.9 Although this will address the
shortage of New Zealand doctors, generally, further initiatives were required to
address the shortage of New Zealand graduates choosing rural practice. These
initiatives have included the Rural Origin Medical Preferential Entry (ROMPE)
scheme and the development of extended exposure to rural medicine during
training.
In 2001, the Dunedin School of Medicine established a 7-week
rotation in Rural Health. All Dunedin 5th-year
medical students were attached to a variety of rural medical practitioners, in
both general practice and rural hospitals. This programme built a cadre of
capable and enthusiastic rural medical teachers and became one of the preferred
5th-year attachments, being described by
students as one of the best learning experiences during medical
training.10
The South Australian Flinders Medical School’s
Parallel Rural Community Curriculum11 had
demonstrated effective academic outcomes and sustainability over 10
years.12,13 The success of the Rural Rotation
programme, combined with the reported success of the Flinders programme led to
the initiation of an extended rural medical curriculum by the University of
Otago Faculty of Medicine, now known as the Rural Medical Immersion Programme
(RMIP).
The model of a single faculty-wide programme is new to the
University of Otago’s Faculty of Medicine. Historically, although overall
objectives have been aligned, delivery of the curriculum has been managed
differently in each of the university’s four constituent medical
schools—the Otago School of Medical Sciences (basic sciences), and three
Advanced Learning in Medicine (ALM) schools for the advanced phase of clinical
learning.
The RMIP now operates across the three ALM schools in
Dunedin, Christchurch and Wellington, drawing similar numbers of students from
each school. There have been both challenges and advantages in this departure
from previous educational structures for the small RMIP subset of all Otago
University 5th-year medical students. The Rural
Rotation programme still operates for all other Dunedin School of Medicine
5th year students.
The Rural Medical Immersion Programme (RMIP)The overall goal of the RMIP was to deliver a nationally
innovative, patient-centred medical curriculum located in rural New Zealand
communities, where opportunities for authentic learning would be maximised. The
programme had to be educationally sound and deliver parallel learning
opportunities over a one-year long immersion experience.
The RMIP aimed to:
Achieving these aims
was expected to have several long-term benefits to both medical education and
New Zealand health care services. These benefits were expected to include:
enhanced links between rural general practice, rural hospitals and urban
tertiary teaching hospitals; enhanced development of distance education
technologies in undergraduate medical education; realisation of rural medical
career opportunities; and encourage both recruitment and retention of rural
doctors.
The 1st yearA pilot year RMIP was carried out in 2007 with funding from
the Minister of Health’s discretionary budget. Six students from the
Dunedin and Christchurch Schools of Medicine studied their
5th-year curriculum at two rural teaching
centres in the South Island, Westland (Greymouth and South Westland) and
Southland (Queenstown). There were three students at each site. They completed
their first 7-week attachment in Dunedin to study public health and have an
introduction to the RMIP before moving to their rural teaching centres.
At the end of the first pilot year the RMIP was evaluated by
the two authors who had initiated a similar programme in Australia (PW and LW).
They reported that “the RMIP has been an outstanding success ... the
commitment of academic staff and clinicians and the enthusiasm and flexibility
of the volunteer students have ensured a very positive outcome for all
involved”.14
The 2nd yearIn 2008 funding for the programme was provided by the
University of Otago Faculty of Medicine. There were 12 students—4 from
each of the 3 Otago University clinical schools. Two additional teaching centres
were established at Tararua (Dannevirke/Pahiatua) in the North Island, and
Clutha (Balclutha/Lawrence/Milton) in the South. Three students studied at each
teaching centre for the entire academic year, apart from a 1-week residential
three times during the year—once at each of the clinical schools in
Dunedin, Christchurch, and Wellington. Residential teaching sessions involved
all 12 students.
The 3rd yearIn 2009 the programme became fully operational with 20
students. As in previous years, they were drawn equally from all three clinical
schools, but with flexibility to draw one or two additional students from any
school to meet demand. Two further teaching centres were established in
Marlborough (Blenheim/Havelock/Nelson) and the Wairarapa
(Masterton/Carterton/Martinborough/Featherston). Residential teaching was as in
the second year.
Teaching centresEach teaching centre has a 0.3 full-time equivalent (FTE)
Regional Coordinator and a team of teachers including rural general
practitioners, rural hospital doctors, paramedics, local and visiting medical
specialists, nurses, midwives, physiotherapists, pharmacists, the Mental Health
team, Māori health workers and the Medical Officer of Health.
Regional Coordinators are employed by the Faculty of
Medicine, teaching by District Health Board (DHB) employees is supported by a
“clinical access” payment to DHBs, and other teachers who are not
DHB employees are paid on a sessional basis. In 2010 a professional development
coordinator was employed to support RMIP teachers.
By far the majority of teaching and learning happens
one-with-one while providing individual patient care. Paediatrics, gynaecology
and complicated obstetrics, orthopaedics, emergency medicine, public health,
clinical pharmacology, Māori Health, bioethics, pathology and microbiology
are taught by either video- or audio-conference or face-to-face at residential
workshops.
Subjects covered at residentials often reflect the teaching
strengths at the different clinical schools and we try to achieve continuity
from one residential to the next, with a focus on the students’
self-perceived learning needs. These workshops also allow for important contact
between RMIP students and their urban peers. Pastoral care unrelated to the
teaching and learning programme has been undertaken by video link by a separate
GP based in Dunedin.
The students are provided with subsidised accommodation,
travel costs, and a laptop computer with cellular wireless internet access to
library and medical databases. Their computers have an electronic logbook in
which they record patient conditions that must be seen and skills that must be
acquired during the 5th year. Case reports are
recorded on a web-based patient-centred case reporter which allows marking at a
distance by both a specialist in the topic and an external rural GP academic.
There are libraries of textbooks and DVDs in the rural bases, including recorded
tutorials from the base medical schools.
During the first 3 years we have developed high bandwidth
video-conferencing at all teaching centres with assistance from the New Zealand
Mobile Surgical Project.15 The three or four
students at each teaching centre are encouraged to form a study group.
Collaborative learning is facilitated by workshops on individual personality
types and preferred learning styles, which help students to understand each
others’ strengths and differences.
The learning objectives for RMIP students are the same as
for students studying the urban-based curriculum of topic-based specialty
learning over seven week attachments.16 The
RMIP curriculum uses real-life, experiential “parallel”
learning.11 Parallel learning means that
students study core topics in parallel throughout the course of each day: they
do not concentrate on a single discipline for an extended time, as in
traditional teaching hospital runs.
In parallel learning, a student may attend a patient with
chest pain in the morning, a motor vehicle accident in the afternoon, and the
birth of a baby in the evening. Students are expected to follow their patients
through different phases of management. A patient seen in a rural general
practice surgery may be tracked through to the rural or provincial hospital
where the student will perform the admission. They also accompany patients who
are transferred to tertiary base hospitals.
One-with-one teaching and learning methods are considered by
the students to be a major educational strength of the programme. In rural
general practice settings, students initially observe consultations between
patient and teacher and then teachers observe students consulting with patients.
When both teacher and student feel confident, students see patients alone and
present patients’ problems to teachers. In rural hospitals, students work
alongside hospital doctors and nurses, admitting and clerking patients, writing
referral letters to tertiary centres, and providing patient care.
With midwives, students perform antenatal and postnatal
checks, attend births and participate in delivering babies. They may also travel
with parents to the base hospital if tertiary obstetric care is required. In all
teaching and learning situations the students report feeling very much part of
the therapeutic team and they feel that their opinion on patient management is
valued by their preceptors (personal communication from student groups).
AssessmentsThere are four internal RMIP assessments throughout the
year. Each assessment includes teachers’ reports (under the headings:
knowledge and skills, clinical competence, and professional relationships), 50
multiple choice questions, 6 Objective Structured Clinical Examination (OSCE)
stations using locally-trained simulated patients, and a portfolio of core case
reports.
Each assessment also includes patient referral and discharge
letters written by the students, after-hours on-call logs, video-recorded
consultations with patients and video-recorded physical examinations on each
other. These results, along with progress noted on the electronic logbook, are
discussed with the programme director as soon as possible after each assessment.
On one occasion each year, patient presentations are made by
the students at each teaching centre. The presentations are beamed by video link
to all Otago University 3rd year medical
students in the form of a medical forum, by students, for students.
The 3rd year students
complete evaluations of the presentations and these also contribute to the RMIP
students’ overall assessment. There are also assignments in public health
(including critical appraisal of research), paediatric longitudinal and chronic
care case reports, and Māori health.
RMIP students sit the same final examination as urban-based
students at the three ALM schools. This examination includes all the clinical
subjects of the 4th and
5th years—general medicine, general
surgery, anaesthetics and emergency care, women’s and children’s
health, musculo-skeletal medicine, primary care and rural health, psychiatry,
public health, bioethics, Māori health, pathology and clinical
pharmacology.
DiscussionThe RMIP is an important innovation in medical education in
New Zealand. The 3 years of RMIP experience that we present in this paper have
shown that parallel community-based training is not only possible in New
Zealand, but also that it delivers an educational experience that ongoing
monitoring shows at least equates to traditional teaching models.
Continuing programme evaluation is planned to closely
monitor RMIP outputs, including (ultimately) whether it has contributed to
solutions to medical workforce problems currently encountered in rural
communities.
The main strength of the RMIP is that it is a model of
medical education for the future, not the past. It explicitly applies the values
expressed in current government
policy17—patient-centredness, continuity
of care, and community responsiveness. It is also educationally efficient in
that it models medical education on the medical experiences of people, with most
healthcare needs being experienced and met outside
hospitals.18
The main weaknesses of the RMIP model of medical education
are its cost (it is more expensive than the traditional hospital-based model)
and capacity constraints in rural communities.
RMIP teaching is authentic because it is based in the real
world and undertaken by the whole multi-professional team providing healthcare
across all settings. We expect that this programme may be a precursor of future
developments that will inevitably unfold over the coming decades.
The next developments are almost certain to be extension
into other clinical years and into urban community-based teaching. A potential
future challenge is to deliver such a programme to a larger number of students
over their entire medical degree course. Australia and Canada have established
rural medical schools to do this.19
Integration with the education of other health professionals
is also along this timeline. Many attempts at inter-professional teaching and
learning have in the past had only very limited
success.20 The team approach to clinical
patient management is made explicit in the RMIP and this suggests very strongly
that inter-professional teaching and learning can be successful in this
environment.
The purpose of New Zealand’s medical schools is first
to train doctors to meet our own country’s needs. We have fallen well
short of achieving this goal in the past, especially for our rural
communities.7 Extended rural clerkships,
combined with preferential entry to medical school of students from a rural
background have been recognised as effective ways of improving the numbers of
doctors going into rural practice and are now
adopted.21 We do not yet know if the RMIP (and
other similar programmes) is able to additionally improve the doctor shortage in
rural areas.
Alternatives to the evolution of medical education in the
ways we predict are that it stays as it is now for most New Zealand medical
students, who gain the bulk of their clinical experiences in the settings where
least patients receive health care,18 or it
moves backwards even further into the lecture theatre dominated teaching models.
Both these alternatives are associated with less financial
burden to universities and the community, but are also less able to deliver the
medical graduates our communities need.
Competing interests: None.
Author information: Patrick Farry,
Director, Rural Medical Immersion Programme, Otago University Faculty of
Medicine, Dunedin, New Zealand; John Adams, Dean, Dunedin School of Medicine,
University of Otago, Dunedin, New Zealand; Lucie Walters, Co-Director, Parallel
Rural Community Curriculum, Flinders University, Mt Gambier, Australia; Paul
Worley, Dean, School of Medicine, Flinders University, Adelaide, Australia;
Susan Dovey, Associate Professor, Department of General Practice and Rural
Health, Dunedin School of Medicine, Dunedin, New Zealand
Acknowledgements: We gratefully acknowledge
the contribution of Ms Michele Wilkie to the development of the RMIP and for
providing background material for this paper. We also acknowledge the teachers
and students who have worked in and for the RMIP with great dedication, and Pete
Hodgson (the then Minister of Health) who provided initial funding for the
programme.
In discussion with the other authors, the first
author—Dr (Pat)rick Farry—completed the draft of this paper before
his death on 9 October 2009. The co-authors have made revisions to the first
author’s final draft, reflecting the awareness and respect we have for his
invaluable insights into medical education and his contributions to the
development of rural medicine in New Zealand.
Correspondence: Associate Professor Susan
Dovey, Department of General Practice and Rural Health, Dunedin School of
Medicine, PO Box 913, Dunedin, New Zealand. Fax: +64 (0)3 4797431; email: susan.dovey@otago.ac.nz
References:
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