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Commentary: What is the evidence for clinical placements in underserved
areas? (Medical Education, 2013: 47(10), 958-960)
David Perkins, Michele Daly,
Broken Hill University Department of Rural Health, Sydney Medical School,
University of Sydney
In this issue of Medical Education, Crampton et al (2013) present an interesting
review looking at the strengths and weaknesses for medical students and
supervisors of community placements in under-served areas1. This complements
a recent review of outcome measures for students, clinicians and community
stakeholders in longitudinal clinical placements2.
Undergraduate clinical education has traditionally been provided in block
specialist placements within teaching hospitals located in large metropolitan
centres. Students have been exposed to a range of the more serious conditions
requiring hospitalization and often supervised by medical specialists or doctors
undergoing advanced training. In recent years the range of placements offered
to medical students has expanded as a strategy to increase recruitment of
doctors to underserved, often but not exclusively, rural areas3 and recently in
countries such as Australia to increase the aggregate number of placements as a
response to a rapid increase in the number of medical students entering
Universities4.
The provision of placements in non-traditional settings has required new
investment in supporting infrastructure such as Rural Clinical Schools,
University Departments of Rural Health, new Rural or Regional Medical Schools,
or outposts of metropolitan medical schools. In most cases the clinical
placements have been located in general medical practices5 although some
include time spent in emergency departments or other settings(p355)6. Such
settings differ from those of traditional placements in scale and in the mix of
patients since those with rare or complex conditions will often be transported
out of communities with few medical specialist staff.
The providers of such placements have been particularly eager to demonstrate
that these placements are not inferior to the traditional model7 and policy
makers are keen to know whether they are likely to contribute to an improved
workforce supply of general practitioners in underserved areas8.
There are a number of difficulties in reviewing these new forms of clinical
experience. Each underserved placement program is different and must adapt to
the resources and challenges of its host community that are far more
heterogeneous than their teaching hospital alternatives. Underserved
communities are by definition low in skills which are relatively abundant in
teaching hospitals and often face problems in the recruitment and retention of
(general) medical staff.
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The findings of the review are grouped into evidence about student performance,
career pathways, student and finally supervisor experiences1. In short, students
appear to do no worse than their metropolitan peers but they are a self-selected
group and may differ in important ways. They appear to have increased clinical
proficiency but less “book knowledge”. Their personal and professional
development may be advanced due to clinical exposure and the beneficial effects
of a dose of social dislocation.
Evidence of a beneficial effect on career pathways shows an impact on general
practitioner career choice and a lesser impact on choice of a rural practice
location.
It should be noted that few systems enable undergraduate and advanced medical
training to take place in rural locations and so there may be an interval of several
years between placement, advanced training and taking up a position as a GP.
Student benefits are drawn from qualitative interviews with medical students
and may benefit from additional interviews as they undertake further training
and see their experience in a broader context. On the down side some students
point to the limitations of their placements in terms of the range of conditions
seen and limitations of the support and supervisory arrangements in what are
after all underserved areas9. The positive factors include opportunities to learn
within a generalist care setting in which patients have not been sorted in
advance and to see patients on several occasions and sometimes in multiple
settings in community, medical practice and hospital10.
Supervisors are drawn from general medical practitioners in underserved areas
who report personal and professional rewards from participation and, one must
assume, hope that their participation will add to the resident workforce and
relieve pressure of work in the future. They report some anxiety about how
their teaching relates to the medical curriculum and this may reflect medical
student concerns about forthcoming barrier exams. Poor alignment between
course goals and curriculum development may weaken placements in underserved communities. In addition health services may be under resourced and
supervisors may not have the time or skills to teach effectively. The “need for
faculty development” to enable quality supervision by willing, well trained
supervisors must be met if underserved communities and students are to benefit
from these placements. Training, development and support of supervisors is
needed as well as motivated students.
This paper reviews a small but rapidly growing and recent body of literature. A
number of key questions remain for further analysis or new research.
It is particularly important to examine the design and structure of placements in
different, underserved communities. To combine two and 52 week placements
as reported in the review helps summarise the evidence but may hide the active
ingredients of placements and inhibit their design and development. Likewise
the contexts of placements differ in amenity, isolation, population needs and
other socio-demographic factors9 suggesting that well chosen and carefully
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conducted case studies might shed light on factors obscured in aggregate
reviews.
Key issues such as the translation of intention to practice rurally into rural
career choices may be influenced by early rural experience and rural origin11 but
may also be affected by factors such as the availability of internship positions
and broader opportunities for career progression in disadvantaged locations.
The evidence summarized in this review raises questions about the objective of a
medical degree. If the aim is to teach general medicine in preparation for
subsequent specialist training these placements have much to offer. If the
objective, formal or informal, is to create a workforce of specialists, subspecialists, or medical researchers the traditional model of block placements
with early exposure to hospital medicine may be the best option. Whether
medical educators or students through their elective choices should make this
choice is a matter for debate.
An under-served community placement can benefit students, supervisors and
the broader community by enabling mutually beneficial relationships and an
additional pair of hands within a service learning model 12. There are good
arguments for all medical students to have some experience of working in
underserved areas because wherever they live and work in future they will treat
patients from such communities and will benefit from their formative
experiences.
It remains to be seen if such programs will contribute to a more equitable
medical workforce distribution and better access for disadvantaged
communities. More research is needed using ethnographic and case study
methods to understand how, why and when these models work and how
they can be better designed to benefit disadvantaged communities.
1.
Crampton P, McLachlan J, Illing J. A systematic literature review of
undergraduate clinical placements in under served areas. Med Educ. 2013.
2.
Walters L, Greenhill J, Richards J, Ward H, Campbell N, Ash J, et al.
Outcomes of longitudinal integrated clinical placements for students, clinicians
and society. Med Educ. [Article]. 2012 Nov;46(11):1028-41.
3.
Ranmuthugala G, Humphreys J, Solarsh B, Walters L, Worley P, Wakerman
J, et al. Where is the evidence that rural exposure increases uptake of rural
medical practice? Aust J Rural Health. 2007;15(5):285-8.
4.
Larsen K, Perkins D. Training doctors in general practices: A review of the
literature. Aust J Rural Health. 2006;14(5):173-7.
5.
Worley P, Silagy C, Prideaux D, Newble D, Jones A. The parallel rural
community curriculum: an integrated clinical curriculum based in rural general
practice. Med Educ. 2000;34:558-65.
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6.
Daly M, Roberts C, Kumar K, Perkins D. Longitudinal integrated rural
placements: a social learning systems perspective. Med Educ. 2013;47(4):35261.
7.
Worley P, Esterman A, Prideaux D. Cohort study of examination
performance of undergraduate medical students learning in community settings.
BMJ. 2004;328:207-9.
8.
Tavernier L, Connor P, Gates D, Wan J. Does exposure to medically
underserved areas during training influence eventual choice of practice location?
Med Educ. 2003;37:299-304.
9.
Roberts C, Daly M, Kumar K, Perkins D, Richards D, Garne D. A
longitudinal integrated placement and medical students’ intentions to practise
rurally. Med Educ. 2012;46(2):179-91.
10.
Hauer KE, Hirsh D, Ma I, Hansen L, Ogur B, Poncelet AN, et al. The role of
role: learning in longitudinal integrated and traditional block clerkships. Med
Educ. 2012;46(7):698-710.
11.
Walker J, DeWitt D, Pallant J, Cunningham C. Rural origin plus a rural
clinical school placement is a significant predictor of medical students’ intentions
to practice rurally: a multi-university study. Rural Remote Health [serial on the
Internet]. 2012; 12(1908 (online)): Available from: http://www.rrh.org.au
12.
Prideaux D, Worley P, Bligh J. Symbiosis: a new model for clinical
education. The Clinical Teacher. 2007;4(4):209-12.
Pre-Print of Commentary "What is the evidence for clinical placements in underserved areas?" Medical Education. 2013,
Vol 47, Issue 10, 958-960