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Ruralising the undergraduate medical curriculum through consultation with key stake holders

R. Hays, D. Price, M. Jelbart and D. Saltman

The Australian Journal of Rural Health © Volume 4 Number 1, February 1996

Aust. J. Rural Health (1996) 4> 4347

Original Article

RURALISINGTHEUNDERGRADUATE MEDICALCURRICULUMTHROUGH CONSULTATIONWITHKEYSTAKE HOLDERS

1Faculty of Medicine, University of Queensland, St Lucia YQ

ueensland and ‘Faculty of Medicine, University of Sydney, Sydney, Austrqlia

ABSTRACT: This paper describes the approach taken at the University of Queensland to broaden

the scope of curriculum design to involve rural general practitioners, medical students and rural

health care consumers. A form of nominal group process in serial telephone teleconferences was

used, with a group of rural general practitioners, to develop and pilot curriculum content, learning

strategies and assessment methods. kIedica2 students assisted in the evaluation of the curriculum

and representatives of rural organisations were consulted about the value of hosting medical

students in rural communities. The three groups made significant contributions to the project. The

results will be trialed for the entire year 6 cohort (240 students) in 1995 and will form the basis of the planned rural practice term in the new graduate course.

KEY WORDS: medical, rural, undergraduate curriculum.

INTRODUCTION

The curricula of Australian medical schools are

influenced heavily by urban teaching hospital

medicine, because that is where all medical

schools are based and where most academic staff live and work. As a result: medical students learn

in an environment where expert help is always close at hand and most role models are sub-

specialists. General practice, the likely ultimate career of almost half of the student body: receives

Correspondence: R. Hays, North Queensland Clin- ical School, University of Queensland, PO Box 1805, Townsville, Qld 4810, Australia.

Accepted for publication May 1995.

surprisingly little curriculum time1 and, until recently, rural practice has received little or no

identifiable curriculum time.’ In response, the

Commonwealth Department of Human Services

and Health has recently funded a series of initia-

tives which should see the introduction of credi- ble rural undergraduate teaching.3

A compulsory rural general practice term in the final year of the present medical course was

introduced at the University of Queensland in 1992. Time constraints did not allow for in-depth

consultation with rural doctors during the early

development. The- term consisted of a loosely

structured 2 week placement with a rural doctor.

During this time students were expected to gain an appreciation of the nature of rural practice and

44 AUSTRALIAN JOURNAL OF. RURAL HEALTH

broad experience in a range of minor procedures.

There was little formal contact with academic

staff and assessment was based on a rating scale

completed by the preceptors and on completion

(by students) of a log book of consultations and

procedures observed or performed. Students

received financial support for travel costs from

Queensland Health.

Teleconference

J Teleconference

1

2

Student Attachment Although students have found the placements

to be highly effective learning experiences, an

evaluation of rural teaching found that almost half

the students and a majority of rural preceptors

reported some dissatisfaction with the overall

structure of the placements.4 There was a per-

ceived lack of guidance for both learners and

teachers and dissatisfaction with the use of a log

book as an assessment tool. This is a concern

because it may impact on recruitment to rural

careers as recent graduates rate the perceived

quality of teaching outside metropolitan areas as

a major influence on their decisions to enter rural practice training.5

Teleconference 3

+ Teleconference 4

J Final Documents

Reporting

FIGURE 1: Schematic diagram ofproject design.

One recommendation that resulted from this evaluation was the need for clearer guidelines to

be developed for learning experiences in rural

placements. This paper reports on a project that

formally sought the views of key stake holders

(students, rural preceptors and rural health care

consumers) in the further development of the undergraduate curriculum for rural practice. The

curriculum and assessment strategies were subse-

quently piloted and evaluated.

second group was comprised of the nine students

who were attached to the preceptors for the trial placements and the third group was comprised of

rural community representatives identified

through the Country Womens Association, the

United Graziers Association and the National Farmers Federation.

METHODS

The project design incorporated a series of con-

sultations with three groups of interested individ- uals. The first group included 11 rural general

practitioner (GP) preceptors who were nominated

by the Rural Doctors Association of Queensland.

Group size was constrained by the capacity of

teleconferencing to allow interaction. All were

experienced rural GPs and 9.of the 11 were expe-

rienced preceptors. Their participation required both active development of the curriculum and

trialing it during placements with students. The

The consultation process for the rural precep-

tors was a form of nominal group process via tele-

conference, as summarised in Fig. 1. A series of

teleconferences was held before and after stu- dents placements and during the period that the

modified curriculum was piloted. The earlier evaluation data and original course outline were

used to develop draft documents with improved

relevance to rural, as distinct from general, prac- tice. The new outlines for curriculum content and

process, including a revised logbook and assess-

ment form, were piloted in student placements. Views of participating students were sought

after the pilot through structured telephone inter-

views. Patient attitudes to the involvement of medical students in their health care were also

RURALISING MEDICAL CURRICULUhI: R. B. H-41-S ET AL. 45

TABLE 1: Guidelines for development of a rural

curriculum developed by rural GPpreceptors

The content should strongly emphasise aspects of

general practice that are specific for the rural

environment

A 2 week term is too short to cover a wide range of

medical experiences and objectives need to be

simple and minimal in number

The medical experiences a student may observe

during the term will vary greatly depending on the

number and type of conditions that present and

therefore the curriculum should not be too

prescriptive.

The preceptor should act’as a role model for the

student. The change of student attitude towards rural

practice is very important. The students need to

gain confidence and realise that a GP can do things

they thought only specialists should do. The

students should realise that being a GP is

intellectually challenging.

The importance and necessity of team work

amongst the health professionals should be

demonstrated.

It is essential that students learn basic procedural

skills.

sought through a questionnaire administered to every 10th patient seen by a student during 7 placements. The questionnaire was developed according to established guidelines6 and leaned

heavily on validated patient satisfaction question- naires.7 The final phase involved a questionnaire

survey of rural community advocates from com-

munities where students were placed during 1994. The questionnaire sought their views on the

value and acceptability of placing medical stu-

dents in their communities and also sought their

suggestions for making the placements more enjoyable for students.

RESULTS

Curriculum development

Two essential learning strategies for all clinical

placements were identified. The first is that the

student and preceptor should negotiate and plan

their approach at the beginning of the term,

preferably using the assessment form as a guide.

The second is that the student should act in the

role of a ‘junior intern” during the term, taking

limited responsibility for the care of at least one

patient who requires on-going management dur-

ing the placement. The rural GP group developed guidelines for

the development of a rural curriculum, listed in

Table 1. The written course objectives were

regarded by the rural preceptors and students as

being more clearly defined and more achievable

than those in the original curriculum. This stu-

dent/preceptor negotiation was regarded highly

by students and preceptors, as it improved their

awareness of what could be achieved during the placement, given that it was not possible to pre-

scribe an achievable list of ‘core’ content. The

defined role of the student within a hospital situa-

tion gave the staff and patients a clear expecta-

tion of the students involvement.

Assessment

The development of the assessment process was

guided by two principles. The first was that the

assessment should be matched to the stated aims

and objectives of the rural placement term and

the second is that the marking format is less important than the learning process that has been

encouraged by the assessment process. The original assessment process proved not to

be discriminating, in that most students in the

1993 cohort were given a high (6 or 7) rating on the 7 point Likert scales in response to a number

of statements (very poor to outstanding). An alter-

native interpretation is that the students were uniformly of a high standard. In either case, 7

point scales were regarded as unnecessary.

-4 combination of yes/no and 1 (poor perfor-

mance) to 5 (excellent performance) scales was

adopted and all questions allowed for open com-

ments. A list of 10 of the most commonly per-

formed procedures (during 1993) w-as included on

the form to act as a guide to the procedures that a

46 AUSTRALIANJOURNALOFRURALHEALTH

student should perform. Space was also provided

for the performance of other procedures to be

recorded. Separate ratings were requested for stu-

dent confidence and competence in the perfor-

mance of essential procedural skills, because of

the variation in the quantity and type of proce-

dures likely to be encountered during a short

time. Comment on ability was regarded as more

important than quantity. Detailed instructions on

how to use the assessment form were developed

and will be sent to preceptors.

COMMUNITY CONSULTATION

Sixty-nine of the 70 patient questionnaires were

returned from the seven practices that had agreed

to distribute them. Patients gave almost invari-

ably positive responses to a series of statements

concerning their interactions with students (e.g.

‘The student was relaxed/seemed competent/

treated me with respect’). Only one patient (a

male) declined to have a medical student (female)

present at the consultation due to the personal

nature of the consultation.

Rural community responses were received

from the Country Womens Association (5

responses from 6 questionnaires), the United Gra-

ziers Association (2 responses from 10 question-

naires) and the National Farmers Federation (1

response from the State Chairperson, based on

consultations with local representatives). The

variation in response rates between organisations

could not be explained. Two responders were not

aware that a doctor in their community had

hosted a medical student recently, although all

but one thought that students needed some train-

ing in rural medicine and all felt that students

should learn about rural life and, perhaps, return.

All respondents believed that rural placements

were an important tool in the recruitment of rural

doctors and suggested that the medical school

could harness better local resources by contacting

directly representatives of rural organisations in

addition to the local doctor.

DISCUSSION

This project has resulted in the development of a

curriculum document that more clearly outlines

the objectives of the term, the learning strategies

to be used and the assessment processes to be

followed. These developments are based on data

from an evaluation of the 1993 placements, from

the experiences of committed rural GP preceptors

and students who were subjected to the new cur-

riculum and from the observations of the recipi-

ents of rural medical care. This deliberate involvement of non-academic staff in curriculum

design addresses the previously reported isolation

of rural stake holders from such processes.8 Preceptor concerns about the lack of a clear

core curriculum content for rural practice terms

are understandable, but these concerns are diffr-

cult to address over one term because rural prac- tice is such a diverse discipline.9 These concerns

will be addressed in the further development of a

longer rural practice term. The main outcome of

the project has been a refined assessment process

that acts primarily as a stimulus to learning. The

assessment form is to be used as a framework

around which the learner and preceptor can nego- tiate mutually agreed and achievable learning

goals. It also will allow them to review progress at the midpoint of the attachment, prior to making the final assessment.

The broader role of rural patients in teaching

and assessment remains unclear. Although med-

ical students should be aware of the importance

of meeting patients needs, the satisfaction ques-

tionnaire used in this project proved to be non-

discriminating. In hindsight, the questionnaire

was probably too long and the wording could have

been improved. This instrument will be devel-

oped further and trialed in a subsequent course evaluation. Alternatively, the offer by rural com-

munity representatives of practical assistance to

welcome students into rural communities will be

taken up within the North Queensland clinical

school, as this can only improve the contact

between students and local residents in other

than professional circumstances.

RURALISING MEDICAL CLrRRICULUM: R. B. HAYS ET AL. 47

In conclusion, key stake holders such as stu-

dents, rural doctors and rural people have an

important role to play in the development of a

rural practice curriculum. Consultation with these

groups will continue throughout the ongoing

process of curriculum and assessment design

? appropriate for the new graduate medical course.

The documentation and assessment process will

be trialed with the entire year 6 cohort during 1995. A copy of the final version of the assess-

ment form is available from the authors. ‘_,

ACKNOWLEDGEMENTS

The authors wish to acknowledge the financial

support of the Rural Health Support Education and Training Program of the Department of

Human Services and Health.

REFERENCES

1 Kamien M. Academic general practice in Aus-

tralian medical schools. Sydney: Australian Asso- ciation for Academic General Practice, 1990.

2 Kamien M, Buttheld I. Barriers to recruitment

Medical Journal of Australia. Part 1. Undergradu-

ate education. :Vededical Journal of Australia 1990;

153:107-112.

Department of Human Services and Health.

Reforming undergraduate medical education for

rural practice. Final Report of the Rural Under-

graduate Steering Committee. Canberra: AGPS,

1994.

Price D, Miflin B. Final report to the Rural Health

Support, Education and Training Program on the

‘Teach the teachers’ Project. Canberra: Department

of Human Services and Health, 1994.

Piterman L & Silagy C. Hospital interns’ and resi-

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Victoria. Medical Journal of Australia 1991; 155:

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Streiner D, Norman G. Health Measurement

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Oxford: Oxford University Press, 1992.

Wise A. Hays RB, Craig M et al. Training for rural

general practice, Medical Journal of Australia

1994;161:314-318.

Hays RB, Craig M, Wise A et al. A sampling

framework for rural general practice. Australian

Journal of Public Health 1994; 18: 273-276.