Preparing for practice with longitudinal integrated placements

Dear Sir

We would like to thank the Cardiff University Surgical Students (Thompson et al. 2014) for drawing our attention to an international comparison of the student experience in shorter 5–8 weeks clinical placements in Wales, and the six months to one-year longitudinal clinical placements in New South Wales (Daly 2013a). We note the students’ endorsement of the many positive aspects of rural placements relating to Preparation for Practice such as quality of supervision, student-to-teacher ratios and diversity in patient population.

In an earlier paper (Roberts et al. 2012) we explored rural extended placements in the context of career intentions of students. We also identified similar barriers to the Cardiff students, such as geographical isolation, family and relationship needs and limited opportunity for sub specialist practice.

We feel that many of these issues can be overcome by medical schools investigating the opportunities provided by longitudinal placements, known as longitudinal integrated clerkships (LICs) in the US (Thistlethwaite et al. 2013). There is probably a national imperative as well to provide the supporting infrastructure that underpins the success of these placements in the long term. Over two decades a key policy response to rural workforce shortages in Australia has been substantial investment in educational initiatives, such as Rural Clinical Schools and University Departments of Rural Health (UDRH). UDRH provides quality rural placements for students from all health disciplines while increasing capacity to take students. Such educational programs are supported by coordination, investments in rural-based infrastructure and support systems (Lyle 2006).

There is an important difference between discipline-based blocks of 5–8 weeks length and the Broken Hill experience, which is an integrated community-engaged education program that runs for a 6–12-month period. It is these differences that further enhance the positive benefits and mitigate the barriers.

Firstly, in an integrated longitudinal placement, three 8-week blocks in surgery, medicine and community are run as one long integrated 24-week block. As a result of this longitudinal extended placement, there were opportunities for continuity of care (Daly 2013a) and many students have identified kinship and belonging in the wider community (Daly 2013b). Secondly, we have noted just how important the extended community of medical and healthcare students who live in Broken Hill was, to overcoming any sense of isolation, not just socially but in terms of learning as well (Daly 2013b).

A unique aspect of the Broken Hill experience was a 4-week rural and remote placement in an Indigenous community, where students get additional opportunities for hands-on experience and opportunities to develop further confidence and resilience through acting-up opportunities. Such experiences are only likely to Cardiff students through international electives.

For those contemplating a career in surgery, undertaking longitudinal rural placements may better benefit those on generalist pathways (Roberts 2012). However, we would like to think that city-based subspecialists had experienced rural surgery to inform future practice.