Abstract
Introduction: In their first clinical year 25% of Western Australia's medical students undertake a clinical longitudinal integrated clerkship in rural and remote Western Australia. Annual evaluations are undertaken.
Method: All students, academic and administrative staff employed by the university were interviewed. Qualitative analysis of interview data was taken, fed back to the coordinators and modifications for the next annual cycle were then discussed and decided upon.
Results: The predominant themes were elation at the excellence of much of their rural experience and frustration at some individual sites because of issues which were not being resolved. Students were overwhelmingly positive in their interpretation of problems seeing them as systems issue to be improved. Staff at some sites, however, had a strong tendency to blame the student and not respond to the actual problem. All students passed their end of year examinations.
Discussion: Most academic evaluation of courses has focussed on comparative academic results with less, if any, attention paid to the qualitative experience of students. Not all clinical clerkship experiences are positive and it is useful to identify what works and what does not work in any medical school. Staff defensiveness is a well-recognised response to challenges and an evaluation system which encourages staff development is an essential component to any School's ongoing improvement.
Introduction
The Rural Clinical School of Western Australia (RCS WA) has been operating since 2003. As part of the process we have carried out a qualitative evaluation. The title of our report of the evaluation of 2003 indicated a mixed response and a high level of student anxiety during the first year of the School's operation (Denz-Penhey et al. Citation2004). Students were more anxious where there were smaller numbers at the site (3–6) and less at the largest site where there were nine of them. They were anxious about the curriculum content, curriculum delivery and assessment particularly on the question of sufficient specialist clinical experience for the end of year examinations. Their high level of commitment tended to lead to burnout because they did not know how to set personal boundaries. Here we report the findings and reflections from the 2007 evaluation.
Background
In their first clinical year 25% of Western Australia's (WA's) medical students undertake a clinical longitudinal integrated clerkship in rural and remote WA. Students from two universities enter this year-long programme which we have described as clinical learning embedded in rural communities (CLERC). This programme delivers a uniquely rural brand of clinical education, which is integrated in approach, case-based in teaching method and firmly located in the generalist tradition of rural medicine. Many Rural Clinical Schools teach an urban syllabus as a ‘‘parallel rural curriculum’’, but the CLERC programme teaches its own curriculum under its own recognised unit. Whilst the CLERC comprehensive unit contains the syllabus for both University of Western Australia and University of Notre Dame Australia, it is not limited to this curriculum. Instead, the CLERC core clinical presentations are indexed to rural caseloads in both primary (GP and Aboriginal Medical Service) and secondary care (local or regional hospital). Similarly, the content of the CLERC curriculum reflects the expanded rural scope of practice in relation to ethics, public health and Aboriginal health, which are experienced, taught and assessed as part of the course.
The RCS WA made no distinction between the students of the two universities and sent the students out to 10 sites in groups of 3–10 scattered around the state. The students were 250–2500 km away from their tertiary training site in communities varying in size from about 4000 to 50,000. Some were sizable regional communities, some with a strong mining workforce and some remote Indigenous communities. In many sites, conditions can be very challenging with months at a time spent with temperatures of over 35°C during the day; some places with very high humidity, and most places with high dust content. Single students and those without partners are in shared accommodation. Those with partners and children find their own accommodation.
Method
Design
The RCS WA has undertaken a continuous thorough evaluation of the curriculum, curriculum delivery and assessment processes since its first full time year in 2003 (Denz-Penhey et al. Citation2004). Qualitative analysis of interview data was taken, fed back to the coordinators and modifications for the next annual cycle were then discussed and decided upon. This cycle has been repeated each year for 5 years. In 2007, 102 student and staff interviews were undertaken, transcribed and analysed (60 out of 62 students, 27 out of 29 academic staff, 15 administrative staff).
Ethics approval
Ethics approval was sought from the University Ethics Committee but was deemed not required as this is part of ongoing evaluation of standard university courses.
Participants
All students, academic and administrative staff employed by the university were able to participate in this study. In practice, this meant that all students at their local site on the day were interviewed and almost all staff employed 0.5 full time equivalent or greater were interviewed annually.
Data collection
Transcribed interviews averaged about three pages, single-spaced for each person for both students and academic staff and about half a page for administrative staff. All interviews were undertaken by the first author, were taped and transcribed verbatim. Open-ended semi-structured questions were used and participants were given as little or as much time as they wished to speak. Interview times varied in length from 15 min to 3 h in several cases. In the few extended interviews, only those aspects which directly addressed systemic or School issues were transcribed. The average length of interview was about 35–40 min for students and academic staff and 5–15 min for administrative staff. Questions each year related to curriculum content, curriculum delivery, site specific issues and personal concerns. Additional data was sought from staff by email and individual conversation after the sharing of the analysis annually and this was added for ongoing analysis.
Data analysis
Data was analysed using the constant comparative method of qualitative methods. Incidents and anecdotes were compared with one another for similarities, variations and differences. Issues and concerns were compared with other issues and concerns, amongst students, amongst staff, between students and staff, between sites, between years, then, issues were compared with developing concepts, concepts compared with other concepts and relationship to relationship. Each year the framework was developed and modified against the findings from the previous years and changes made for the following year's curriculum delivery.
Rigour
Rigour was ensured by linking a range of validity and reliability checks suitable to qualitative methods (Whittemore et al. Citation2001). Additional sampling questions were added when unexpected findings arose so that disconfirming data could be sought, or the new insights clarified. Findings were shared on an ongoing basis with staff and their feedback added to the analysis process. Confirmation of the fit between data and categories was gained through discussion with senior management, the staff feedback sessions and through the data from following year's interviews and emails; through frequent and extensive memos, and the development of an audit trail of the conceptual development of the theoretical framework. While feedback was accepted from the academic staff it was the data that drove the naming process. There were staff who did not accept some of these findings particularly where it related to their own sites, even as data was presented to support the constructs.
Results
The predominant themes of the 2007 evaluation were satisfaction at the excellence of much of their rural experience expressed by students in every site. Even where students acknowledged problems and limitations they also expressed satisfaction of the overall teaching and learning opportunities.
However, although there were several sites where almost everything was positive, there was also frustration at some sites because of issues which were not being resolved.
Sites with greatest satisfaction reports
Those sites where both students and staff reported greatest satisfaction were those where the coordinators had integrated past feedback about what worked into their structure of the teaching and learning week. This included
A strong clinical focus, averaging seven half days seeing patients, with one of these sessions being during a busy evening or weekend in the Emergency Department.
Academic learning (such as the various formal types of tutorials) averaging three half days where the teaching was offered in a structured focussed way covering only one or two of the disciplines each week.
“It's been great. I don't know what it's like in the city, but I assume it's similar to what we did last year. I like what we are doing here a lot more, I feel more comfortable, more supported, more encouraged. People just know who you are and what you are there for and I don't know if it's because I'm happier about being here or if it is different but the patients are more receptive to you being there.”
High expectations versus the reality of their site
The overwhelming student response to the question of why they wanted to come to the RCS WA was that they expected better teaching and learning than they would be able to achieve in the city. They also expected to do at least as well as their peers in the city in the end of year examinations. They expected the rural experience to be “better” in the sense of more exciting, more hands on, and more opportunity to work closely with their teachers. Overall students were happy with the curriculum, the curriculum documents and assessment across all of the sites.
“We have good resources, it's all online and most of it is in hard copy as well. If we want it all printed out we can do that too, on the RCS printers.”
“Assessment, no problems. If anything, it is better because the teachers know you and what you can do and so it is more accurate to how you really are.”
“Half the books that are supposed to be in the library aren't in the library, over the years they have been lent out … visiting students come and sign out the books and we have no idea who they were. We need someone to chase them up.”
“I have issues and we [students] have issues. They [staff] struggle with our group as much as we struggle with them.”
“That's another bugbear. We don't have any discussions about patients. I would dearly like a session about the patients we see. They said that wouldn't be happening but if we had particular concerns we could make an appointment to talk about it. I didn't have a problem or a concern I wanted to just be able to talk, to discuss what I was learning from and about the patients. It just hasn't been part of the culture here.”
‘The younger students are a trial.’
‘We have the least motivated students here.’
‘We have a number with very real personal problems.’
Genuine lack of understanding
There were a number of sites where coordinators and students had differing awareness of what was actually happening at the site. For example, at two sites, shortage of clinical rooms meant that students were having a difficult time getting to see patients on their own, taking histories, examining and developing management plans. When, at one site, it was recognised that this was not an emotional overstatement but an observation by all students, the issue was addressed. At the second site the coordinators could not recognise there was an issue, and assumed there were a couple of students ‘who were problems.’
‘The GP rooms aren't set up for taking patients on your own, it can make it quite hard to get one a week. Practically it is challenging.’
The two university issue
The first year that both the UWA and UNDA students were educated together in the RCS was in 2007. There were a number of differences between the courses and therefore a number of issues with respect to prior learning had to be addressed. The UWA students had clinical experience in their fourth year, but the UNDA students had not. In addition the UNDA metropolitan curriculum contained third year courses in surgery and psychiatry, which the UWA students already had in their pre-clinical year. This difference between the two groups led to some dissatisfaction from UWA students as the UNDA students had to ‘come up to their level’ in those areas. Personality and relationship issues at some sites were renamed by some students as inherent, unsolvable between-university problems.
‘They haven't had the pharmacology, infectious diseases and pathology and we are going through things we have to do extra because they haven't learnt them or don't understand them so we will have to stop and spend extra time talking about that, their curriculum is so different its hard to combine them both.’
‘I have to just deal with people who need to grow up. It's hard because people have been really rude, like children.’
‘Having the extra surgery and psychiatry means I don't get the full time exposure to focus on paediatrics and I really need that.’
Site structure versus ‘problem student’
Students were generally positive in their interpretation of problems. They saw them as systems issue to be improved, even in cases where there were shortcomings in the way individual staff members managed particular circumstances. Staff at some sites, however, had a tendency to blame the student and not respond to the actual problem. The perceptions of staff attributed the problems to ‘poor group dynamics,’ ‘having a difficult group of students this year ‘or having ‘problem’ students.’
The students’ perception of poor academic organisation included
‘We are getting almost 18 hours, way too much … We have lectures Monday and Tuesday, 9 till 1 … and Friday is the only day we have no teaching and that is the quiet day in hospital.’
‘It bugged me a lot … getting a lot of formal teaching, between 12 and 15 hours a week and I didn't think we were getting much out of the scattered approach to the content and so I felt I was just waiting to get out to see the patients.’
‘Why do I have to do 6 weeks at the same place when the others have 2 week rotations?’
‘We are adult self directed learners but they don't let us be that’,
‘They are treating us like children.’
‘Mother is always watching us and telling us what we must and must not do.’
Too many students were late to clinics and tutorials or not turning up at all.
Some students were disruptive, difficult, and this year there was poor group dynamics at some sites.
Some students were manipulative, negative, depressed or with other psychological characteristics such as ‘borderline’.
There was a need to set tutorials at times when the staff could be there to run them.
Many students were not making the most of their clinical experiences and needed to be managed to maximise their case load.
‘Its been very interesting, a few learning curves and a few problems … some of the students are a challenge … in general they are always late, often miss sessions, don't turn up to clinical sessions and despite repeatedly asking, things are not done. In tutes they are quite disruptive, loud, a bunch of high school kids on camp … There are two or three bordering on psych problems which has made me feel quite down at the end of the week. They are quite belligerent.’
House and student relationship issues
Students at most sites got on well with each other. At some sites, however, there were issues surrounding one or more students not doing their share of house cleaning, sharing the costs of running the house or whose need for silence and time alone (or noise and sociability) was different from others in the house. Problems were encountered also by pets being brought and then asking others to look after them, and when new partners stayed over at the house where there was most food, and/or was the tidiest, partaking in what was there and not doing their share of cleaning up or sharing in the cost of food.
‘First thing he does in the morning is turn on the TV, it sends me crackers.’
‘I really feel I don't fit. I have been so miserable, as if everyone blames me.’
‘The group hasn't got on well together.’
‘It's good despite problems’
Despite problems at four sites only one student wished to be transferred to another site and that was because of student–student dynamics, rather than teaching and learning or staff issues. The rest chose to stay where they were. The following quotes are all from different students at these four sites.
‘I've been talking to my friends in [the city] and we are getting heaps more hands on opportunities than they are.’
‘The doctors and specialists are always keen to teach in the wards, no issues.’
‘I have to take every opportunity … My RCS buddy and I have given our phone numbers to our clinical teachers so if a patient comes in after hours they call us and we can go in to assist with surgery that we wouldn't otherwise see or interesting things in casualty. I've never worked so hard or had it so good.’
‘I love it, I'm having a great time, the medicine is fantastic, doing clinical medicine for the first time is a huge learning curve and being here in the Aboriginal Medical Service, I'm quite emotionally fond of it now as well as getting clinical skills. It's where I cut my teeth and I'm happy it could have been this place where it happened. From a medicine point of view I'm learning heaps and heaps, getting a good ‘hands on’. The teachers, the doctors are really good with us, take time with us despite being very busy.’
‘It has definitely simplified my life to leave the city. It took a while to set up a social network but I've found the clinical stuff fantastic, academically I'm doing well and I've caught 15 babies so far.’
Discussion
The clear intention of this programme was to establish longitudinal clinical clerkships in areas of workforce shortage and difficulty, all of which were a long way from the base campus, so it is not surprising that the students had some difficulties. The title of this article is taken from the comments of one of our 2003 students who said, ‘What makes the RCS really, really good makes it really bad … Balance and boundaries are not yet realistic.’ From the beginning of the venture it was obvious that, given the scattered and isolated nature of the sites, a system which allowed students and staff to give appropriate feedback was going to be necessary. It might seem impossible to accept that the teaching and learning opportunities really are good when four sites containing thirty students stood out as having what might seem to be major problems, but qualitative evaluation with individual feedback means that the process is examined ‘warts “n” all’. Problems that were identified were addressed immediately by senior academic staff and where necessary sites were visited regularly and frequently over the remainder of the year.
Much of the evaluation of the effectiveness of clinical longitudinal integrated clerkships has concentrated on quantitative methodologies which seek to compare the marks of students working in rural and remote locations as compared to those who study in tertiary teaching hospitals (Worley et al. Citation2004; Halaas Citation2005; Oswald et al. Citation2001; Waters et al. Citation2006; Schauer & Schieve Citation2006). However less attention has been paid to the experience of students working in these situations using valid qualitative methods such as are described above. Using this methodology, we have been able to demonstrate over five annual iterations, the positive and negative aspects of a complete year in the bush. This extends the findings of a recent small qualitative study (Denz-Penhey & Murdoch Citation2008) and emphasises that there are negative human costs as well as positive outcomes as a result of the process. In the words used for that study – ‘learning is more than marks.’
This evaluation was carried out in mid-year and it is known that many of the issues identified were corrected shortly after the evaluation. However the apparent reluctance in some sites to discuss the systemic negative aspects of longitudinal clerkships reflects both the influence of positivism on medical professionals and a missed opportunity to improve the performance of our School.
While publications on rural and longitudinal clerkships have produced ample evidence of the marks of students, there has been little recognition of the potential for social harm to students through the process. Traditional clinical education, however, has long been known to be a potentially harmful process (Rosenberg et al. Citation1984). Styles (1993) has pointed out that ‘medical education fails to prepare doctors for dealing with the stresses that they will encounter later in their careers.’ A recent study has reported that the prevalence of sexual harassment during clinical clerkships in various studies ranges from 18% to over 60% (Rademakers et al. Citation2008). In another study (Lempp & Seale Citation2004) 21 of 36 students reported 29 incidents of humiliation: 10 they had observed or heard about and 19 direct personal experiences, particularly during their clinical years. A qualitative study of stress in medical students (Radcliffe & Lester Citation2003) has suggested that transition periods, particularly between school and medical school, preclinical and clinical training and clinical training to approaching qualification were particularly stressful. It is perhaps not surprising that students living and studying in WA's isolated situations were subject to stress.
The major issue is the mismatch between the high student expectation of their teachers and the belief by some teachers that any educational difficulty has its root in student personality. The students saw their problems as system issues to be improved, even in cases where there were shortcomings in the way individual staff members managed particular circumstances. Staff at some sites, however, had a strong tendency to blame the student and not respond to the actual problem. Teachers faced with ‘difficult’ students, such as physicians faced with patients whose illnesses cannot be explained, are apt to attribute the problem to the student, rather than the system. This is a theme well recognised in action research and its companion methods – action science and action inquiry. Reason (Reason Citation1994) in discussing the work of Argyris (Argyris et al. Citation1985) said ‘One of the major difficulties of action science rests in the defensiveness of human beings, their ability to produce self-fulfilling and self-sealing systems of action and justification, often with patterns of escalating error.’
The overall message is that medical students are not machines to be refined and calibrated through medical education but individual ‘complex adaptive systems’. There is a need to develop an organisational culture to explore the previously unexplored culture of assumptions and presuppositions that each staff member brings to their teaching practice, along the lines articulated by Senge (Senge Citation1999).
This would also assist with the need for an extended scope of responsibilities for the rurally based teacher. Our rural and remote staffs are required to provide a social component additional to those based in large metro campuses. City educationalists are not expected to undertake social and personal counselling of medical students in a routine manner. However, rural preceptors must have a strong pastoral component for we cannot afford for students to ‘fall apart’ several thousand km away from home, or even 250 km from the city.
There has been a call in urban situations (Hirsh et al. Citation2007) for continuity to be an organising principle for clinical education reform. Their summary of the situation seems appropriate:
Students appear to benefit from longitudinal ambulatory care experiences by developing more effective relationships with patients, gaining insight into the psychosocial aspects of care, and understanding the longitudinal management of chronic illness. Continuity of supervision also provides the luxury of intergenerational, iterative dialogue grounded in practice about values, professionalism, and lifelong learning. In this way, the entire learning community nurtures and maintains a spirit of idealism — idealism that will surely be translated into enhanced learning, greater patient satisfaction, and more efficient and effective medical care.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
Additional information
Notes on contributors
Harriet Denz-Penhey
HARRIET DENZ-PENHEY, PhD, is the Research Associate Professor in The Rural Clinical School of Western Australia and the Coordinator-in-Charge of Evaluation and Research since the first full year's intake of students in 2003.
J. Campbell Murdoch
J. CAMPBELL MURDOCH, MD, was the founding Head of The Rural Clinical School of Western Australia since its inception until the end of 2007 and is Professor of Rural and Remote Medicine at the University of Western Australia and the University of Notre Dame. He is currently undertaking ongoing research and evaluation.
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