Living and working with the people of ‘the bush’: A foundation for rural and remote clinical placements in undergraduate medical education

Abstract

Background: The Australian Government's policies and programmes to redress the medical workforce shortage in rural and remote areas focus on recruitment of rural students and provision of rural clinical placements. The University of Notre Dame's Rural and Remote Health Placement Programme (RRHPP) uses an additional approach to address this issue.

Aim: This article describes the RRHPP undertaken by all medical students in the first 2-years of their course and examines the educational worth of this approach.

Method: Data were obtained from curricular documents, publications about the RRHPP and evaluation questionnaires administered to students and supervisors.

Results: The RRHPP provides students with opportunities to develop a patient- and community-centred perspective on the health issues of rural and remote populations by having them live and work with people in these areas prior to clinical placements. It is based on sound educational principles and underpinned by participation of rural/remote communities as experts and equal teaching partners. The RRHPP is valued and perceived by a majority of students and placement hosts as a useful strategy to develop medical students’ understanding of the rural/remote community context and its impact on health.

Conclusion: This community participatory approach benefits medical students and rural/remote communities.

Introduction

Equitable health care provision for rural and remote populations is a constant challenge for countries with geographically dispersed populations. In particular, medical workforce shortages in rural and remote regions (in Australia, termed ‘the bush’) are recognised internationally (Dunbabin & Levitt 2003; Ranmuthugala et al. 2007) as a major element in hindering the provision of quality care. In Australia, based largely on experience from overseas that rural origin students and those experiencing early and repeated rural exposure during training are more likely to practise in a rural location (Dunbabin & Levitt 2003), the Australian Government has implemented a national strategy to address the medical workforce shortage.

In undergraduate medical education, the Department of Health and Ageing funds the Rural Clinical Training and Support (RCTS) programme which aims to improve recruitment in rural and remote medical practice by enlisting Australian medical schools to deliver rural medical training, recruit rural medical students, promote and encourage rural medical careers and increase opportunities for Aboriginal and Torres Strait Islander students (Department of Health and Ageing 2011a). The RCTS programme requires, inter alia, that Australian medical schools provide a variety of compulsory rural clinical placements for undergraduate medical students.

Table

Practice points

Medical students need to understand the rural/remote community context and its impact on the health of rural/remote populations. This can be taught by immersing medical students in rural/remote communities through ‘community’ as distinct from ‘clinical’ placements. Educators should consider engaging rural/remote communities as experts and equal partners in medical education.

Rural clinical placements, both as a compulsory part of the medical course or via a scholarship programme, are based on the traditional clinical rotation model that applies to clinical education in urban community practices and teaching hospitals. Students are mentored by a rural medical practitioner in his/her practice with the major objective being that students gain clinical knowledge and skills. Involvement with other rural health services and the communities they serve, therefore, are experienced from the perspective of medical practice.

The University of Notre Dame Fremantle's School of Medicine (SoM) has added an extra element – the Rural and Remote Health Placement Programme (RRHPP) – to the clinical placements model. The RRHPP aims to provide a foundation for, and complement the medical focus of, rural clinical placements. It provides prospective medical practitioners with personal experience of living and working in the bush and opportunities to develop patient- and community-centred perspectives on rural and remote area health prior to their clinical placements in these areas. The expectation is that graduates, regardless of where they practise medicine, will understand the issues that influence the health of rural and remote populations and have empathy with their health needs.

This article describes the RRHPP and analyses how it is perceived by medical students and rural and remote communities.

The rural and remote focus of the medical curriculum at Notre Dame

The University of Notre Dame Fremantle's SoM offers a 4-year graduate entry medical course comprising 2 years of a problem-based learning (PBL) curriculum followed by a series of clinical rotations in the final 2 years. It was established with the mission of graduating knowledgeable, skilful, dutiful and ethical doctors who will want to work in Australia's areas of unmet need, including rural and remote Australia. To address this mission, the SoM developed a broad strategy of experiential learning in rural and remote areas throughout the 4-year course, comprising:

1. a first year community placement in rural Western Australia (WA);

2. a second year community placement in remote WA; and

3. clinical placements in rural and remote areas during the third and fourth (final) years.

The first two of these experiences constitute the RRHPP, funded by the Australian Government under the auspices of the RCTS programme.

Rural and remote health placement programme

The RRHPP was developed after extensive consultation with residents and local governments in the targeted communities (Toussaint & Mak 2010).

In Year 1, students spend 4 days in the Wheatbelt region (Figure 1), which covers 154,862 km²; population 69,000. As its name suggests, this is an agricultural region with broadacre cereal crops, wool and livestock being the main industries (Wheatbelt Development Commission 2011).

Figure 1. Map of WA showing the Wheatbelt and Kimberley regions. The Perth metropolitan area (WA's capital) is the unlabelled region on the coast between the Wheatbelt and the South West.

In Year 2, students spend 8 days in the Kimberley region (Figure 1) which covers 420,000 km² with a population of approximately 35,000, about one half of whom are Aboriginal people (Kimberley Development Commission 2011). Major contributors to the region's economic output are mining, tourism, pearling, the pastoral industry and agriculture.

Aims of the RRHPP

The Programme aims to achieve the SoM's mission by providing a foundation for, and complementing, rural and remote clinical placements in the latter years of the medical course.

The specific objectives of the RRHPP within this broader goal are:

• to provide students with opportunities to develop competencies in rural and remote area living (as opposed to rural and remote area clinical practice) and

• to provide students with opportunities to gain insights into the particular circumstances, including personal, socio-cultural, geographic, climatic and economic, that influence impact the health and well-being of rural and remote populations.

Structure of the RRHPP

The RRHPP is integrated into the PBL curriculum of Years 1 and 2. Throughout these years, students in small groups address one patient problem per week. Problems are specifically designed for the RRHPP to inspire learning objectives about health and illness in rural and remote areas. The community placement is a resource, similar to a lecture, tutorial or clinical skills session, for facilitating achievement of some of the learning objectives that students generate from analysis and discussion of the problems in their small groups.

In both components of the Programme, students in pairs are required to live with, and undertake useful, non-clinical work for their host community or organisation, and are billeted with members of the community who are not paid.

In the Wheatbelt rural health placement (in week 7 of Year 1), students are presented with a problem entitled ‘Trapped by space’. The clinical scenario is of a farm worker who is found to have depression while being treated for an unintentional, work-related injury. The problem is designed to stimulate students to generate learning objectives from that they may address during their Wheatbelt placement. Learning objectives include: what it is like to live and work in a rural community; the concept of social capital; prevalence and impacts of mental illness in rural versus urban areas; the social impacts of alcohol and principles of injury prevention (revision from earlier problems). While the School provides additional resources (in the form of orientation and post-experience briefings, lectures, readings on relevant topics and structured site visits), the experience of being billeted with a local family is the major resource for students to address learning objectives related to life and work in the country and the social factors that determine health and well-being in rural communities.

In the Kimberley remote area health placement (weeks 30 and 31 of Year 2), students address a problem entitled ‘Living on medicine’. The clinical scenario involves an Aboriginal man from a remote community with end-stage renal failure. Again, the problem is designed to stimulate students to generate learning objectives that they may address during the placement. The School provides resources similar to those for the Wheatbelt placement mentioned above, including extensive and compulsory preparatory studies to orient students to the historical, cultural and linguistic facets of the region, as well as structured site visits (Mak et al. 2010). The experience of living and working in the community is the major resource for students to address learning objectives about the factors that determine health and well-being in remote communities and why people (including health professionals) choose to live and work in remote areas.

In the Wheatbelt, students spend their days with their colleagues and staff supervisor attending tutorials by local health care staff, structured visits to health services, farm safety demonstrations speaking to primary and high schools students about tertiary education and undertaking 4 h of community service (selected and organised by the local government authority and/or service club). Students and staff are billeted with families in towns and on farms. Students are required to cook at one meal for their host family and to host a farewell function for billet families and community members who have contributed to the placement. Examples of community service undertaken by students include:

• clearing land and planting new gardens at an aged care facility;

• erecting a series of rest seats along a heritage trail;

• relocating the town museum; and

• renovating a disused building into a child-care centre.

The first 2 days of the Kimberley placement comprise a cultural and linguistic orientation workshop delivered by local Aboriginal people, conversations with local medical practitioners and visits to health services and cultural sites. Student pairs then spend five working-days and one leisure-day with their host, which could be a pastoralist, school teacher, Aboriginal community, aged- or child-care worker or small businesses owner. Some students are located within or around the towns of Derby and Fitzroy Crossing, while others are up to 200 km from either town, necessitating trips of 2–4h by four-wheel drive or charter flights in light aircraft. While some hosts provide accommodation in their homes, some students are accommodated in station bunkhouses or in the offices of the host organisation, in which case, the SoM provides students with sleeping ‘pods’ (an off-the ground, enclosed stretcher-type bed). Students are expected to work within the placement as required by hosts and within the School's requirements for safety. Staff visit students and their hosts once during the placement. Examples of work undertaken by students include:

• cleaning and repairing windmills and water pumps;

• assisting teachers in classrooms;

• assisting with region-wide school sports carnivals;

• assisting environmental officers with patrols of weed infestation;

• local radio and newspaper journalism; and

• assisting with domiciliary and hostel-based aged care.

To optimise learning, students attend pre- and post-placement briefings, debriefing and other learning activities with staff and fellow students and are required to complete a reflection on each community placement for their professional portfolio (Mak et al. 2010). Evaluation of these activities has already been published by Mak et al. (2010); so, this article will focus on the community hosts’ views of the RRHPP and educational aspects of the students’ experiences with their hosts.

Methods

Students, staff, hosts and other community members involved with the programme are asked to provide feedback on their experiences via questionnaires, interviews and debriefings.

Feedback from hosts, local government representatives and other community members involved in the RRHPP was obtained by SoM staff during the course of their interactions with these people while organising the placements, supervising students on placement and hosting the farewell dinners. Additional feedback regarding the Kimberley remote area placement was obtained in 2008 through a formal study of community hosts’ perceptions of the programme undertaken by an independent anthropologist (Toussaint & Mak 2010).

Feedback from students was obtained by the SoM's Medical Education Support Unit via de-identified, online questionnaires completed by students 1–4 weeks post-placement. Students were asked to respond to a series of statements about the educational value of the placement and the quality of their interaction with their host using a five-point Likert scale where one (1) indicated strong disagreement and five (5) strong agreement. The data were analysed using Microsoft Excel. Median scores are presented as the data were not normally distributed.

Ethics approval was not required for collection of these data as they were obtained during the course of ongoing quality improvement activities.

Results

Community views of the RRHPP

The community's valuing of the RRHPP is shown by their ongoing support for, and participation in, the programme since it was established in 2005. Many billet families have hosted students every year, and the School has had no difficulty recruiting further billets as student numbers have increased. The same farmers host the students on their farms for the farm safety demonstration every year. Schools continue to welcome medical students’ interactions with their students, despite multiple changes of school principals. Typical of the nature of many rural people, their feedback is in action (continued and enthusiastic participation) rather than words. The strength of the relationships that the SoM has built with communities is illustrated by the following examples:

• A billet ‘mother’ held an art exhibition in Fremantle during the 2011 university mid-year break. The School responded by hosting an afternoon tea for her, after which several staff viewed her exhibition. In addition, her billet ‘sons’ visited her and her exhibition, as did representatives of the Medical Student Association of Notre Dame.

• In June 2011, Australia's live cattle export ban resulted in significant economic and personal hardship for pastoralists across Northern Australia, including the Kimberley (Gillard & Ludwig 2011). Despite this, the proportion (about 30%) of medical students who undertook their placement on a cattle station in 2011 was unchanged from previous years, indicating strong support from pastoralists.

Key findings from the formal study of the Kimberley remote area health placement (Toussaint & Mak 2010) were:

• The Programme was seen as effective because it provided structured, constructive means for prospective doctors to appreciate the richness of remote area living and encouraged them to think and act cross-culturally.

• The Programme was seen as beneficial for the long-term health needs of Kimberley because:

  • at least ‘one good doctor’ might return to work in the region;

  • prospective doctors, whether they chose to return to the bush or practise in the city, would be better-informed about the particular circumstances of patients from the bush, including the conditions in many Aboriginal communities; and

  • prospective doctors were stimulated to reflect on their own attitudes and practices.

• Hosts wanted more time with students outside of work hours to relax with, and show students the Kimberley's attractions, as a way of thanking them for their work. This suggestion was implemented from 2010 onwards, with hosts extending their hospitality by 1 day during which they include students in their weekend leisure activities, including camping, fishing, football and bush walking.

Student views of the RRHPP

Ninety-five of 101 Wheatbelt (94%) and 85 of 97 Kimberley (88%) placement students in 2011 completed the questionnaire. The results in Table 1 indicate that the vast majority of students appreciated the opportunities provided to understand the health issues of people living in rural areas, especially from the personal perspective of their host families. The following comments are indicative of the views of this majority:

The trip was very beneficial … chance to discuss health matters one-on-one in a relaxed setting, over dinner, hearing personal experiences from people about sensitive issues like isolation, depression, etc.

It was eye-opening to climb onto the farming equipment and watch sheep being shorn. This made it so much easier to comprehend the unique physical and mental challenges of rural life and the effect this has on health … and the conditions where farming accidents can occur. (Extract from media release written by students for a local newspaper.)

The Kimberley Remote Area Health Placement was the highlight of my academic year … It was most useful in stirring an interest in rural and remote medicine.

I had an overwhelmingly positive experience on this trip. The interpreting lecture [by the Kimberley Interpreting Service] was the best lecture related to Indigenous people that I have ever had

Table 1  Student responses to the 2011 Wheatbelt and Kimberley placements

	Wheatbelt, n = 95				Kimberley, n = 85
Statement	Median score	SD/D (%)	Neutral (%)	A/SA (%)	Median score	SD/D (%)	Neutral (%)	A/SA (%)
I have a better understanding of the health issues of people living in rural/remote areas	4	3	11	86	4	8	18	74
The placement enhanced my interest in rural/remote area practice	4	17	19	63	4	21	26	52
The placement provided me with positive experiences of living in rural/remote areas	4	5	18	76	4	20	20	59
The remote area health placement prompted me to question some of my beliefs and opinions	4	19	24	57	4	17	20	63
The ‘Trapped … by space’/‘Living on medicine’ PBL problem focused my learning on the placement	4	25	19	56	3	49	29	23
I met most learning objectives using the resources provided before and during the placement	4	20	25	55	3	43	29	29
The placement provided me with opportunities to learn from rural/remote area residents about factors influencing their health	5	4	6	89	4	17	20	63
I have a better understanding of the diversity of cultures and languages in remote WA	N/A	N/A	N/A	N/A	4	11	7	82
The placement helped me to reflect on attitudes to health and values associated with treatment/management that I had/may have previously taken for granted	N/A	N/A	N/A	N/A	4	9	19	71
I have a better appreciation of ‘remoteness’, e.g. the magnitude of distances, the issues of communication, the isolation from others and from services	N/A	N/A	N/A	N/A	4	9	9	81
My host family made me feel welcome	5	1	3	96	N/A	N/A	N/A	N/A
My work placement host made me feel welcome	N/A	N/A	N/A	N/A	5	4	5	92
My accommodation/leisure placement host made me feel welcome^a	N/A	N/A	N/A	N/A	5	2	1	62
I felt safe (in a personal sense) during the placement	5	0	1	99	4	14	14	71
The length of the placement was appropriate	4	9	7	84	4	27	18	55
I recommend that the placement be retained in the MED100/MED200 curriculum	5	0	6	94	4	11	17	73

Notes: 1, strongly disagree (SD); 2, disagree (D); 3, neutral; 4, agree (A); and 5, strongly agree (SA) (Percentages may not add to 100% because of rounding.).

^a34% answered N/A because their work placement host was also their accommodation/leisure placement host.

Those who responded negatively to this statement tended to be rural origin students who believed that they already had an adequate understanding. The following comment illustrates this:

Note that the only reason I didn’t find this placement helpful is because I have always lived and worked rural and remote.

Other rural students appreciated the opportunity to see the bush from the new, developing perspective of a prospective medical practitioner, and a perspective that was focussed by a PBL case:

This was a really fantastic trip and, being from a rural background, I may not have learnt as much as other people as I was already aware of the issues facing country people, but overall, I found … that I really enjoyed it and I learnt from it.

Students were not as appreciative of the PBL cases that were designed to focus their learning from the placement. These students were distressed by being required to undertake a community placement and pursue a different type of learning, especially when their natural propensities led them to generate substantial science and clinical management learning objectives from the problems. For this minority group, the placements interfered with or distracted them from learning ‘real’ medicine. The following quote expresses these concerns:

This money would be better spent on providing tutorial sessions giving students an opportunity to ask questions to a consultant seeing as PBL tutors are not allowed to teach us

Alternatively, negative comments were made by students who seemed to miss the point of the placement, being to understand the human and community factors that impact on the provision of health care in remote regions prior to clinical learning in later placements. Examples of such comments are:

this placement [was] far too long and after a few days was not experiencing anything new but was just resenting being forced to be there and forced to do free manual labour.

It must have some medical aspects to it and … some real medical experience … if we were at least placed with doctors and medical personals (sic) then we would get much more out of the placement.

In contrast, another student commented:

… my billet family (working farm) had experienced their driest and leanest year which had placed additional stress on their family life and it gave me a first-hand view into the mental and emotional strain placed on farmers …

Despite the above mentioned ‘complaints’, the student representative's speech at every graduation ceremony since the school's inception has referred to the Kimberley remote area placement as the highlight of the course. The following comment indicates that many students continue to learn from their RRHPP experiences even after its completion.

… during my placement I did not appreciate the experience as much as I do now after reflecting on it.

The last words represent the type of student feedback that inspires the SoM to continue the Programme:

I am quite familiar with this environment already … giving us a positive example of living in this part of the country is an excellent idea.

I had an amazing time, and highly recommend keeping the placement in following years. It really consolidated my desire to work in a rural/remote area, and got me even more excited about Rural Clinical School next year.

The Kimberly placement without doubt provided an incentive to work remotely. It broke down the unknowns and showed me that there is a totally different life available to be lived.

Discussion

Students’ and hosts’ responses to formal evaluations and continued enthusiastic participation of hosts indicate that the RRHPP is valued and perceived by a majority of participants as a useful strategy to develop medical students’ understanding of the rural/remote community context and its impact on health. A minority of students (more so in Year 2 than Year 1) found it difficult to relate the experiential learning of a community placement to their PBL problem because of the disproportionate focus on science and clinical management in their learning objectives.

Involvement of rural communities in medical student education is not unique to this programme. The John Flynn Placement Programme (JFPP) in which students spend 2 weeks each year over 4-years, and the rural clinical schools (RCSs) initiative, in which students are immersed in a rural community for 1-year, suggest that involvement of medical students with the rural community as well as with health professionals while on rural/remote placement enhances their learning. In the JFPP (Young et al. 2011), students valued the cultural and social connectedness that they developed with their rural/remote communities, and that this was a result of the repeated exposure that is integral to the JFFP. The RCSs are required, under the terms of their funding, to ensure that community members are involved with students on placement and that students are ‘well-looked after’ by the community (Department of Health and Ageing 2011b). There is also evidence from South Australia (Worley et al. 2006) and Canada (Strasser 2010) of the positive effect that community involvement with the medical school and students on placement has in enhancing the learning experiences of students, particularly about geographic, social and cultural diversity. However, in all the programmes referenced, the focus is most definitely on the clinical learning experience, and it appears that students in these programmes value this aspect of their experience more than any other (Department of Health and Ageing 2011b). Moreover, during JFPP placements, students usually live with the local practitioner/mentor, and during RCS placements, students live with fellow students in specially designed accommodation provided by their university.

The RRHPP aims to add an extra dimension to these initiatives. Unlike the above-described programmes which are available only to students who apply for them, the SoM requires all students to undertake the RRHPP in Years 1 and 2. Second, the SoM explicitly requires students to learn how to live in the bush and to understand the views of people living in the bush, before providing them with clinical placements in rural and remote areas in Years 3 and 4. Third, by placing medical students in non-clinical work settings, the RRHPP shifts the balance of power from the medical profession (represented by medical students) and academia to people of the bush, whose role in the programme is that of an expert and equal partner.

The SoM accepts that not all of its graduates can, or will want to, work in the bush. However, all medical practitioners should be equipped to provide quality care to people of all backgrounds, including those of the bush. Understanding of, and empathy with, the circumstances and concerns of one's patients, one of the RRHPP's goals, is an integral part of medical care. Therefore, the SoM provides the RRHPP to all its students regardless of where they intend to practice. As one Kimberley host commented (Toussaint & Mak 2010):

… and if they don’t return to the bush and want to stay and work in Perth … at least they’ll have an understanding of life in a remote area, and so when a patient from here goes there … they should be in a good position to treat a bush person.

A strength of the RRHPP is that it recognises that ‘rural background’, the clearest predictor of rural/remote practice (Dunbabin & Levit 2003; Laven et al. 2003), is a proxy marker for whether someone has the attitudes, skills and knowledge to survive and thrive out bush, not an inherent, unacquirable characteristic. Therefore, in addition to selecting students with rural backgrounds, medical schools can also assist students, regardless of their background, to acquire these attributes. The people most qualified to teach these attributes are not city-based academic staff but people who live in the bush who are, therefore, necessarily involved in delivering a medical curriculum that teaches the attitudes, skills and knowledge to survive and thrive out bush. The importance of these attributes is consistent with Maslow's (1954) hierarchy of needs and the humanistic model of learning which argues that it is inappropriate to expect people to be willing/able to work in the bush until they have learned how to live there. The RRHPP facilitates such learning by billeting students with members of the community to live with them and undertake meaningful non-clinical work alongside them, so that they may come to understand the realities and values, as well as some of the nuances, of rural and remote culture, and of living effectively in them.

Arguably, immersion in the community before students adopt a clinical role has a greater chance of fostering empathy and self-reflection than in clinical placements. While there are opportunities to develop relationships with, and learn from, communities and individuals during clinical placements (Strasser 2010; Young et al. 2011), it is likely that medical student clinicians are perceived by community members in a markedly different way from a student who is a co-worker or a learner in the community host's area of expertise. Community members are much more likely to feel they have sufficient authority and the confidence to teach and engage with students on an equal footing when the student is working in the host's comfort zone and area of expertise, as opposed to in a clinical setting. Another advantage of situating the RRHPP outside clinical settings is that it allows communities and individual hosts to participate as equal partners because whether, and how, they choose to be involved in the programme will not be seen as having possible effects on their medical care.

As well, Beagan (2003) found that social and cultural awareness taught in the classroom can be negated in the clinical learning environment: ‘it's all very nice to talk about it in theory, but ultimately it makes no difference’ because of the pragmatic considerations of the ‘real world’ of the clinic. Awareness developed through lived experience rather than lectures may be better able to resist such negation. As one student reported to the community who hosted him in the Wheatbelt:

The experience of living and interacting with someone at this level can never be replicated in any lecture theatre and will be treasured. … The importance of water and rain (for farmers) has never been so clearly demonstrated to me.

The limitations of the RRHPP in achieving its ambitious objectives are clear. Despite RCTS funding, SoM resources for the Programme are stretched. The Programme would be impossible without the generosity of the host families and organisations. The durations of both placements are relatively short in terms of the objectives of the Programme. Some hosts argue that a longer placement would ‘teach’ much more. However, until long-term evaluation of the effectiveness of the Programme is possible, greater demands on host families and financial cost to the RCTS are not justifiable.

Since the first incarnation of the RRHPP, a minority of students have had difficulty in understanding and accepting that the practice of medicine entails more than science and clinical skills. There is well-documented evidence from other PBL medical courses that regardless of the multi-dimensionality evident in patient presentations, some students tend to regard some dimensions of medicine as more important for learning than other dimensions (MacLeod 2011). For this minority group, the rural and remote placement experiences interfered with or distracted them from learning ‘real’ medicine. Furthermore, some students and staff have difficulty accepting that knowledge and expertise relevant to the practice of medicine may lie outside clinicians and the biomedical model of health (Tervalon 2003) In regard to these students, the SoM accepts that while is it possible to provide opportunities and encourage students to reflect on their own biases about what is important about this type of learning, it is impossible and unethical to force them to do it. The School is not alone in facing resistance. As Beagan (2003) reports, there is tremendous resistance to this type of learning because it is not ‘real medicine’.

However, there is always hope. As Crandall et al. (2003) argue, there are stages of development in sensitivity that range from a beginning level in which there is no insight about the influence of culture (including rurality and remoteness) on medical care to a developed level in which attention to culture is integrated into all areas of practice. It seems that for some students, development through these stages simply takes longer than for others. This reality reinforces the value of the staged approach to rural and remote exposure that the SoM Notre Dame has designed. Students have several opportunities over time in the staged curriculum to re-visit the issues that confront rural and remote communities.

The ultimate effectiveness of the RRHPP will not be known for several years until the first graduates of the SoM Fremantle have completed postgraduate specialist training. The School has been informed by the Postgraduate Medical Education Council of WA that Notre Dame graduates have indicated their willingness to work outside the metropolitan area and requested that more intern and postgraduate training places be developed in rural health services (Mak et al. 2011). Currently, the School is aware of several graduates undertaking prevocational and vocational training positions in rural and remote locations in WA and interstate (personal communication from graduates to author DB Mak). However, as medical training is lengthy and decision to practise medicine in the bush or in the city is determined by a broad range of both internal and external influences during medical training (Jones et al. 2009), a much larger and longer study is required to distinguish the contribution of the RRHPP as opposed to other influences on our graduates’ career decisions.

The expectation in Australia is that the Medical Schools Outcome Database and Longitudinal Tracking Project established in 2004, funded by the Department of Health and Ageing and conducted by the Medical Deans of Australia and New Zealand (2011), will provide the ‘comprehensive, methodologically rigorous longitudinal studies extending beyond basic training’ (Ranmuthugala et al. 2007) that are necessary to identify the relative roles of specific factors and influences on decisions for rural and remote practice. This Project includes data from 18 Australian and 2 New Zealand medical schools and the influence of the RRHPP and other rural initiatives will be considered in these longitudinal studies.

Conclusion

Improving the health provisions for rural and remote populations is a complex task. Addressing workforce shortages in these regions is certainly an important strategy to achieve this aim not only in medicine but in all of the health professions. The Australian Government has focussed on recruitment as a priority, by funding medical schools to increase the numbers of rural origin students, providing support to students with an interest in rural practice throughout their studies and by funding rural clinical placements.

The SoM Notre Dame actively encourages its students to contribute to the health care needs of rural and remote Australians after they graduate, regardless of whether they work in a metropolitan, rural or remote area. It does this using a staged approach to the development of an understanding of and empathy with the social, cultural, geographic and economic factors that impinge upon health care first, from the perspective of the real people of rural and remote communities, and second, and latterly, from the perspective of clinical practice in these communities. This account of the Programme may inspire others to reflect on their own curricular efforts to improve health care for the people of rural and remote communities and in doing so, to engage ‘the people of the bush’ as experts and equal partners.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.