A Qualitative Investigation of the Experiences of Students and Preceptors Taking Part in Remote and Rural Community Experiential Placements During Early Medical Training

Introduction

Rural communities struggle to retain physicians which contributes to health inequities characterised by higher rates of disease morbidity and mortality. ¹ For example, in Canada, rural residents have a shorter life expectancy than those living in urban centres. ² Although this is in part due to a higher incidence of workplace accidents in rural communities, increasing access to health care services remains a key priority in rural settings. ¹ While insufficient physical infrastructure is sometimes evident in rural locations, it is the lack of health-care practitioners that predominantly underlies the poorer health status of rural residents. ³ The reasons for the lack of rural physicians are many and include personal and professional factors such as geographic remoteness, lack of professional support including high workload, lack of recreational facilities, minimal or no education choice for children, and a deficit of employment opportunities for spouses.^4–6 These actual or perceived negative aspects of rural practice have had a detrimental impact on both recruitment and retention of physicians leading to a mismatch between supply and demand. For example, although 31% of Canadians live in rural areas, only 17% of family physicians, and 4% of specialists live and work rurally, with this disparity being expected to increase.^7–9 Improving the health of rural populations is therefore, at least in part, conditional on increasing the supply of physicians practicing in rural communities. Training physicians to possess the necessary knowledge, skills, and attitudes for rural practice is a key mechanism to address this gap, with rural community-based medical education being a primary mechanism for achieving this. ¹⁰

The development of community-based medical education has been driven by the desire to train doctors where they will base their future practice, a practice which occurs increasingly within communities. This is in contrast with the more traditional method of teaching students in large urban hospitals. Underlying this change is the idea that medical practice is place-dependent, and that learning in one location does not necessarily equip the student to practice somewhere else. ¹⁰ , ¹¹ This applies both to the knowledge and skills learned, but also to the attitude and adaptivity of the graduate to practice in contexts familiar or unfamiliar to them, as well as to develop a place-informed professional identity. ¹² As such, the training of physicians who can, and who want to, practice in rural communities is best done experientially in rural settings. ³

Informed by the wider place-based education movement, ¹³ it is this idea that has led to the development of the Remote and Rural Community Placements (RRCP) at the Northern Ontario School of Medicine (NOSM) which form the subject of this study. ¹⁴ The RRCPs were based upon rural elective placements at other institutions which began at Dartmouth in the 1970s, and later at the Morehouse School of Medicine and Eastern Virginia medical school in the 1980s.^15–18 Such placements had been shown to be effective for developing rural physician identities,^8–21 and nurturing positive attitudes towards rural medicine.^22–25 NOSM was established in 2005 with a social accountability mandate to improve the health and healthcare of those living in Northern Ontario, a large region covering approximately 800 000 square km. ¹⁴ Although some residents live in smaller cities of approximately 80 000–100 000 residents, many live in small rural and often remote communities, communities which have experienced difficulties recruiting and retaining physicians. ¹⁴ The RRCPs represent one of the main approaches for training physicians in rural communities in a manner that prepares them for their later practice in the same northern communities.

The NOSM MD programme comprises a 2-year mainly classroom-based foundational phase occurring in the two largest cities in the region, followed by a longitudinal integrated clerkship which occurs in smaller rural communities, followed by a rotation-based clerkship in the hospitals located in the two larger cities. The RRCPs are embedded within year 2 of the NOSM MD programme and are mandatory experiences which all students must complete before progressing to year 3. ¹⁴ , ²⁶ The RRCPs occur within a 6-week teaching module with the first and last week of the module being on-campus. Both placements are 4 weeks long providing students the opportunity to live in a rural community and learn from one or more of the physician preceptors. Each RRCP placement week includes 15 hours of ‘clinical time’ and 3 hours spent with other health professionals in the community or healthcare-related agencies. These experiences are in addition to the academic curriculum, which is taught using either pre-recorded lectures or phone-in small group sessions while the students are away from their home campuses. The curriculum of the clinical time component of the RRCP was deliberately left only very generally defined as ‘(Students) will learn about what it is like to live and practice medicine in these settings’ ²⁷ due to a desire to allow the preceptor to teach students what they view as being relevant to the practice of medicine in their own community. This has, however, left it rather unclear as to what occurs during the placement and how these relate to the desired outcome of preparing students for rural practice.

To address this gap this study investigated the experiences of medical students and their preceptors in the RRCPs to better understand the pedagogies that contribute to meaningful engagement and preparation. The study sought to understand what occurs during the placements, identify outcomes of the RRCPs, and guide future models for RRCPs and similar activities occurring elsewhere. Moreover, given that the RRCPs are experiential in nature they fall within the ‘Perceptual’ dimension of place-based education, ²⁸ and we ask, ‘perception of what?’.

Methods

Results

Preceptors and students (interviewed after the first RRCP) were asked about their experience of the RRCPs and what they found meaningful regarding their participation. In the data, four main themes emerged: (1) motivation of preceptors; (2) clinical experiences of students; (3) communication between preceptors, students and/or the institution; and (4) valuing place and community in medical education, which is described below.

Discussion and Conclusion

Our data suggests that both students and preceptors view the RRCPs as valuable and as a formative clinical experience. The RRCPs gave the students an opportunity to apply and improve their classroom acquired knowledge in an authentic clinical setting (see Theme 2). The findings suggest the RRCPs contribute to increased clinical confidence, a similar outcome to that of other early clinical experiences in medical school. ³² There was also evidence, in the data collected from students, that the RRCPs may be viewed in part as an ‘orientation’ for clerkship and we suggest that programmes which seek to include community-based clerkships also include shorter ‘in residence’ placements in earlier years of their undergraduate programmes for this reason (see Theme 2.i). In addition, it is notable that the RRCPs and community-based clerkship occur in different places. This may allow the student to develop an understanding of how place effects practice and, in doing so, improve their ability to adapt to new practice contexts. As such, an explicitly sequenced curriculum in which students build on that learned in previous placements, perhaps using a combination of articulated learning objectives in concert with a process of self-reflection, may be warranted.

Our study (see Theme 2.iii) also indicates that the RRCPs allowed students to discern experientially important features of rural healthcare such as interprofessionalism, health-care teams, and generalism, both widely accepted as key components of rural medical practice.^33–36 Students also learned about the limits of rural community-based care, and how urban and rural physicians interact to deliver healthcare. There was evidence of students developing a positive regard for rural medicine which may act to enhance the reputation of rural medicine within the profession, as well as to allow students to build their identity as rural physicians, in agreement with previous studies.^18–21, ³⁷ As such, experiencing rural medicine early in training may be effective in forming such an identity, as opposed to experiencing rural practice later in training when a, presumably non-rural, identity has already formed. ³

What can be clearly concluded from the data, however, is that the RRCPs allow students to learn about rural medicine and discern whether, or not, they see themselves as rural physicians in training. The impact of poor learning experiences such as (as suggested by our data and that of others), ³⁸ , ³⁹ feeling overwhelmed, not being able to gain desired clinical experiences, or having conflict between student and teacher, may reduce the desire to practice rurally as they relate to the personal and professional aspects of community life that are known to effect physician recruitment and retention. ⁴⁰ , ⁴¹ Indeed, the suitability of such an exposure model, promoted by both NOSM and elsewhere, ⁴² , ⁴³ as an aid to physician recruitment is unclear. This is a key question as it is an important motivator of physician involvement (see Theme 1.ii). While NOSM and others have reported that rural-based training enhances the likelihood of future rural practice, ¹⁸ , ²⁰ , ²² , ⁴⁴ , ⁴⁵ it is unknown how the RRCPs effect physician recruitment to these communities. Indeed, preceptors voiced concerns that clinical capacity had not been increased in their community, this being compounded by a lack of senior learners, for example, residents, being placed there that could offset the drag on clinical practice that novice learners represent. Having various stages of learners in the same community at the same time, termed integrated clinical learning, can reduce this effect as more senior learners can add to clinical capacity, but this clearly had not occurred at all placement sites. ⁴⁶ Such comments also suggest a quid pro quo of preceptors taking junior learners with the understanding they would also be able to share their clinical and teaching load with more senior learners or fully qualified physicians, although this also requires further investigation. In the meantime, we would recommend that those designing similar placements pay close attention to the overall student experience if enhanced recruitment to rural communities is desired given that the affective outcome of the placement likely plays an important role.

Our data also indicated that in addition to a desire to teach students about rural medicine and build clinical capacity, the RRCPs also contribute to the development of the professional identity of preceptors as academic physicians, something that is the norm in large centres but is much less a part of rural medicine. Viewed in this way the RRCPs may play an important role in the development of rural academic medicine in that they represent an important initial step towards increasing clinical teaching capacity in small communities that previously had very little. Further movement along such a developmental trajectory is dependent on ongoing and effective communication with the placement communities, something our data suggest can be difficult, perhaps due to geographic isolation. While improved communication in the distributed learning environment may be advantageous for the enhancement of collaborative partnerships with community, using this to exert too much control over the learning experience may not be universally welcomed (Theme 3). While broad curricular aims should be articulated and made mandatory, we would suggest that more detailed curricular materials should de made optional to be utilised by those who need more assistance in structuring their own teaching, particularly those who have had little experience teaching novice learners.

One aspect of our data that we found surprising was the different value of students and preceptors placed on learning outside of the clinic. Given that developing a place-based professional and social identity is key to recruitment of physicians to rural communities, this is, in this study, a significant finding, ¹¹ and highlights that curriculum intent and actual student experience can markedly differ. Viewed through the lens of place-based educational theory this is fundamentally a difference of how students and preceptors relate to the sociocultural aspects of the placement location, as short-term residents students would not be expected to value the learning about the wider community context compared to the permanently residing preceptors. ²⁸ In other words, to answer the question about perception asked in the introduction to this paper, what is desired to be perceived and, to a large extent what is perceived, differs between students and their teachers. It is therefore likely that including mandatory community exploration experiences to the curriculum would not result in students valuing such learning unless there is a well articulated connection to clinical work. It is advisable that those contemplating inclusion of such placements in early clinical learning consider making this aspect of curriculum visible in the form of conveying more precise placement learning objectives and facilitating the better communication between students and preceptors, perhaps in the form of formalised learning agreements which include a plan to learn outside of the clinical environment.

In summary, this study highlights that the RRCPs were valued by both students and teachers alike and are effective vehicles to learn about the rural medicine and places. Our study shows, however, that students and their teachers may place different value on experiences gained inside and outside of the clinical environment, something that we would advise needs to be explicitly addressed in the curriculum within the overall context of rural medical education. We also would recommend that those contemplating the inclusion of rural placements during early clinical education play close attention to the overall student experience and the quality of communication with the placement sites, particularly if the placements are intended to aid in recruitment of rural physicians.