A tale of three hospitals: solving learning and workforce needs together

Northern Queensland has been in the vanguard of trends to regionally based medical education in Australia. The first new Australian medical school in over 20 years was established at James Cook University (JCU) in 2000, producing its first graduates in 2005.1 JCU’s 6-year undergraduate program is entirely regional, involves at least 20 weeks of clinical placement per student in small communities, and has an emphasis on rural, remote, Indigenous and tropical health.2,3 With medical student numbers doubling nationally, and many new medical schools having been established since 2000, educators are looking to develop new clinical teaching sites and opportunities.4,5 Evidence supports the success of the “rural pipeline”, recruiting rural students through rurally based education into postgraduate training.6 Academic performance of rurally based students remains strong, and interest in rural careers and regional internships is rising.7,8 However, increased demand for rural teaching placements has not yet been accompanied by increases in the rural workforce and the capacity to train students.

Scrubbing — skill acquisition by students on rural clinical placement.

Before the establishment of the JCU medical school, northern Queensland had an existing vertically integrated training system for general practice and rural medicine, and an established network of teaching practices.9 Since 2000, the region has had to rapidly accommodate increasing numbers of medical students in a health system simultaneously facing the challenges of meeting the clinical demands of a growing population in the context of a national health workforce shortage.

Two rural hospitals, in Atherton and Proserpine, have provided notable leadership in meeting the challenges of increasing teaching capacity. Other hospitals, such as Cooktown Hospital, are developing similar models. The locations of the three hospitals (Atherton, Proserpine and Cooktown) are shown in Box 1, and a comparison of their features is shown in Box 2. We believe the local experiences of the health care providers at these rural hospitals in evolving their clinical services into a “teaching health care system” are instructive. In this article, we describe the development of these services, their impact on capacity to teach and deliver health care services, and the long-term implications for workforce, planning and policy at these sites and elsewhere.

Medical students at JCU are predominantly school-leavers, and most are from non-metropolitan backgrounds. In their early years, they are based in Townsville, but in Years 5 and 6, they attend clinical schools in Mackay, Townsville, Cairns and Darwin (in the Northern Territory). All students are given early clinical exposure and undertake 20 weeks of rural placements.10 The three rural placements during the course offer a broad choice of locations and different sequenced learning objectives, including experiencing rural health care (Year 2), clinical skills and pathology (Year 4), and taking more responsibility for clinical care in the Year 6 rural internship.3,10

On the basis of previous experience, and of formal evaluations performed for the Rural Undergraduate Support and Coordination (RUSC) program,11 JCU medical school identified three key elements of successful rural clinical placements: student accommodation and teaching space, committed clinical teachers, and an appropriate caseload. Each leg of this “three-legged stool” is considered critical — if any one is missing, the placement will “fall over”. As student placements were developed, infrastructure was progressively secured while academic staff provided preceptor support.

The rural hospitals in Atherton and Proserpine have successfully implemented models allowing them to increase their teaching capacity, and case studies of these two hospitals are provided. A glimpse of Cooktown Hospital’s journey toward becoming a rural teaching facility is described in a brief personal perspective by its Medical Superintendent (Box 3).

Boosting the capacity of the clinical training pipeline in regional Australia is an urgent policy imperative, given the doubling of medical graduate numbers and potential impact of rural training on the rural medical workforce. These insights into the three rural hospitals illustrate ingredients for success in transforming small service hospitals into sustainable teaching, learning and research facilities.

Senior doctors in these hospitals function as consultants, supervising junior doctors and students in an extension of the traditional teaching hospital consultant–registrar–resident model. This vertical teaching model can solve the paradox of the most skilled, motivated and experienced clinical teachers generally having the least time to teach.

Each institution has energetic medical leadership, strong community support and partnerships with the local university. Local coordination, professional support and commitment have brokered strategic linkages between key organisations. Sustainability is assured by recruiting appropriate staff into a growing system, developing administrative support and academic appointments while maintaining flexibility with roles and funding to allow backfill and creative delegation of tasks (including clinical and management tasks, and undergraduate or postgraduate teaching). The third leg of the three-legged stool, student accommodation and teaching space, is the final key to ensuring a sustainable local teaching service.

As a result of these developments, the workforces in these hospitals are stabilising, infrastructure and teaching culture is established, and they are attractive to students, junior doctors and Fellows. The transformation to a vertically integrated teaching health care service brings net gains to the system. Students’ vitality, energy and enthusiasm invigorate staff. Senior students can contribute to the workforce (“service learning”) and develop a sense of belonging in the team. Student engagement is vital to this process. Close connections with the central campus ensure thorough preparation for their placement, they appreciate the opportunities and facilities available, and return positive evaluations. In turn, they enthuse, encourage and inspire their mentors and subsequent students.

Further investment is needed, but if models like these are replicated widely, we believe Australia will be better placed to manage the bulge in demand for clinical training while also addressing workforce needs. Sustaining the pipeline from positive rural experiences for medical students through to completion of rural generalist training may well see learning and workforce needs solved together.

1 Locations of the three rural hospitals, and the James Cook University medical school campus and clinical schools

3 Personal perspective — Cooktown Hospital

I arrived in Cooktown in 1997 as a medical student with a John Flynn Scholarship. My term there had an incredible impact on me, both personally and professionally. As a result, I undertook internship in Cairns, and then took up a Senior Medical Officer position in Cooktown in 2003, working alongside a supportive and skilled Medical Superintendent. The original attraction to the variety of medicine, spanning acute and primary health care, in a challenging geographical location — the essence of rural medicine — developed into a lifelong relationship. Subsequently, I completed vocational training and returned to Cooktown permanently in 2007. The opportunity to develop the hospital and its services has allowed growth of the medical workforce, and expanded investment in medical education. My personal experience is a testament — now a commitment — to the benefit of early positive supported exposure to rural medicine. Cooktown now has two additional Senior Medical Officers, an intern rotating from Cairns (referral centre connection and support cannot be understated), James Cook University students in Years 2 and 6, and students from other medical schools as capacity permits. Cooktown is participating in the Physician’s Assistant Pilot Program,12 and continues to grow as a rural teaching facility. Natasha Coventry, Medical Superintendent