Through its Rural Undergraduate Support and Coordination Program (RUSC), Northern Territory General Practice Education (NTGPE) is responsible for 2–8-week elective placements undertaken by medical students from around Australia in remote Aboriginal communities in the Northern Territory (Box 1). Most students report high levels of satisfaction with their experience (unpublished data, NTGPE, 2006), and these placements are highly sought after.1
The literature on international electives suggests they promote the uptake of general practice; encourage doctors to work in public health and with underserved populations; and provide benefits to students’ personal and professional development.2-4 However, there are also concerns about the risks, which include important ethical issues for patients as well as students.5 If students work beyond their experience and are “expected to diagnose and treat patients without direct supervision from a qualified doctor”,6,7 patients may be placed at risk. This raises difficult questions. Is some care better than no care?8 Is the student the “most qualified” health care worker present to fulfil the patient’s right to quality care? The personal safety of the student is also crucial; in remote locations, students are at greater risk of accidents, infectious diseases, personal violence and even political threats.9
We conducted a retrospective file audit of all RUSC student placements in Central Australia for a 2-year period from January 2006 to December 2007. Sources of information included the written notes in students’ files such as the application form, teleconference notes, debrief notes and any other file and action notes. Students were ideally debriefed weekly by group teleconference, and at the end of their placement by a medical educator and program administrator. However, debrief attendance was variable, and students were not specifically asked about adverse experiences. While NTGPE staff were aware of some incidents that had not been recorded in the files, anecdotal or verbal recall was not regarded as sufficient for this study.
Ethics approval was obtained from the Central Australian Human Research Ethics Committee.
We used an educational institution-based definition of a “critical incident”10 to develop a student placement-specific definition of an incident as: an event, or the threat of one, which may
cause, or is likely to cause, significant physical and/or emotional distress or harm to the student experiencing or witnessing the event
be regarded as outside the normal range of experience of the persons affected
threaten, disrupt or prevent the ordinary functioning of the student placement.
Two subgroups were identified:
Clinical: events related to medical or clinical work by the student or other clinicians, or to patient morbidity and mortality (eg, accidental, avoidable or traumatic deaths or suicides; near-misses; needle-stick injuries; lack of supervision judged necessary for student competence; improper or negligent practice).
Non-clinical: events outside the direct medical, patient-related work of the student or clinic (eg, motor vehicle accidents; physical or verbal assault; bullying or harassment; extreme weather conditions; cultural transgressions; culture shock).
Face validation of cases was achieved by independent file review by two other staff (M V and H T N), who assessed whether the identified case met the agreed definition of an incident. Broad descriptors were developed to categorise the cases by common themes (Box 2). The three reviewers independently recorded which descriptors they thought best applied to each case. There was no discussion of which descriptors were applied by each reviewer, and each descriptor could therefore be applied multiple times to a case.
A total of 163 placements were identified (97 in 2006 and 66 in 2007). Of these, 98 (60%) had sufficient documentation to determine whether an incident had occurred.
A total of 31 files with possible critical incidents were identified on initial screening. After face validation by the three investigators, six needed review; three were discarded, leaving a total of 28 identified cases (17% of all placements). There was a preponderance of female students placed, and this was proportionately represented in the incidents (Box 3).
Thematic analysis of the 28 cases found that clinical supervision, professional practice and administration were the key issues causing distress for the students (Box 4). A small sample of cases is described in Box 5.
This study suggests that, during the 2-year audit period, potentially distressing incidents occurred in at least 17% of medical student placements in remote Aboriginal communities in Central Australia. In 2006, from the 75 anonymous feedback forms completed by the cohort of 97 students, 64 (85%) rated their overall placement as above average or excellent, and 61 (81%) believed it had increased their interest in rural practice, while only four (5%) considered the placement below average or poor, and three (4%) reported less interest in rural practice as a result (unpublished data, NTGPE, 2006). Thus, there were many more students who experienced critical incidents than those who rated the placement poorly, suggesting that a “distressing” incident does not necessarily lead to an overall negative placement and may in fact be a powerful learning experience.
Personal qualities such as resourcefulness, self-confidence and cross-cultural skills will aid students in making the most of their elective. However, a “medical tourist” attitude may undermine the learning component and lead to mismatched expectations. Some students may be experiential learners and “keen to have a go”; they may appreciate a lack of supervision as it allows them to do more, but they may lack insight into their own capabilities and have “strategies to appear as competent as possible”.11,12 All these attitudes and perceptions can challenge the inexperienced supervisor.
A review from the United Kingdom recognised the value of more structured approaches to medical electives to maximise learning and minimise the risks.13 Strategic planning can address some of the challenges of clinical education14 in the primary care and remote Aboriginal community setting, and should be applied to student electives. Immediate strategies can include organisational systems for risk management; staff and student commitment to processes such as ethical practice; feedback and debriefs; and employing staff who are familiar with local conditions. Establishing more intimate partnerships with communities, universities and clinics with stable staffing, developing rigorous standards for selection of supervisors, and resourcing interprofessional training in clinical education are some longer-term practical strategies.
1 Northern Territory General Practice Education (NTGPE) Rural Undergraduate Support and Coordination Program (RUSC) process
2 Descriptors for potentially harmful incidents
4 Frequency of descriptors for 28 critical incident cases,* 2006–2007
* Each case could have more than one descriptor applied, and each descriptor could be applied more than once (ie, by two or three reviewers).
Provenance: Not commissioned; externally peer reviewed.
Abstract
Objective: To assess the number and characteristics of potentially harmful incidents occurring during placement of medical students in remote Aboriginal communities in the Northern Territory.
Design, participants and setting: A retrospective audit of medical students’ files from Northern Territory General Practice Education placements in Central Australia for the period from January 2006 to December 2007.
Main outcome measures: Number and type of potentially harmful incidents.
Results: A total of 163 placements were undertaken. Of these, 98 (60%) had adequate documentation to determine whether an incident had occurred. There were 28 cases (17%) where potentially harmful incidents were judged to have occurred. Most incidents fell under several descriptive categories, but clinical supervision, professional practice and administrative issues were most common.
Conclusions: One in six students experienced a potentially harmful incident during remote area placement in 2006–2007. While acknowledging the exploratory nature of this investigation and the major educational benefits that clearly arise from these placements, our findings indicate problems with clinical supervision and administration.