Safeguard or mollycoddle? An exploratory study describing potentially harmful incidents during medical student placements in Aboriginal communities in Central Australia

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 Most students report high levels of satisfaction with their experience (unpublished data, NTGPE, 2006), and these placements are highly sought after.1

Although RUSC students are drawn from Australian universities and placed within Australia, there are similarities between the remote Australian context and international electives in developing countries. These include physical isolation and a challenging environment; communities with health beliefs and norms different to mainstream Australian culture; higher rates of poverty, poor housing, unemployment and violence; and health problems that are different in their presentation, prevalence and severity. Models of health care provision are also different: government and Aboriginal community-controlled primary health care clinics are the norm, staffed by remote area nurses and Aboriginal health workers. A doctor may not be on-site or available for clinical care and supervision. Services are often understaffed and underresourced, with difficult access to secondary or tertiary care.

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 therefore aimed to assess the number and characteristics of potentially harmful incidents occurring during placement of medical students in remote Aboriginal communities in the NT.

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.

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.

This retrospective audit has several limitations. The large number of files with inadequate documentation and the reliance on self-reporting by students increases potential bias. The primary feedback noted was from students and NTGPE staff, rather than supervisors, clinic staff or patients. The interviewers’ own experiences, both of the clinical context and in counselling skills, may inform how they interpret and attach significance to feedback. The number of descriptors and the brevity of their explanations may have led to a lack of clarity for the reviewers and a wider spread of descriptors. Multiple descriptors applicable to a case may also be interrelated: for example, clinical supervision is dependent on functional interpersonal relationships, appropriate professional practice, and professional attitudes.

Good supervision promotes professional development, but we found that the quality of clinical supervision appears to be a major concern. Complex patients with multiple morbidities; major traumatic events; lower health and language literacy; clinics characterised by understaffing, high staff burnout and turnover; and some recruitment practices (eg, appointment of short-term locums) all make it difficult to develop and maintain supervisory and teaching quality. Clinical workloads can be high and students seen as a valuable “pair of hands” and left to see patients on their own. The tension between service delivery demands and teaching may result in the teaching role being seen as a low priority. Clinics are staffed by interprofessional teams; non-medical staff may supervise medical students, and there may be a lack of clarity in roles, commitment or confidence in supervising across professional disciplines. Students may not value the roles of remote area nurses or be reluctant to accept their authority as supervisors, and have attitudes perpetuating the traditional hierarchical medical–nursing divide. Lack of training and skills in clinical supervision, compounded by remoteness and difficulty in attending training, may hamper the professional development of supervisors. These factors suggest that students require particularly careful clinical supervision to protect patients’ and students’ safety and promote ethical practice.

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.

While student placements are attractive and have demonstrated positive outcomes, they demand due consideration be given to safeguarding students, supervisors and, most importantly, patients. This is timely given the increasing burden of clinical education that is being placed on community-based health services and general practice, and in rural and remote Australia.

1 Northern Territory General Practice Education (NTGPE) Rural Undergraduate Support and Coordination Program (RUSC) process

4 Frequency of descriptors for 28 critical incident cases,* 2006–2007

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* Each case could have more than one descriptor applied, and each descriptor could be applied more than once (ie, by two or three reviewers).