Medical schools as agents of change: socially accountable medical education

From early observational studies, the evidence has accumulated that student selection is a key strategy for producing doctors who are more likely to choose rural careers. For example, rural-origin students are two to three times more likely than their city counterparts to practise in rural areas after graduation.21,22 Similarly, doctors graduating from regionally based medical schools are more likely to practise in rural areas.11,21 Bonded scholarships and other return-of-service obligations have an impact, as does the availability of rural-based postgraduate training.23 While linear associations are difficult to disentangle in what is typically a set of complex interventions and observational studies, it seems likely that a curriculum with a rural orientation, combined with rural clinical placements for students, also has a positive impact.24-26

Political advocacy from the rural sector and accumulating evidence from academic research, reviews and collective experience11,24 has helped policymakers implement programs that produce a rural medical workforce. As a country, Australia has exercised notable leadership in this regard, with the range of policy interventions now including:

• bonded medical rural scholarships and bonded medical places;

• rural medical placement support;

• rural clinical school campuses of metropolitan programs;

• wholly regionally based medical schools;

• selection targets for rural-origin students; and

• university-based, rural-health clubs for students.27,28

There are many principles from medical education in the rural context that can be applied more generally — particularly in places where resources are thin and health care needs unmet. For example, an important principle applied in effective rural programs has been that of “symbiosis”, whereby universities and health services build mutually reinforcing relationships. Students receive good teaching and in turn make an authentic contribution to the work of the health service. The university presence brings infrastructure, advocacy and recognition to the rural health service.29,30 This support reduces the risk that busy rural health services run in taking on a teaching workload, which might not deliver the future rural workforce that is the essential rationale.

Under this principle of symbiosis, there is an expectation that students will undertake extended placements in rural settings, rather than visit for short rotations or for some form of “medical tourism”. Furthermore, there is evidence that students undertaking long placements in rural settings perform better in medical school examinations.29,30

As part of the symbiotic relationship between universities and health services, universities will work with health services to achieve their priorities of attracting a future workforce. From a community perspective, it is obvious that priority should be given to long-term rural placements for those students who demonstrate a genuine vocational interest in rural practice — that is, “merit” from the community perspective.

There are lessons for policymakers too. The success of rural medical education reforms in Australia would not have been possible without government acceptance that providing clinical teaching in distributed, community-based models requires significant resources for accommodation, infrastructure and staffing. The substantial injection of federal government health-sector funding through the Rural Clinical School and University Department of Rural Health programs both enabled and helped drive these reforms. Programs were structured to ensure that funds were directed towards those activities known to deliver a future rural workforce, rather than diverted to other university priorities.

Aboriginal leadership in health, growing out of the establishment of Aboriginal community-controlled health services (ACCHSs) in the 1970s and 80s, has been a critical factor in health professional education reform. The landmark National Aboriginal Health Strategy (NAHS) report in 1989 set out a comprehensive blueprint for change, including better education for all health professionals, as well as the imperative to recruit and train more Indigenous doctors and nurses.33 All health professionals working with Indigenous peoples should not only provide treatment, they also need skills in advocacy to assist individuals and communities in crises, and with housing, legal, employment and other issues. The NAHS report found that, in the teaching of health professionals, scant attention had been paid to the context of Aboriginal history to Aboriginal health and that, as a result, there were problems with “unrealistic expectations . . . and intolerance based on lack of understanding”.33

The NAHS report, driven strongly by community leaders, anticipated many of the contemporary themes in socially accountable medical education: curriculum reform to “reflect a primary health care approach [and the] linkages between community empowerment, social justice, equity and health”; the need for formal clinical placements in communities and in community-run health services; and special measures needed to support Aboriginal students to undertake tertiary studies.33 The momentum from the NAHS led to partnerships between peak Aboriginal health bodies (National Aboriginal Community Controlled Health Organisation and Australian Indigenous Doctors’ Association), the medical colleges (Royal Australian College of General Practitioners and Australian College of Rural and Remote Medicine), and medical schools (the then Committee of Deans of Australian Medical Schools). These partnerships produced a national Indigenous health curriculum plan for general practice in 1994, and a national curriculum framework for medical schools in 2004, both of which are now reflected in accreditation documents.34

There are instructive lessons for curriculum development in the Indigenous health context. For instance, the progress made in formal curriculum development in Indigenous health can be undermined if the “hidden curriculum” is not identified — in both the classroom and in health care settings.35 Experiences of subtle and overt discrimination and racism have a negative impact on learning for Indigenous students, who can find the experience of medical school alienating.36

The importance of quality practical experience for students in community-centred models of health care delivery is a key consideration; there is a limit to what can be achieved in the classroom. This issue is emerging as a key rate-limiting step in medical schools’ efforts to prepare graduates to work effectively with Indigenous patients and communities. Many of the roughly 140 ACCHSs across the country provide such placements in a comprehensive primary health care model. However, given funding, staff and capacity constraints and a necessary focus on providing care to communities, diverting resources to support student placements can be a challenge. Like other community-based care environments (and unlike tertiary teaching hospitals), ACCHSs have generally not been designed nor resourced as training facilities for learners. The demand for quality “immersion” experience in ACCHSs comes not only from the 18 Australian medical schools, but also from students of other health professions, junior doctors, and general practice and other specialty registrars.

As in the rural setting, the socially accountable approach for a medical school in this context is to build an authentic partnership with local ACCHSs and to develop arrangements that have reciprocal benefits in workforce, service, research and other community-identified priorities. This includes providing or brokering the human and capital resources required to make student placements work. University clinical academics directly participating in clinical services in an ACCHS can be part of this engagement. Well planned and coordinated placements then increase, rather than drain, the resources available to communities that need health care most.

Two developments — the establishment of regionally based medical schools, and the recruitment of Indigenous students and students from rural areas — are helping to broaden medical student diversity in Australia, and deliver medical graduates into areas of workforce shortage. However, this is not without its own challenges: the barriers that rural-origin and Indigenous students often face in accessing medical education need to be anticipated. The requirement to physically relocate and live independently may force students to take on substantial paid employment or to seek scholarships with return-of-service obligations.40 For some, disconnection from support networks can result in social isolation and poor social and emotional wellbeing.41 While scholarships and government financial support can help lessen the economic burden for those who are able to access them, medical schools, working with the student body, need to be prepared to cope with problems arising from social and cultural isolation.

University rural-health clubs are an example of an initiative that attempts to address social isolation as well as nurture student interest in rural health and rural careers. Student-led rural-health clubs were first established in the early 1990s, as part of a “rural counterculture” within the orthodoxy of medical schools.42 With federal government funding support, multiprofessional rural-health clubs have been established at 29 Australian universities and are represented by the National Rural Health Students’ Network (NRHSN).43

These clubs have been important agents of change in medical education. Extracurricular educational and social activities provide positive rural experiences, promote careers in rural health and assist in recruitment of students from rural secondary schools.44 Rural-health clubs exercise influence within medical curricula through educational committee membership and direct representation around issues such as rural clinical placements and interprofessional education. At the national level, the NRHSN provides leadership and advocacy, along with regular forums for students to meet with policymakers.