Rural general practice placements: alignment with the Australian Curriculum Framework for Junior Doctors

As part of the strategy to meet growing workforce demands in the Australian medical system, medical student numbers have been increased. In 2014, 3108 students are expected to graduate — up from 1335 in 2006.1 This growth is associated with challenges for education and training systems, including shortfalls in clinical placements and in adequate supervision for students and junior doctors. The growth also presents an opportunity to redress the current workforce maldistribution, but it is unrealistic to rely solely on a “trickle-out effect” that assumes increased numbers will lead to more medical graduates practising in traditionally underserved areas.

Consideration of alternative training settings provides an opportunity to explore socially accountable approaches in learning objectives and curricula,2,3 provision of high-quality clinical experiences in underserved populations4-6 and expansion of training options in rural areas. To ensure that students and junior doctors currently training are appropriately equipped to practise in a range of underserved areas, a strategic approach among educators and training institutions is required, including expanding training options in areas that are outside the traditional vocational training rotations.7-10

Offering general practice placements for interns is an important strategy for avoiding the expected shortfall of clinical placements and supervisors in the hospital system. While medical schools and vocational training are already providing training experiences in underserved areas such as rural sites, it is timely to investigate the option of a rural general practice placement during the intern year. Such placements must ensure that experiential learning is aligned with outcomes expected from the Australian Curriculum Framework for Junior Doctors (ACFJD). The ACFJD was designed by an experienced group of clinicians who outlined the knowledge, skills and behaviours required of junior doctors in postgraduate years 1, 2 and above. Areas covered by the framework include clinical management, professionalism, communication, skills and procedures, and clinical symptoms, problems and conditions. All clinical placements for prevocational doctors in Australia must meet the standards outlined in this framework. We have reviewed the available literature regarding skills and competencies gained by junior doctors in rural general practice placements, with particular reference to the ACFJD competencies.

Recommendations from a recent Senate report11 identified the need for a review of current literature to identify and develop a strategy to address gaps in research and knowledge affecting rural health service delivery (Recommendation 2). Although not a systematic review, our work provides a narrative review conducted in a systematic way. A recent publication12 stated that mixed methods reviews are an emerging field of research. The authors suggested that reviews in medicine using both quantitative and qualitative data should be considered within the scope of systematic reviews. Our literature review provides a starting point for documenting evidence related to rural training settings for junior doctors and the clinical skills they learn during a rural placement.

The review was undertaken in May 2011 using three different strategies. All strategies followed a similar systematic approach using the search criteria outlined in Box 1. Initially, articles published in English that reported rural placements for junior doctors were identified from the OvidSP and Scopus databases. The search terms for rural included definitions that incorporated regional centres as well as more rural and remote locations. Articles were identified by keywords, subject heading, title or abstract using criteria outlined in Box 1. Reviewers systematically worked through all the articles and then collated the relevant content under one or more core competencies outlined in the ACFJD.

A poor initial return rate meant the search was re-evaluated. Using the same criteria, we conducted a hand search of contents pages of relevant journals such as Medical Education, Academic Medicine, the Medical Journal of Australia and Australian Family Physician. Data were also sourced from reports, conference abstracts and grey literature available from government and other organisations (Box 2).

Articles reporting undergraduate and junior doctor outcomes in the same article were included, while articles reporting medical student outcomes were only included if they provided evidence of outcomes that would be transferable to junior doctors undertaking rural clinical placements. Articles were discarded if they focused on: topics outside the scope of this review; education and training needs of qualified general practitioners; general practice workforce or registrar issues, such as recruitment, retention, gender roles and training posts in rural hospitals; or undergraduate curricula or placements exclusively.

Publications ranged from 1997 to 2011. The highest number in any year was six in 2005. The countries most often included were Australia (17 articles or reports) and the United Kingdom (13). The most common research design used in the literature was qualitative (14 publications). This was followed by survey (9), retrospective cohort (7) and opinion piece (6). Box 3 outlines these results, and a summary of the relevant literature is shown in Appendix 1.

From these publications, we report learning outcomes for junior doctors training with rural GPs, including only documented skills and procedures. As we used data that were already in the public domain, ethics approval was not required.

Most of the literature initially identified as potentially relevant provided evidence about skills gained by medical students or vocational trainees in rural general practice placements, or the distribution of GPs in Australia, patient characteristics and reasons for encounters across a range of geographical locations. There was little published research covering the range of skills or competencies gained by junior doctors on rural clinical placements, especially non-traditional placements such as rural private general practices. The 36 articles and reports we identified as relevant focused on the advantages of junior doctor rural general practice placements for gaining advanced skills in communication and professionalism, as well as for developing autonomy in clinical management and decision making. Benefits for academic performance were also noted. Less evidence was available regarding exposure to particular clinical conditions, awareness of the impact of continuity of care, the development of specific clinical skills and the impact on later academic performance.

While relatively little research has been published confirming the value of non-urban general practice settings for intern and junior doctor learning, particularly against the competencies identified in the ACFJD, there is evidence of high-quality learning experiences and outcomes for placements in community and non-urban locations at the undergraduate medical student level and at vocational training level.21,22 There is also evidence of a wide range of clinical conditions managed, patient demographics and investigations occurring in rural general practices when compared with urban practices.34,35

Rural general practice placements have the potential to be as beneficial for junior doctors as hospital placements, and provide complementary learning experiences.10 As increasing numbers of medical graduates enter the health system, alternative placements to tertiary hospitals are required to provide high-quality clinical training while developing the aptitude, interest and skills of junior doctors for subsequent practice in areas of high unmet need.9

Many of the competencies identified in the ACFJD should be achievable in rural general practice placements, contingent on adequate supervision and mentoring. However, the placement must be of similar quality to more traditional placements, with facilities available for junior doctors to consult, learn, study and seek advice. Building the capacity of a small number of distributed teaching sites as teaching centres of excellence, resourced with adequate preceptor training and support, may be one way of furthering this agenda.35 Implementation of a rural general practice placement during the intern year is an important strategy for ameliorating expected training pressures in the health system while broadening the range of experiences available to junior doctors.